POC AFFILIATION

LEVEL -IV
COMPILATION
2
3
4
5
PRESENTATIONS
fracture
• A fracture is a break in the continuity of bone and is defined
according to its type and extent.
• Fracture is abreak in any bone in the body.
fracture
• A fracture is a break in the
continuity of bone and is
defined according to its type
and extent.

• Fracture is a break in any

bone in the body.
Causes
of
fracture
• Direct blows

• Crushing forces
• Sudden twisting motions • Extreme muscle contractions
Types of fractures
• Closed fractrure • Open fracture
Classification according to the anatomical
placement
Greenstick fracture
• A fracture in which one side of
a bone is broken while the
other is bent (like a green
stick)
Spiral fracture
• A fracture, sometimes called
torsion fracture in which a
bone has been twisted apart
Comminuted fracture
• A fracture in which bone is
broken, splintered or crushed
into a number of pieces
Transverse fracture
• A fracture in which the break
is across the bone, at a right
angle to the long axis of the
bone
Compound fracture
• A fracture in which the bone is
sticking through the skin. Also
called an open fracture
Compression fracture
• A fracture caused by
compression, the act of
pressing together.
Compression fractures of the
vertebrae are especially
common with osteoporosis
Other fracture
• Avulsion • Depressed
> Fracture which occurs when a > A fracture in which fragments
fragment of bone tears away are driven inward (seen
from the main mass of bone frequently in fractures of skull
and facial bones)
Other fracture
• Epiphyseal • Pathologic
> A fracture through the It occurs through an area of
epiphysis diseased bone (eg,
osteoporosis, bone cyst, bony
metastasis, tumor);
Can occur without trauma or
fall
Other fracture
• Stress
> A fracture that results from
repeated loading without bone
and muscle recovery
pathophysiology
Due to any etiology (crushing movement)

Fracture occurs, muscle that were attached

to bone are disrupted and cause spasm

Proximal portion of bone remains in place, the distal portion can

become displaced in response to both causative force and spasm in
the associated muscles

In addition, the periosteum and blood

vessels in the cortex and marrow are
disrupted

Soft tissue damage occurs, leads to

bleeding and formation of hematoma
between the fracture fragment and
beneath the periosteum
Bone tissue surrounding the fracture site
dies, creating an intense inflammatory
response

Release of chemical mediators (histamins,

prostaglandins)

Resulting in vasodilation, edema, pain, loss of function, leukocytes,

and infiltration of WBC
Clinical manifestations
• Pain
• Loss of function
• Deformity
• Shortening
• Crepitus
• Swelling and discoloration
manageme
nt
MEDICAL /SURGICAL MANAGEMENT OF
FRACTURES:
• Reduction
Reduction of a fracture (“setting” the bone) refers to restoration
of the fracture fragments to anatomic alignment and rotation.
Open reduction
It’s a surgical approach, the fracture fragments are reduced.
External/Internal fixation devices (metallic pins, wires, screws,
plates, nails, or rods) may be used to hold the bone fragments
in position until solid bone healing occurs
MEDICAL /SURGICAL MANAGEMENT OF
FRACTURES:
• Internal fixation
MEDICAL /SURGICAL MANAGEMENT OF
FRACTURES:
• External fixation
Closed reduction
• closed reduction is accomplished by bringing the bone
fragments into apposition (ie, placing the ends in contact)
through manipulation and manual traction.
• Extremity is held in the desired position while the physician
applies a cast, splint, or other device.
• X - rays are obtained to verify that the bone fragments are
correctly aligned.
• Traction (skin or skeletal) may be used to effect fracture
reduction and immobilization.
immobilization
• Immobilization may be accomplished by external or internal
fixation.
• Methods of external fixation include bandages, casts, splints,
continuous traction, and external fixators.
• Metal implants used for internal fixation serve as internal splints
to immobilize the fracture
traction
• Traction is the use of weights, ropes and pulleys to apply force
to tissues surrounding a broken bone.
traction
• Skin traction
-Bucks traction used for knee,hip bone fracture
Weight usually 5-7 pounds attach to skin
Skeletal traction
Needs invasive procedure
Weight is upto 10 kg attached to bone
SPLINTING
• Splinting is the most common procedure for immobilizing an
injury.

