Exam 3 Lecture 3 (LAST!)

Can patient care for self? rehab floor, convalescent home with rehab floor

Can they live independently, or do they have help at home?

Do they need assistive devices?

Are there steps, stairs, or other barriers to recovering at home? no throw rugs

Assess learning needs and get a medication history. 6 P's, know when to report, if pt has CKD then do not give NSAIDS

Assess pain, gait, bending ability, listen for crepitus (popping and cracking in joints) when they bend.

Check strength and skin

Check neurovascular status (if someone has ant kind of injury we always check this often because bone moving can cause break in vein/vessel and cause hemorrhage. 6 P's

Assessment After Injury (MSK)

Muscles and bones change

- Kyphosis (hump of spine)

- Scoliosis

- Disc degeneration (discs have shock absorption)

- Flexibility diminishes (hip/knee replacement)

- Osteoporosis (sponge bone)

- Muscle loss

Hand function

- Reduced due to degenerative changes

-- Rheumatoid arthritis (p. 1078-1082)

-- Osteoarthritis (p. 1122-1124)

aging effects on MSK

X-rays: cheaper, lots of info on bones

CT Scan: quick easy

MRI: long, claustrophobic, noises

Arthrography: picture

Bone densitometry: osteoporosis!!!!!!! most important diagnostic study

Bone scans: how bones are doing

Arthroscopy

Arthrocentesis

Electromyography

Biopsy

Lab studies

Diagnostic Studies (MSK)

Causes:

- Excessive bending, reaching, pushing, and/or lifting

- Moving improperly

- Weak core muscles

- Degenerative disc disease (cant do anything about this)

- Compensation for pain in the lower extremities (limping because pain in knee/foot/etc.)

low back pain

neck pain can cause pain/weakness in the arms

Acute or Chronic

Injury

Anything make pain better or worse?

Assess gait and posture

Loss of strength or sensation

- Sciatica (pain down the leg) or radiculopathy

- Cauda equina Syndrome (the nerves are impinged and you lose function of the bowel)

Assessing Low Back Pain

Short-term pain medications

- Anti-convulsant (gabapentin) (nerve pain)

- Muscle relaxants (relax muscle bc nerve constantly firing)

- NSAIDs (not good for pt with CKD)

Exercise and PT

- Core exercises and walking, if tolerated well

- Stretching

Avoid bending, twisting, pushing, and reaching

Low Back Pain Treatment

Good posture

Proper lifting techniques (lift with legs, legs shoulder width apart)

Body mechanics

Stress relief

Self care

Weight loss

Low Back Pain Education

Prevalence

- Most prevalent bone disease in the world

- Causes 1.5 million fractures every year

- More than 10 million Americans have it

-- 33.6 million have low bone mineral density (BMD)

-- Precursor to Osteoporosis

- 1 of 3 women and 1 of 5 men over 50 will have a fracture caused by this in their lives

- spongy

- breakdown from inside out

- lots of idiopathic fractures

- Peak bone mass happens between 18 and 25 years old

-- Low vitamin D levels

-- Low calcium in diet

-- Caffeine use

-- Smoking

-- Drinking soda

-- Alcohol consumption

osteoporosis

- Decrease in bone mass

- Deterioration of bone matrix

- Decrease in bone strength

- Starts after menopause in women, men get it later in life (bc men are big boned)

-- Calcitonin and estrogens decrease

-- PTH increases

Pathophysiology of osteoporosis

Small-framed women at highest risk

- Asian and Caucasian women

- Bariatric surgery patients (not absorbing)

- Immobility (bones need to move for strength)

Bone formation

- Reduced when not active

- Increased with resistance and impact exercises

Risk Factors of osteoporosis

- DEXA scan

- BMD studies

- Lab & X-ray studies

-- r/o other causes of bone loss

NEED TO KNOW BONE DENSITY TEST

Assessment and Diagnostics of osteoporosis

Medical management

- Diet, exercise, limit alcohol, quit smoking

Pharmacology

- See Table 36-1 p. 1138

- Bisphosphonates have severe GI effects (sit up for at least 30 minutes after taking drug bc it will erode the esophagus)

