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Kyphosis (Greek – kyphos, a hump), in general terms, is a curvature of the upper spine.

It can be either the result of bad posture or a structural anomaly

in the spine. In the sense of a deformity, it is the pathological curving of the spine, where parts of the spinal column lose some or all of their lordotic
profile. This causes a bowing of the back, seen as a slouching posture. Symptoms of kyphosis, that may be present or not, depending on the type and
extent of the deformity, include mild back pain, fatigue, appearance of round back and breathing difficulties. Severe cases can cause great
discomfort and even lead to death.


SUBJECTIVE: “Nanghihina ako, pakiramdam ko hindi ko kayang gumalaw”
(I feel weak, I can’t move)
as verbalized by the patient.
Muscle atrophy.
V/S taken as follows: T: 37.1 P: 89 R: 20 BP: 110/90
Impaired physical mobility related to neuro-mascular impairment.
(Greek -
, a hump), in general terms,
is a curvature of
the upper spine. It can be either the result of bad posture or a structural anomaly in the spine. In the sense of a deformity, it is the pathological curving
of the spine, where parts of the spinal column lose some or all of their lordotic profile. This causes a bowing of the back, seen as a slouching posture.
Symptoms of kyphosis, that may be present or not, depending on the type and extent of the deformity,
After 8 hours of nursing interventions, the patient will demonstrate techniques or behaviors that enable resumption of activity.
Continually assess motor function by requesting patient to perform certain actions like shrugging shoulders, spreading fingers.
Assist with full range of motion exercises in all extremities and joints using slow, smooth movements.
Position arms at 90-degree angle at regular intervals.
Elevate lower extremities at intervals when in chair or raise foot or bed when permitted in individual situation.
Plan activities to provide uninterrupted rest periods. Encourage
involvement within
individual tolerance or ability. Encourage use of relaxation techniques.
Inspect skin daily. Observe for pressure areas and provide meticulous care.
Consult with physical therapist.
Evaluates status of individual situation, affecting type and choice of interventions.
Enhances circulation, restores muscle tone and joint mobility.
Prevents frozen shoulder contractures.
Loss of vascular tone and muscle action results in pooling of blood and venous stasis in the lower abdomen and lower extremities, with increased risk of
hypotension and thrombus formation.
Prevents fatigue, allowing opportunity for maximal efforts or participation by the patient.
Reduces muscle tension, may limit pain of muscle spasm.
Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation.
Helpful in planning and implementing individualized exercise program and identifying assistive devices to maintain function, enhance mobility and
After 8 hours of nursing interventions, the patient was able to demonstrate techniques or behaviors that enable resumption of activity. include mild back
pain, fatigue, appearance of round back and breathing difficulties. Severe cases can cause great discomfort and even lead to death.

Clavicle Fracture (Broken Collarbone)
A clavicle fracture is a break in the clavicle bone (also called the collarbone). It connects the sternum (breastplate) to the shoulder.
Are common childhood fractures, that also affects adult patients as well.
Can result in neonates from birth trauma, and generally sustained in later age from sporting injuries, falls and violence.
The clavicles superficial location, its thin midshaft, and the forces transmitted across it makes the clavicle a common site of
The doctor will ask about your symptoms, physical activity, and how the injury occurred, and will examine the injured area.
Tests may include:
X-rays —a test that uses radiation to take a picture of structures inside the body, especially bones to look for a break
 Arthrogram--Diagnostic record that can be seen on an x ray after injection of a contrast fluid into the shoulder joint to outline
structures such as the rotator cuff. In disease or injury, this contrast fluid may either leak into an area where it does not belong,
indicating a tear or opening, or be blocked from entering an area where there normally is an opening.
 MRI (magnetic resonance imaging)--A non-invasive procedure in which a machine produces a series of cross-sectional images of the
 Other diagnostic tests, such as injection of an anesthetic into and around the shoulder joint
Case study:

• 16 year old boy arrives at triage holding his left arm adducted close to his chest and supporting it with his right hand.
• He sustained an injury to his left shoulder during a ‘wrestling’ encounter with his older brother
• On examination he was moderately distressed with a pain score 5/10. Palpation revealed pain over clavicular region, and
limited range of movement for the left shoulder, in particular he was unable to actively abduct his left arm.
• He was given oral analgesia and sent for X-ray…
• Assessment of Clavicle Fractures:

 Patients generally present with pain and swelling over the area and report a history of trauma or fall onto the area.
 Children not presenting with a history of trauma should be evaluated for malignancy, rickets, and non-accidental injury.
 Severe displacement can cause tenting of the skin and ecchymosis.
 Assess for tenderness, crepitus, oedema, deformity, and decreased pulse and perfusion distal from the injury.
 An anteroposterior X-ray of the shoulder usually shows the fracture clearly.
 Occasionally, special views will be required to delineate medial clavicle injuries.
 Chest X-ray is indicated if pneumothorax is suspect
 Look for associated local injuries such as gleno-humeral dislocation, scapula and rib fractures and potential intrathoracic injury such

• Pneumothorax
• Subclavian artery and vein injury
• Internal jugular vein injury
• Axillary artery injury
• Management of clavicle fractures

• Support the weight of the arm in a triangular sling, and give an analgesic such as paracetamol/codeine preparations, or NSAIDs.
• The traditional figure-of-eight bandage has generally been abandoned, as it is uncomfortable and difficult to keep tight.
• Refer the patient to the next Fracture clinic, for follow up X-rays and further management.
• Displaced or communited fractures, and fractures with more than 15 to 20mm clavicle shortening, should be referred
immediately to the orthopaedic surgeon, for operative management to prevent nonunion.
• Planning
• Keeping the pieces together while the bone heals itself
• Putting the pieces of the bone back in position, which may sometimes require anesthesia and more rarely surgery
• Exercises-When your doctor decides you are ready, start shoulder range-of-motion and strengthening exercises. You may be
referred to a physical therapist to assist you with these exercises. Do not return to sports activity until your clavicle is fully
• Build strong muscles to prevent falls and to stay active and agile.
• Do not put yourself at risk for trauma to the clavicle bone.
• Eat a diet rich in calcium and vitamin D.
Medical history and physical

• Medical history (the patient tells the doctor about an injury or other condition that might be causing the pain).

• Physical examination to feel for injury and discover the limits of movement, location of pain, and extent of joint instability.
• Intervention:A shoulder separation is usually treated conservatively by rest and wearing a sling. Soon after injury, an ice bag
may be applied to relieve pain and swelling. After a period of rest, a therapist helps the patient perform exercises that put the
shoulder through its range of motion. Most shoulder separations heal within 2 or 3 months without further intervention.
However, if ligaments are severely torn, surgical repair may be required to hold the clavicle in place. A doctor may wait to see
if conservative treatment works before deciding whether surgery is required

Generic -Ibuprofen

(200mg/5ml) Adverse effect- Hct, bone marrow - Check I&O ratio

4ml q6h for CNS:Hea dache, depression - Assess
T>/= 39oC hepatotoxicity
dizziness, Respiratory: - Assess for
Action-Inhibits somnolence,
prostaglandin insomnia,fatigue, Dyspnea, allergic
synthesis by hemoptysis, reactions, visual
decreasing tiredness, dizziness, pharyngitis, changes and
enzyme needed tinnitus, ototoxicity
for biosynthesis; ophthalmologic
analgesic, anti- bronchospasm,
effects rhinitis - Identify prior
inflammatory, drug history
antipyretic Other:Pe r iphe r al
CV:Hypertensio n, edema, - Identify fever:
palpitations, anaphylactoid
Indications-Relief of arrhythmia reactions to length of time in
signs and Dermatologic: Fever reduction evidence and
symptoms of Rash,prurit us, - Assess pain related
rheumatoid - Assess symptoms
arthritis and
osteoarthritis sweating, dry
-Relief of mild to mucous membranes, musculoskeletal
moderate pain stomatitis status: ROM
-Treatment of primary before dose and
dysmenorrhea GI:Nausea, 1 hr after.
-Fever reduction dyspepsia, GI pain,
-Unlabeled uses: diarrhea, vomiting, ActionFever
Prophylactic for constipation, reduction
migraine; flatulence,GI
abortive treatment for bleeding Nursing
migraine GU: Dysuria, renal management
Contraindications impairment,
-Contraindicated with menorrhagia
allergy to ibuprofen, Hematologic: - Monitor liver
salicylates, or other function studies
NSAIDs (more - Monitor renal
Bleeding, platelet function studies
common in inhibition with higher
patients with rhinitis, - Monitor blood
doses, neutropenia,
asthma, chronic eosinophilia,
urticaria, leukopenia, studies: CBC,
nasal polyps). pancytopenia, Hgb, Hct,
aplastic anemia, protime if patient
decreased Hgb or is on long-term
Generic Name: naproxen (na PROX en)
Brand names: Aleve