WHY DO WE SPLINT?
To stabilize the extremity
To decrease pain
Actually treat the injury
Possible items for splinting
• Soft materials. Towels, blankets, or pillows, tied with bandaging
materials or soft cloths.
• Rigid materials. A board, metal strip, folded magazine or
newspaper, or other rigid item.
Soft splints
• Splinting Using a Towel
• Splinting using a towel, in which the towel is rolled up and
wrapped around the limb, then tied in place.
Guidelines for splinting
1. Support the injured area.
2. Splint injury in the position that you find it.
3. Don’t try to realign bones.
4. Check for color, warmth, and sensation.
5. Immobilize above and below the injury.
Maintaining and restoring function
• Restlessness, anxiety, and discomfort are controlled with a
variety of approaches, such as reassurance, position changes,
and pain relief strategies, including use of analgesics.
• exercises are encouraged to minimize disuse atrophy and to
promote circulation.
• Participation in activities of daily living (ADLs) is encouraged to
promote independent functioning and self-esteem.
Treating an Open Fracture
• Do not draw exposed bones back into tissue.
Treating an Open Fracture
DO:
• Cover wound.
• Splint fracture without disturbing wound.
• Place a moist 4" x 4" dressing over bone end to prevent drying.
• Assist the surgeon in debridement of wound
Complication of fracture
• Early complications
• Shock
• fat embolism
• compartment syndrome
• deep vein thrombosis
• disseminated intravascular coagulopathy
• infection
• Delayed complications
• delayed union and nonunion
• avascular necrosis of bone
• reaction to internal fixation devices
Compartment syndrome
• develops when tissue perfusion in the muscles is less than that
required for tissue viability.
• patient complains of deep, severe pain, which is not controlled
by opioids.
• Reduction in size of muscle compartment
• It increase pressure in the muscle compartment
• Reduce microcircualtion,leads to muscle and nerve anoxia and
necrosis
Fat embolism syndrome
• occurs most frequently in young adults
• fat globules may move into the blood because the marrow
pressure is greater than the capillary pressure
• usually occurring within 24 to 72 hours
NURSING MANAGEMENT
• Patients with closed fractures
• Encourage patient not to mobilize fracture site. • exercises to
maintain the health of unaffected muscles for using assistive
devices (eg, crutches, walker).
• teach patients how to use assistive devices safely. • Patient
teaching includes self-care, medication information, monitoring
for potential complications, and the need for continuing health
care supervision.
• Patients with open fractures
• administers tetanus prophylaxis if indicated. • wound irrigation
and debridement in the operating room are necessary. •
Intravenous antibiotics are prescribed to prevent or treat
infection. • wound is cultured.
• fracture is carefully reduced and stabilized by external fixation or
intramedullary nails. • Any damage to blood vessels, soft tissue,
muscles, nerves, and tendons is treated. • Heavily contaminated
wounds are left unsutured and dressed with sterile gauze to
permit swelling and wound drainage.
Care of client with cast
• Before application of a cast preparation of the client includes:
• Detailed explanation of the procedure
• Skin preparation involves through cleansing of the skin
• Presence of unremovable particle or dust should be reported to
the physician
• Roll the cast material are individually submerged in clean water
and excess water is squeezed from the roll ,apply bandage is
applied to encircle the injured the body parts
• As the water evaporates the cast will dry
• plaster cast generates while drying so instruct patient for heat
sensation
• Do not cover the cast
• Windowing or bivalving a cast means cutting a cast along both
sides then splitting it to decrease pressure on underlying tissue.
• Window may also be cut into cast to allow the physician or
nurse to visualize wounds under the cast or removes drains.
• Neurovascular assessment:
• It should be performed every 30 minutes for 4 hours.
• Assess the cast extremity for color, warmth, pulse distal to the
cast, capillary refill.
• Movement of the distal fingers or toes, awareness of light touch
distal to the cast, change in the sensation.
• Assessment of the pain: Assess the degree of pain
• Assessment of the cast: The skin around the cast edges should
be observed for damage or swelling.
• “Hot spots” areas of the cast that feel warmer than other section
may indicate tissue necrosis or infection under the cast.
• “Wet spots” may indicate drainage under the cast
Care of external fixation
• Assessment-
• pain, nerve supply,infection,pin site etc.
• Small bleeding from pin site is normal
• Critical, If extend more than 24 hours
• Administer antibiotics, analgesic medication
Care of traction
• Assessment
skin breakdown, pain, neurovascular ,constipation
Stool softner
Plenty of fluids
Provide bedpan and urinals for elimination
Encourage clients activity
Nursing
diagnosis
• Acute pain related breakdown of continuity of the bone as
evidenced by facial expressions and verbalization of patient.
• Goals: Patient will not feel pain
• Intervention:
Assess the onset, duration, location, severity and intensity of
pain.
Administer the analgesic according to physician order. •
Provide comfort devices like sand bags for immobilization of
affected parts.
Provide diversion therapy
• Impaired physical mobility related to application of traction or
cast as evidenced by assessment
• Goal: Patient will able to move unaffected area.
Intervention:
Provide range of motion exercises to the patient.
Assist the patient in ambulation after recovery of fracture.
Provide assistance while using walker or crutches if required.
Prevent from complication which usually occurs due to
immobility.
• Self care deficit related to fracture as evidenced by poor
personal hygiene.
• Goal: Patient will maintain the personal hygiene
Intervention:
 Assess the need of self care
 Encourage the patient or relatives to do self care activity
 Head to foot care to be provided to the patient.
 Educate about importance of maintaining personal hygiene.
BUERGER’S
DISEASE
By: hsu, Hsin-Tan T.
 What is buerger’s disease? 61

Buerger's disease is a rare

disease of the arteries and veins
in the arms and legs. Buerger's
disease also called
thromboangiitis obliterans.