Fracture management

- Joint replacements, kyphoplasty (inject cement into fracture)

osteoporosis treatment

- Education about meds

- Discuss treatment plan

- Increased risk for subsequent fractures

- Pain management

-- High fiber diet

Osteoporosis Nursing management

Infected joint

Elderly have greatest risk

Single joint affected

Prompt treatment

- Can lead to sepsis and death

Pathophysiology of septic arthritis

Signs of infection

May not have wound or recent trauma

Assessment and Diagnostics

- Infection source

- Synovial fluid

- CT or MRI

Clinical Manifestations of septic arthritis

IV antibiotics***

- Broad spectrum until cultures come back

Aspiration to remove pressure

Immobilize

Pain medication

Progressive ROM exercises

Nursing Management

- Same as for osteomyelitis

BEFORE ANY AMBULATION GIVE PAIN MEDS 30-40 MINUTES BEFORE GETTING OUT OF BED

Medical Management of septic arthritis

Bone infection

- Causes inflammation, necrosis, and new bone formation

- Can be chronic

Causes

- Bloodstream infection

- Bone or joint surgery/open fracture

- Vascular insufficiency

IF IT CANT BE TREATED THEN WE HAVE TO AMPUTATE IT

LONG TERM IV ANTIBIOTICS (4-6 MONTHS) SO NEED PICC LINE

HOME CARE IS EXPENSIVE

MOST COMMONLY SEEN IN DIABETICS

ULCERS CAN LEAD TO OSTEOMYELITIS

INGROWN TOENAIL CAN LEAD TO AN UNDER KNEE AMPUTATION

osteomyelitis

Clinical Manifestations

- Constant, pulsating pain that gets worse with movement

- Chronic cases can have ulcer

Diagnosis

- X-rays, bone scan, MRI

Treatment

- Long-term IV antibiotics

- 6-12 weeks

- Surgical debridement

- Amputation

Nursing Management

- Education about treatment regimen (give antibiotics on time)

- Assess need for home health nurse

- Medication administration (how to give the meds themself)

- Equipment

- Importance of strict adherence to treatment

osteomyelitis treatment

May be benign or malignant

Benign more common

- Osteochondroma is the most common

-- Ends of long bone

Malignant—Primary or Metastatic

- Primary are rare

-- Sarcoma or Multiple Myeloma

- Metastatic cancer

-- Osteosarcoma

-- Mets to lungs

Clinical Manifestations

- Localized bone pain

-- May have palpable mass

- Metastatic tumor

-- Primary cancer in body

-- Skull, spine, pelvis, femur, and humerus

--- Usually affects more than one

- Cancer invades and weakens bone

- You will learn more about this in oncology lecture

Nursing management

- Education about treatment plan

- ADLs and resources for assistance

- Medications and pain control

- What to look for and report to provider

- Stress compliance with treatment and follow-up

bone tumors

Noninflammatory degenerative joint issue

- Most common

- Primary or secondary

-- Primary has no history

-- Secondary has previous injury or inflammation

- Not systemic

- Starts in the 30s, peaks in the 60s

- Incidence increases with age

note Heberden's nodes in the picture: these show up due to repeated hand labor

osteoarthritis

Articular cartilage breaks down

- Damages bone over time

- Bone spurs

- Joint space narrows

- Septic arthritis can occur

Risk factors

- Older age

- Female

- Obesity

- Playing sports/hard labor

- Previous injury

Pathophysiology of osteoarthritis

Pain

Stiffness

- Usually <30 min in morning (chill for the first 30-45 minutes after waking up)

Functional impairment

Enlarged joint

Decreased ROM

Weight bearing joints (hips/knees)

Clinical Manifestations of osteoarthritis

X-ray

- Narrowing joint space

- Osteophyte formation (bone spurs)

- Dense, thickened subchondral bone

Medical Management

- Pain control

- Maintain mobility of joint

- Exercise and strength training

- Weight loss, if applicable

USE EXTERNAL NSAIDS LIKE VOLTAREN CREAM FOR JOINT PAIN... NO PO NSAIDS BC THEY ARE DAMAGING

Assessment and Diagnostics of osteoarthritis

NSAIDs are commonly used OTC (BAD)