Action:nonsteroidal anti-inflammatory drugs (NSAIDs). It works by reducing hormones that cause

inflammation and pain in the body.Naproxen is used to treat pain or inflammation caused by conditions
such as arthritis, ankylosing spondylitis, tendinitis, bursitis, gout, or menstrual cramps.Naproxen may also
be used for other purposes not listed in this medication guide.
Side effects:

• chest pain, weakness, shortness of breath, slurred speech, problems with vision or balance;
• black, bloody, or tarry stools;
• coughing up blood or vomit that looks like coffee grounds;
• swelling or rapid weight gain;
• urinating less than usual or not at all;
• nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes);
• fever, sore throat, and headache with a severe blistering, peeling, and red skin rash;
• bruising, severe tingling, numbness, pain, muscle weakness; or
• fever, headache, neck stiffness, chills, increased sensitivity to light, purple spots on the skin, and/or seizure (convulsions).

Nursing management: Do not share this medication with others. Laboratory and/or medical tests may be performed periodically to monitor
your progress or check for side effects. Consult your doctor for more details.

Indication: effective as other non-steroidal anti-inflammatory agents (e.g. diclofenac, piroxicam). Its symptomatic action is
particularly suited for rheumatic ailments. Its effects on arthroses and chronic polyarthritis have been examined most thoroughly.
Subjects with ankylosing spondylitis (Bechterew's disease), juvenile arthritis, gout seizures or soft tissue rheumatism can also be
treated with naproxen. Naproxen's relatively long duration of action is therefore often considered an advantage.

Benign bone tumor-A bone tumor refers to a neoplastic growth of tissue in bone. Abnormal growths found in the bone can be either benign
(noncancerous) or malignant (cancerous).

Medication-One of the major concerns is bone density and bone loss. Non-hormonal bisphosphonates increase bone
strength and are available as once-a-week prescription pills. Metastron also known as strontium-89 chloride is an
intravenous medication given to help with the pain and can be given in three month intervals.

Surgical treatment

• Amputation-Treatment for some bone cancers may involve surgery, such as limb amputation, or limb sparing surgery (often in
combination with chemotherapy and radiation therapy). Limb sparing surgery, or limb salvage surgery, means the limb is spared from
amputation. Instead of amputation the affected bone is removed and is done in two ways (a) bone graft, in which a bone from
elsewhere from the body is taken or (b) artificial bone is put in. In upper leg surgeries, limb salvage prostheses are available.

Risk Factors for Bone Cancer

Age: Bone cancers are more common in children and young adults when bones grow rapidly.
Hereditary medical disorders: A very small number of bone cancer cases appear to have a hereditary cause. For example, children that suffer
from hereditary retinoblastoma (a rare form of eye cancer) and Rothmund-Thompson syndrome (a medical disorder where children are short
and suffer from skeletal problems and rashes), or adults with Li-Fraumeni syndrome (a hereditary disorder caused by a mutation of the p53
tumor suppressor gene) and multiple exostoses (a hereditary disorder characterized by bone bumps, deformities and fractures) are at higher risk
to develop bone cancer, especially osteosarcomas.
Non-hereditary medical disorders: Adults that suffer from Paget's Disease [a bone disorder, common in middle-age adults and elderly,
characterized by an abnormal development of new bone cells and excessive bone destruction and disorganized bone structure, leading to
heavier and thicker bones, frequent fractures and skeletal deformities] and osteochondroma (benign tumors of the bone and cartilage) are at
higher risk for developing osteosarcomas.
Previous medical procedures and treatments:
Bone marrow transplantation: In some cases, patients that had bone marrow (stem cell) transplantation developed osteosarcomas.
Radiotherapy and chemotherapy: Patients that had radiotherapy and chemotherapy for other forms of cancer have a higher risk for
developing bone cancer. The risk for bone cancer increases when the patient was exposed to high doses of radiation therapy at younger ages.
Exposure to radioactive materials: Radium and strontium are two radioactive materials which increase the risk for
bone cancer because during the exposure, these minerals can build up in the bones and lead to cancerous cells to
Nsg management-different pain management techniques, therapeutic approaches can be classified in two ways: pharmacological and non-
pharmacological. Pharmacological pain control involves the use of analgesics (pain medications), as well as other medications that intensify the
analgesics' effects or modify your mood or pain perception. The following are some non-pharmacological approaches to pain management:

• Behavioral techniques
• Emotional counseling and support
• Radiation
• Surgery
• Neurological and neurosurgical interventions
• Traditional nursing and psychosocial interventions

Pain Assessment

An accurate assessment of your pain experience helps your CTCA care team determine which pain management techniques will be best suited
to your needs. To make an assessment, the pain management team may examine any of the following dimensions of your pain:

• Location
• Intensity
• Factors influencing its occurrence (i.e., what makes it better or worse)
• Observed behaviors during pain
• Psychosocial variables (e.g., attitudes, situational factors)
• Effects of therapy and patterns of coping

Diagnostic procedure-The indications of surgical treatment of benign bone tumours are strongly related to the clinical behaviour, the patient's
complaints and the activity in Tc-bone scan. Some lesions--like the nonossifying fibroma--that can safely be diagnosed by conventional x-rays
may not be treated surgically--as long as the patients are free of pain, and there is no risk of pathologic fracture. In case of clinically relevant
lesions, activity in Tc-bone scan, or a risk of fracture, biopsy and curettage combined with autologous or homologous bone grafting is
indicated. Some aggressive tumors, like the giant cell tumor, have to be treated more aggressively by curettage with adjuvant measures
(Phenole) or by marginal excision.
Clinical manifestations that are suspicious for locally advanced malignant disease are nipple retraction or elevation; skin dimpling or
retraction; heat and erythema of the breast skin; and skin edema or peau d'orange ("skin of the orange"), which is characteristic of malignant
Pathophysiology of Bone Metastases
Left In osteolytic bone disease, (1) metastatic tumor cells release humoral factors that stimulate osteoclastic recruitment and
differentiation. (2) Osteoclasts begin to break down bone. (3) Bone resorption results in the release of growth factors that
stimulate tumor cell growth. (4) As the tumor proliferates, it produces substances that increase osteoclast-mediated bone
Right In osteoblastic bone disease, (1) metastatic tumor cells release growth factors that stimulate the activity of
osteoclasts. (2) Tumor cells also secrete growth factors that stimulate the activity of osteoblasts. (3) Excessive
new bone formation occurs around tumor-cell deposits. (4) Osteoclastic activity releases growth factors that
stimulate tumor cell growth. (5) Osteoblastic activation releases unidentified osteoblastic growth factors that also
stimulate tumor cell growth.
physical assessment and examination
The focus of the assessment should be on gathering data that differentiate bone cancer from arthritic or traumatic pain. The patient usually
reports the gradual onset of pain described as a dull ache. The patient often notices a swelling or the inability to move a joint as before. A
distinctive trait of bone cancer pain is its tendency to be worse at night. Generally, it is a localized, aching pain, but it may also be referred
from the hip or spine. The sudden onset of pain does not rule out bone cancer, however, because a pathological fracture may be present. If the
cancer has spread, the patient may report weight loss and fatigue.
diagnosis: Impaired physical mobility related to weakness, loss of limb, or pain.
intervention and treatment
Radiation has variable effectiveness in bone cancer. It is quite effective with Ewing’s sarcoma, moderately effective
with osteosarcoma, and relatively ineffective in chondrosarcoma. Even when a cure is not possible, radiation is often
used to decrease pain and slow the disease process. External beam radiation therapy, where the radiation is delivered
from outside of the body, is the type most often used to treat bone cancer.
health care guidelines
Teach the patient how to promote healing at the surgical site by keeping the incision clean, dry, and covered. Explain
that the stump needs to be wrapped to promote shrinkage and proper shaping for the prosthesis. Teach exercises to
maintain strength and range of motion and to prevent contractures. Explain the roles of the interdisciplinary team
members in the patient’s rehabilitation. If the patient receives outpatient chemotherapy or radiation, teach the patient
the purpose, duration, and potential complications of those treatments.
• Metastatic Bone Disease
Cancer that arises in an organ, such as the lungs, breast, prostate, kidneys, thyroid, and others, and subsequently
spreads to bone is termed metastatic bone disease (MBD). More than 1.2 million new cancer cases are diagnosed each
year, and approximately 50 percent of these tumors can spread or metastasize to the skeleton.
Medical Treatment
Medical treatment options for patients with skeletal metastases include chemotherapy, endocrine therapy, bone-specific
therapy, or a combination of treatments. Conventional chemotherapy has been effective in select cancer types such as
lymphoma, small cell carcinoma, breast cancer, and germ cell tumors.