-- Nephrotoxic

- Acetaminophen

- Topical analgesic agents (GOOD)

- Corticosteroid injections

- Gel injections in the joint

Arthroplasty for severe cases

Nursing management

- Pain management

- Optimal functioning

- Education

Pharmacologic Therapy of osteoarthritis

Autoimune disease

- Unknown origin

- 1-2% of the population affected

- Women 3x more than men

- Usually occurs between 30 and 60 years old

Risk Facstors

- Increased risk with age

- Family history

- Diet

- Geographic location

- Nulliparity (never having a baby or getting pregnant)

- Smoking

- Obesity

rheumatoid arthritis

Autoimmune reaction

- Breaks down collagen

- Destroys collagen

- Erodes bone

- Muscle fibers degenerate

- Tendons and ligaments lose elasticity

Nerves can be compressed

NOTE ON PICTURE:

SIDEWAYS FINGERS

SWAN NECK DEFORMITIES

Pathophysiology of rheumatoid arthritis

Diagnosed with a scoring system

- Joint involvement

- Serology

- Symptom duration

- Joints with synovitis (inflammation of the joints)

- Bony erosions on X-ray

Symptoms

- Morning stiffness for >1 hour (do the most you can and take rest periods)

- Spongy bone

- Fluid in joints

- Systemic disease (everywhere)

- Ulnar deviation and swan neck deformity (hand/fingers go out)

INCREASED C REACTIVE PROTEIN (CRP)

Clinical Manifestations of rheumatoid arthritis

Rheumatoid nodules

RF present in many (rheumatoid factor blood test)

Anti-CCP in 95%

Baseline labs and X-rays

MRI can detect small erosions

Assessment and Diagnostics of rheumatoid arthritis

Decrease pain, swelling, deformity

- Clinical remission

- Minimize disability

- Early and aggressive treatment

- DMARDs

- JAK inhibitors

- NSAIDs

methyltrexate: chemo drug that blows out the immune system and decreases blood production

Medical Management of Rheumatoid Arthritis

Focus on education about

Comorbities (these people will almost always have these)

Pain management

Fatigue (pain tires you out)

Maximal mobility

side effects of meds

Resources and support services

nursing management of rheumatoid arthritis

reserved for the most severe cases

Partial or total joint replacement

- Severe pain or loss of function

- Avascular necrosis in a joint (dead bone bc no blood flow to it: frequent neuro checks)

-- Knees and hips most common

Nursing Management

- Blood loss monitoring

- VTE/Infection Prevention

- Pain management

arthroplasty

Complications and Expectations

- Dislocation of prosthesis

- Flexing >90 degrees (BAD BAD BAD)

-- Pain

-- Shortening of extremity

-- Abnormal rotation

-- Restricted movement

-- Popping sensation (bone popping out of joint)

Excessive drainage

VTE

Infection (day 1 not worried if inflamed and red but DAY 2 BE CONCERNED.. especially if there is fever)

Pressure injury on heel

4-6 month recovery

hip arthoplasty

Complications and Expectations

- Watch for:

-- Excessive drainage

-- VTE

-- Infection

-- Pressure injury on heel

-- 4-6 month recovery

Ice or cold pack is applied

Check neurovascular status regularly (6 P's)**************

PT will get them up

May be discharged to rehab facility (if they can not take care of themselves)

Knee Arthroplasty

soft tissue injury produced by blunt force

Pain, swelling, and discoloration: ecchymosis

Contusion (bruise)

Pulled muscle injury to the musculotendinous unit

Pain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded first, second, and third degree

Strain

injury to ligaments and supporting muscle fiber around a joint

Pain (may increase with motion), edema, tenderness; severity graded according to ligament damage and joint stability

CHECK 6 Ps

Sprain

articular surfaces of the joint are not in contact

A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility

CHECK 6 Ps

Dislocation

partial or incomplete dislocation

Does not cause as much deformity as a complete dislocation

CHECK 6 Ps

Subluxation

RICE

- Rest

- Ice

- Compression (loosen if pt has compartment syndrome, it could make it worse)

- Elevation

Immobilize

Management of Soft Tissue Injuries

Closed or simple

- No break in the skin

Open or compound/complex

- Wound extends to the bone

- Grade I: 1 cm long clean wound

- Grade II: larger wound without extensive damage

- Grade III: highly contaminated, extensive soft tissue injury, may have amputation

Intra-articular

- Extends into the joint surface of a bone

Types of Fractures #1

Acute pain

Loss of function

Deformity

Shortening of the extremity

Crepitus

Local swelling and discoloration

Diagnosis by symptoms and radiography (xray/ct scan)

Patient usually reports an injury to the area

Manifestations of Fracture

Immobilize the body part (WE DO THIS. THIS IS IN OUR SCOPE... NOT MOVING THE BONE BACK IN PLACE)

Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilized

Assess neurovascular status before and after splinting (check the 6 Ps before calling the provider)

Open fracture: cover with sterile dressing to prevent contamination

Do not attempt to reduce the fracture (not in our scope)

Emergency Management of Fracture

Fracture reduction: restoration of the fracture fragments to anatomic alignment and positioning

Closed

- Uses manipulation and manual traction

- Traction may be used (skin or skeletal)

Open

- Internal fixation devices hold bone fragment in position (metallic pins, wires, screws, plates) (NO CASTS!!!!! TAKE CARE OF THE WOUND)

Immobilization

- External (cast, splints) or external fixations

Medical Management of Fracture

Inadequate fracture immobilization

Inadequate blood supply to the fracture site or adjacent tissue

Multiple trauma (breaking a bone in multiple places)

Extensive bone loss

Infection

Poor adherence to prescribed restrictions

Malignancy

Certain medications (e.g., corticosteroids)

Age >40 years

Comorbidities (e.g., diabetes, rheumatoid arthritis)

Factors that Affect Fracture Healing

Early complications

- Shock (TREAT IMMEDIATELY)

- Fat embolism (going to lungs, quick onset of SOB, feel like you are dying, cant be cured, do a bronchoscopy to get some fat out of the lungs)

- Compartment syndrome

- VTE, PE

Delayed complications

- Delayed union, malunion, and nonunion (bone does not grow back together)

- Avascular necrosis of bone (if 6 Ps are not constantly being assessed)

- Complex regional pain syndrome (CRPS) (compression causes CRPS and it is forever)

- Heterotrophic ossification

Complications of Fractures

Clavicle

- Use of clavicular strap or sling

- Exercises for elbow, wrist, fingers asap

- Do not elevate arm above shoulder for approximately 6 weeks

Humeral neck and shaft fractures

- Slings and bracing

- Activity limitations until adequate period of immobilization

lower limb restriction: no weight bearing

Upper limb restriction: activity limitations

Rehabilitation Related to Specific Fractures #1 (thorax)

VERY IMPORTANT***

Elbow fractures

- Monitor regularly for neurovascular compromise and signs of compartment syndrome

- Potential for Volkmann contracture (arm stuck and cant move

- Active exercises and ROM are encouraged to prevent limitation of joint movement after immobilization and healing (4 to 6 weeks for nondisplaced, casted) or after internal fixation (about 1 week)

Radial, ulnar, wrist, and hand fractures

- Early functional rehabilitation exercises

- Active motion exercises of fingers and shoulder

Rehabilitation Related to Specific Fractures #2 (UE)

Pelvic fractures

- Management depends on type and extent of fracture and associated injuries

- Stable fractures are treated with a few days of bed rest and symptom management

- Early mobilization reduces problems related to immobility

Hip fracture

- Surgery is usually done to reduce and fixate the fracture

- Care is similar to that of a patient undergoing other orthopedic surgery or hip replacement surgery

Rehabilitation Related to Specific Fractures #3 (pelvis)

Femoral shaft fractures

- Lower leg, foot, and hip exercises to preserve muscle function and improve circulation

- Early ambulation stimulates healing

- Physical therapy, ambulation, and weight bearing are prescribed

-Active and passive knee exercises are begun as soon as possible to prevent restriction of knee movement

bone marrow comes from long bone... bone marrow is fat.... risk for fat embolism

Rehabilitation Related to Specific Fractures #4 (femur)