Surgical TreatmentSurgery should be considered when an area of the skeleton is so involved that a break is highly
likely or has already occurred. Important factors must be carefully assessed by the orthopaedic surgeon to determine
whether a site of metastatic bone disease is at significant risk of breaking; for example, the way the area of involvement
appears on the radiographs and how the patient feels.

Pathophysiology-The venous blood systems of the body, that part of the circulation responsible for returning the blood
to the heart, includes a complex network that he guessed might account for the distribution of metastatic spread of
cancer. The most common sites of metastasis for all cancers (not just those that also go to bone) are the lung and liver,
where the venous system is quite prominent. The venous system around the spine described by Oscar Batson, MD, is
proposed to explain why prostate cancer cells distribute preferentially to the pelvis and spine. This plexus involves a
long set of veins that parallel the spinal column and allow back flow to bypass the more central system. Seventy-five
years later, these two theories may not be mutually exclusive. The blood flow may help dictate the course of tumor cell
travel, but inherent properties of the tumor cells and site of spread environment may facilitate growth.



Human bones have two components that give themselves strength: collagenous proteins and mineralization with calcium and phosphorous.
These materials are deposited by bone cells called osteoblasts, which are balanced by bone cells called osteoclasts that break down portions of
bone. Decreases in bone density occur when there is imbalance towards osteoclastic activity. A variety of factors can increase the risk of
osteoporosis, including but not limited to estrogen deficiency following menopause, immobility, vitamin D deficiency, hyperparathyroidism,
alcohol use, and smoking.
ASSESSMENT-The nurse practitioner notes that Mrs. Bauer’s vital signs are all
within normal limits. She has full range of motion of all extremities
and is able to stand and bend over, but she reports discomfort
when returning to the upright position. Mrs. Bauer has a slightly
pronounced “hump” on her upper back and is 1 inch shorter than
her stated height on admission.Her muscle strength is symmetric
and strong.
• Acute pain of the lower spine, related to vertebral compression
• Deficient knowledge, related to osteoporosis and treatment to
prevent further damage
• Imbalanced nutrition: Less than body requirements, related to inadequate
intake of calcium
• Risk for injury, related to effects of change in bone structure
secondary to osteoporosis
• Verbalize a decrease in back pain.
• Be able to describe ways to treat her osteoporosis and prevent
further complications.
• Verbalize an understanding of the current research and treatment
regarding osteoporosis.
• Verbalize how stopping smoking can help
prevent further progression of osteoporosis.
• Seek consultation for supplements and medications to prevent
further bone loss.
• Design a program of physical activity to prevent complications
of osteoporosis.
• Verbalize safety precautions to prevent fractures due to falls.
• Teach back strengthening exercises.
• Refer to an osteoporosis support group, if available.
• Provide realistic, yet optimistic, feedback about loss of height
and bone integrity and the potential outcomes of treatment.
• Assess current knowledge base, and correct misconceptions
regarding treatment of osteoporosis.
• Provide current educational literature regarding treatment of
• Instruct in dietary and calcium supplements that help prevent
effects of osteoporosis.
• Discuss physical exercises that help prevent complications due
to osteoporosis.
• Review safety and fall precautions, and provide literature regarding
how to create a safe home environment.
On her return visit 6 months later,Mrs. Bauer reports that she feels
much better. She is no longer irritable and does not experience
mood swings, because she has been taking her prescribed hormone
replacements for 6 months. She is eating products rich in
calcium and taking a daily supplement of calcium with vitamin D.
Mrs.Bauer has reduced her wine intake to one glass in the evening
and now drinks decaffeinated coffee and tea. She also states that
since she stopped smoking, she has been walking 30 to 45 minutes
every day.