Before application

- General health assessment (CHECK THE 6 Ps)

- Emotional status

- Presenting signs and symptoms and condition of the area

Monitoring of neurovascular status and for potential complications (INFECTION)

Treat lacerations and abrasions before cast, brace, splint

Provide information about the purpose of treatment

Prepare patient for application by explaining procedure

compartment syndrome: bad pain after pain meds and cast = immediate trip to the OR

Assessment of the Patient with a Brace, Splint, or Cast #1

Assessing for neurovascular changes using "6 Ps"

- Pain

- Pallor

- Pulselessness

- Paresthesia

- Paralysis

- Poikilothermia

Monitoring and treating pain

- Describe exact site, character, and intensity of pain

- Treat with elevation, ice packs, and analgesics

Assessment of the Patient With a Brace, Splint, or Cast #2

NEED TO KNOW

Acute Compartment Syndrome:

- Serious complication

- Occurs from increased pressure in a confined space

- Compromises blood flow (necrosis)

- Ischemia and irreversible damage can occur within hours

Clinical assessment of 5 Ps; pain is the early indicator

Treatment: Notify physician, cast may be removed, and emergent surgical fasciotomy may be necessary (remove the cast to decompress, infection risk bc it has to be left open

Potential Complications of the Patient with a Brace, Splint, or Cast #1

Pressure Injuries: caused by inappropriately applied cast

- Lower extremity sites most susceptible

- Patient reports painful "hotspot" and tightness

- Dx: May cut window in the cast for inspection and access

- Treatment: dressing applied over exposed skin

Disuse Syndrome: muscle atrophy and loss of strength

- Treatment: Isometric exercises, muscle setting exercises

-- draw the ABCs with your toe to promote movement and circulation

Potential Complications of the Patient with a Brace, Splint, or Cast #2

Impact of injury to physiologic functioning (ADL, IADL)

Activity, exercise, rest

Medications

Techniques for cast drying

Controlling of swelling and pain

Care of minor skin irritation

- Pad rough edges with tape or moleskin

- Blow with hair dryer to relieve itching

- Do not stick foreign objects into the cast

Education Needs of the Patient with a Cast, Brace, or Splint #1

Signs and symptoms to report:

- Persistent pain or swelling (cast too tight, pain doesnt go away with meds)

- Changes in sensation, movement, skin color, or temperature

- Signs of infection or pressure areas

Required follow-up care

- Cast removal and after care

Education Needs of the Patient with a Cast, Brace, or Splint #2

Used to manage open fractures with soft tissue damage

Provide support for complicated or comminuted fractures

Patient requires reassurance because of appearance of device

Discomfort is usually minimal, and early mobility may be anticipated with these devices

Elevate to reduce edema

Monitor for signs and symptoms of complications, including infection

Pin care

Patient education

External Fixator Devices

Health history and presence of concomitant problems

Pain

VS, respiratory status, LOC, and signs and symptoms of shock

Affected extremity including frequent neurovascular assessment

Bowel and bladder elimination; bowel sounds, I&O

Skin condition

Anxiety and coping

Assessment of the Patient with Fracture of the Hip

Hemorrhage

Peripheral neurovascular dysfunction

VTE

Pulmonary complications

Skin breakdown

Loss of bladder control (cant get to bathroom in enough time)

Delayed: infection, nonunion, AVN

Collaborative Problems and Potential Complications for the Patient with a Fracture of the Hip

Major goals include:

- Relief of pain

- Achievement of a pain-free, functional, and stable hip

- Healed wound

- Maintenance of normal urinary elimination pattern

- Use of effective coping mechanisms

- Remains oriented and participates in decision making

- Absence of complications

Planning and Goals for the Patient with Fracture of the Hip

Fracture: clavicle, wrist, ankle, metatarsal stress

Dislocations: shoulder, elbow

Sprains: wrist, ankle

Knee: sprain, strain, and meniscal tears

Common Sports-Related Injuries

Use of proper equipment; running shoes for runners, wrist guards for skaters, and so on

Effective training and conditioning specific for the person and the sport

Stretching

Hydration

Proper nutrition

Prevention of Sports-Related Injuries

Nursing ranked top 10 occupations most involved

Common injuries include

- Strains, sprains, tears

- Cuts, lacerations, contusions, bruises

Prevention measures may include:

- Safe patient handling training and proper use of equipment

- Correct use of body mechanics

Occupation-Related Injuries

May be congenital or traumatic or caused by conditions such as progressive peripheral vascular disease, infection, malignant tumor, trauma

Performed to control pain or disease process, improve function, and improve quality of life

Health care team needs to communicate a positive attitude to facilitate patient acceptance and participation in rehabilitation

use compression on the stump to stop the bleeding and model it into prosthesis

phantom pain... TREAT THE PAIN BC IT IS REAL EVEN IF THEIR LIMB ISNT THERE

Amputation

use next place that has a pulse*****

Neurovascular and functional status of affected extremity or residual limb and of unaffected extremity

Signs and symptoms of infection

Nutritional status

Concurrent health problems

Psychological status, grief, and coping

Assessment of the Patient with an Amputation

Postoperative hemorrhage

Infection

Skin breakdown

Phantom limb pain

Joint contracture

DO NOT MOVE THE STUMP AROUND

Collaborative Problems and Potential Complications of the Patient with an Amputation

Major goals include:

- Relief of pain

- Wound healing

- Acceptance of altered body image

- Resolution of grieving process

- Independence in self-care

- Restoration of physical mobility

- Absence of complications

DO ADLS AS MUCH AS POSSIBLE

Planning and Goals for the Patient with an Amputation

Relieving pain

- Administer analgesic or other medications as prescribed

- Changing position

- Putting a light sandbag on residual limb

- Alternative methods of pain relief: distraction, TENS unit

Promoting wound healing

- Handle limb gently

- Residual limb shaping

Resolving grief and enhancing body image

- Encourage expression of feelings

- Create an accepting, supportive atmosphere

- Provide support and listen

- Encourage patient to look at, feel, and care for the residual limb

- Help patient set realistic goals

- Help patient resume self-care and independence

- Referral to counselors and support groups

therapeutic communication

Promoting independent self-care

- Encourage active participation in care

- Continue support in rehabilitation facility or at home

- Focus on safety and mobility

Assisting the patient to achieve physical mobility

- Proper positioning of limb; avoid abduction, external rotation and flexion

- Turn frequently; prone positioning if possible

- Use of assistive devices

- ROM exercises

- Muscle‐strengthening exercises

- "Preprosthetic care"; proper bandaging, massage, and "toughening" of the residual limb

Nursing Interventions for the Patient with an Amputation

Pelvic Exam

beginning at age 21 annually

Pap Smears

every three years from 21-64 (more frequent if results are abnormal)

- Colposcopy if abnormal cells are found

Breast Exam

BSE monthly, provider annually

diagnostics/screenings

STI screening

Mammogram

annually 40+

Endometrial Biopsy

test for uterine cancer only if symptoms (thickened uterine lining, post-menopausal bleeding)

- Altered estrogen production associated with menopause are responsible for many changes

-- Decreased circulating estrogen and other sex steroids

-- Breast and genital atrophy

-- Decreased bone mass

-- Increased rate of atherosclerosis

Effects of Aging on Reproductive Systems (Women)

permanent physiologic cessation of menses associated with declining ovarian function

clinical manifestations

psychological considerations

medical management: HRT; risks and benefits

bleeding after menopause

menopause

premenarche, perimenopause, menopause, low estrogen levels

pregnancy or oral contraceptives

poor hygiene

tight garments and synthetic clothing

frequent douching

antibiotics

allergies

diabetes

intercourse with infected partner, oral genital contact, HIV

Risk Factors for Vulvovaginal Infections

The most common sexually transmitted disease among sexually active young people

Vaccine (age 11/12)

Treatment of genital warts

Associated with cervical dysplasia and cervical cancer; need annual Pap smears

Human Papillomavirus (HPV)

a recurrent lifelong viral infection

an STD that also may be transmitted by contact and that may be transmitted when the carrier is symptomatic

causes painful itching and burning herpetic lesions

no cure

antiviral agents acyclovir, valacyclovir, and famciclovir can suppress symptoms

recurrences may be associated with stress, sunburn, dental work, inadequate rest, and inadequate nutrition

risk for infants delivered vaginally to become infected; therefore, cesarean delivery may be performed

Herpes type 2 Infection (genital herpes)

25% living with HIV are women

Counseled about safer sex and informed about the dangers of unprotected sex

Because there is a risk of perinatal transmission, decisions to conceive or to use contraception must be based on education, accurate information, and care

Pregnant women are advised to have an HIV test. The use of antiretroviral agents by pregnant women significantly decreases perinatal transmission of HIV infection

HIV

Inflammatory condition of the pelvic cavity that may begin with cervicitis and involve the uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), pelvic peritoneum, or pelvic vascular system

Risk factors - multiple sexual partners, sex without condoms, history of STIs

Gonorrheal and chlamydial organisms are common causes

Short- and long-term consequences can occur

- Ectopic pregnancy, peritonitis, abscess, infertility, adhesions.

symptoms:

- Vaginal discharge

- Dyspareunia (painful sex)

- Lower abdominal pelvic pain, and tenderness that occurs after menses that may increase with voiding or with defecation

Other symptoms if progresses

- Fever, general malaise, anorexia, nausea, headache, and possibly vomiting

Pelvic examination—intense tenderness may be noted on palpation of the uterus or movement of the cervix (cervical motion tenderness)

Pelvic Inflammatory Disease (PID)

broad spectrum antibiotics

treat sexual partner to prevent reinfection

analgesics for pain relief

adequate rest and nutrition

patient education

PID treatment

fistula - risk for infection

uterine prolapse - pushes into vaginal canal

fibroids - can occur anywhere, genetic

ovarian cysts - hormonal imbalance/old follicle; burst: pain/pressure; PCOS: obese, diabetes, etc.

Benign lesions with endometrial tissue migrate in the pelvic cavity outside the uterus.

Symptoms - pain, depression, infertility

Treatment

- Pharmacological - analgesics, hormonal therapy

- Surgery - Laparoscopy, laser surgery, hysterectomy

SEVERE MENSTRUAL PAIN

Endometriosis

Testosterone levels decline in men as they age

Physical, psychologic, sexual manifestations are gradual

- Increased prostate size

- Decreased sperm production, scrotal muscle tone, size and firmness of testicles

- Erectile and sexual dysfunction may occur

Effects of Aging on Reproductive Systems (Men)

prostate specific antigen (PSA)

screening starts at age 50

>4 indicates prostate cancer, BPH, prostatitis and needs to be further evaluated

early prostate cancer antigen (EPCA-2)

specific to prostate cancer

>30 is highly suggestive of prostate cancer

transrectal ultrasound (TRUS)

contraindicated in patients with latex allergy

prostate biopsy

confirms cancer

The inability to achieve or maintain an erect penis

Psychogenic (anxiety, depression, body dysmorphia) and physical causes (CV, diabetes, liver failure, etc.)

Treatment

- Treat underlying cause

- Pharm - sildenafil (viagra) - contraindicated in pt taking nitrates and having cardiac arrhythmias

- Penile implant or vacuum

Erectile Dysfunction

Inflammation of the prostate gland usually caused by infectious agents, urethral stricture, or BPH.

Symptoms - fever, dysuria, frequency, urgency, nocturia, pain with ejaculation (TREAT WITH ANTIBIOTICS)

Management - antibiotics, tamsulosin, analgesics, sitz baths

Education - medications, avoid sexual activity, seek treatment for symptoms of UTI early, follow up is necessary for 6 months - 1 year, avoid sitting for long periods of time.

Prostatitis

Hypertrophy or enlargement of the prostate gland

- Patho not well understood

- Occurs >40, 90% of men over 85 will be affected.

Symptoms - urinary frequency, urgency, nocturia, hesitancy, incomplete bladder emptying, dribbling, urinary retention (could cause bursting bladder), recurrent UTIs.

- Generalized symptoms - fatigue, nausea, anorexia, pelvic discomfort

- Complications - kidney failure

Medical management - catheterization for inability to void

- Tamsulosin (alpha adrenergic blockers: to relax to help urine flow), finasteride (5 alpha reductase inhibitor to decrease size of prostate)

- Surgery

Benign Prostatic Hyperplasia (BPH)

an infection of the epididymis, which usually spreads from an infected urethra, bladder, or prostate

Symptoms - develops slowly over 1-2 days - low grade fever, chills, heaviness, swelling, and pain in affected testicle, pain in lower abdomen and pelvic, urethral discharge, blood in semen, pain with sex and ejaculation.

Diagnosis - urinalysis, cbc, urethral culture, STI screening, rule out testicular torsion

Treatment - antibiotics, local anesthetic, reduced physical activity, ice packs, nsaids, sitz baths, scrotal elevation, avoidance of sexual stimulation.

Epididymitis

rotation of the testis, which twists the blood vessels in the spermatic cord and therefore impedes the arterial and venous supply to the testicle and surrounding structures in the scrotum

Symptoms - sudden pain in the testicle, nausea, lightheadedness, swelling of the scrotum, an elevated testis, and a thickened spermatic cord.

Diagnosis - physical exam and ultrasound

Treatment - emergency surgery within 6 hours of symptom onset

E M E R G E N C Y

testicular torsion

Rare, occurs between 15 and 35 years old, high survival rate

Risk factors - undescended testicles, family history, personal history, Caucasian, HIV-positive

Symptoms - gradual symptom onset, painless mass, lump, or enlargement, heaviness in scrotum or lower abdomen, backache, abdominal pain, weight loss, general weakness.

Screening - testicular self exam monthly starting in adolescence. Annual exam by clinician.

Diagnosis - exam, u/s, tumor markers, biopsy to confirm.

Treatment - orchiectomy, sperm banking, radiation, chemo

Testicular Cancer

A collection of fluid located between the visceral and parietal layers of the tunica vaginalis of the testis. This condition is the most common cause of scrotal swelling

Physical examination, an easily transilluminated (penlight --> illuminate --> hydrocele), painless, extra testicular mass is found

- Ultrasonography is recommended for large hydroceles to differentiate them from testicular tumors (Chapple et al., 2020).

Treatment - none unless large, then needle aspiration

Hydrocele

is an abnormal dilation of the pampiniform venous plexus and the internal spermatic vein in the scrotum (the network of veins from the testis and the epididymis, which constitute part of the spermatic cord).

Symptoms - usually asymptomatic, but scrotal pain, tenderness, heaviness, and infertility are possible

- Feels like worms in scrotum

Treatment - scrotal support, surgery

Varicocele

most common procedure on women

Surgical removal of the uterus to treat cancer, dysfunctional uterine bleeding, endometriosis, nonmalignant growths, persistent pain, pelvic relaxation and prolapse, and previous injury to the uterus

Total hysterectomy (uterus, cervix) - (laparoscopic/vaginal)

Radical hysterectomy (only for cancer, uterus, vagina, ovaries, fallopian tubes, lymph nodes, tissue) - (most invasive - not laparoscopic)

Types of approaches

- Laparoscopic

- Vaginal

- Abdominal (open) - risk for infection

Hysterectomy **

stop anticoagulants (when is the last time you took it? hysterectomies have a high risk of hemorrhage, any NSAIDS (aspirin, ibuprofen, naproxen))

pregnancy test (all females need one before surgery but especially for hysterectomy)

prophylactic antibiotics (nurse will pull the meds but most likely wont give them, that is someone elses job)

VTE risk assessed (blood clot risk)

pre operative management (hysterectomy)

1. prevent and monitor for hemorrhage

- perineal pads, check incisions, monitor vital signs, CBC

2. prevent and monitor for infection

- CBC, temp, check incisions, administer antibiotics

3. prevent and monitor for DVT

- ted hose, ambulation, SCD

4. assess and treat bladder dysfunction

- foley care, bladder scans, in and out cath

(if there is not pee after 4-6hrs be concerned)

5. pain: prior to ambulation, PO prior to discharge, give pain meds before ambulation

post op management (hysterectomy)