This eventually damage or

destroys skin tissues and may
lead to infection and gangrene.

Virtually everyone diagnosed with

Buerger's disease smokes
cigarettes or uses other forms of
tobacco, such as chewing
tobacco.
 What are the symptoms? 62

➜ pale, red, or blue-tinted hands and feet.

➜ cold hands or feet.
➜ severe pain in hands and feet.
➜ pain in the lower arms and legs while at rest due to limited
blood supply.
➜ pain when walking in the legs, ankles, or feet
➜ sores or ulcers on the hands and feet that are often painful.
➜ lack of blood flow to fingers and toes in cold weather
➜ very rarely, if abdominal (mesenteric) arteries and veins are
affected, extreme heaviness and pain in the abdomen, as well
as possibly weight loss.
 63

What causes buerger’s disease?

➜ The exact cause of Buerger's disease is unknown.

While tobacco use clearly plays a role in the
development of Buerger's disease.
 What are the Risk factors?

• Tobacco use
• Gingivitis (Chronic gum disease)
• Gender
• Age (20-40 yrs old)
 65

Pathophysiology

Smoke- carbon monoxide and nicotinic acid

Vasospasm & hyperplasia of intima

Thrombosis of vessels

Oblitration of vessels

Panarteritis segmental
 66

Diagnostic test
➜ Blood tests -to look for certain substances can rule out other
conditions that may cause similar signs and symptoms.
➜ Allen’s test - will show how quickly the circulation in our hand
returns our skin to its normal color. This will give insight into the
health of our arteries, as slow blood flow may indicate Buerger’s
disease.
➜ Angiogram - helps to see the condition of our arteries.
 Treatment for buerger’s disease 67

➜ Medications helps to
dilate blood vessels,
➜ no treatment can cure
improve blood flow or
Buerger's disease, the dissolve blood clots (anti-
most effective way to inflammatories and blood
stop the disease from thinners)
getting worse is to quit
using all tobacco
products
 Nursing diagnosis
• Ineffective peripheral tissue perfusion
related to impaired circulation.
• Pain related to diminished oxygen flow to
the affected extremity.
• Fear and anxiety related to actual or
potential serious complications
 69

Medical/surgical management:

➜ Nerve surgery. Surgery to cut the nerves to the affected

area (surgical sympathectomy) to control pain and increase
blood flow, although this procedure is controversial and
long-term results haven't been well-studied
➜ Growing new blood vessels. Medications to stimulate
growth of new blood vessels (therapeutic angiogenesis), an
approach that is considered experimental
 70

➜ Bosentan (Tracleer). This medication has been

approved for treating high blood pressure in the lungs.
The drug improved blood flow in small studies of people
with Buerger's disease.
➜ Blood vessel procedure. A thin catheter threaded into
the blood vessels might open blood vessels, restoring
blood flow. Although this procedure — called
endovascular therapy — isn't widely used, it might be
effective.
 71

Nursing management
• Patient teaching, instruct the patient to do the following
several times a day:

• Lie flat on a bed with both legs elevated above the

level of the heart for two to three minutes.
• Next sit on the edge of the bed with the legs
dependent for three minutes
• Then exercise the feet and toes by moving them up,
down, inward, then outward.
• Lastly, return to the first position and hold for five
minutes.
 72

➜ Provide additional intervention to promote venous return

and healing, maximize comfort and provide client
education for measures to prevent venous stasis ulcer.
➜ Administer medications which may include antibiotics.
➜ The patient is encouraged to make the lifestyle changes
necessitated by the onset of a chronic disease, including
pain management and modifications in diet, activity, and
hygiene (skin care).
➜ The nurse assists the patient in developing and
implementing a plan to stop using tobacco.
 73

Lifestyle and home remedies

• Exercise
• Skin care
• Infection prevention
• Gum care
 74

Thank you!! 
CONGENITAL
CLUBFOOT

ELLA MAY B. TERBIO

DESCRIPTION
– CLUB FOOT REFERS TO A CONDITION IN WHICH A
NEWBORN’S FOOT OR FEET APPEAR TO BE ROTATED
INTERNALLY AT THE ANKLE
– THE FOOT POINTS DOWN AND INWARDS, AND THE
SOLES OF THE FEET FACE EACH OTHER
– ALSO KNOWN AS TALIPES EQUINOVARUS (TEV) OR
CONGENITAL TALIPES EQUINOVARUS (CTEV)
ETIOLOGY
– CLUBFOOT IS MAINLY IDIOPATHIC
RISK FACTOR
– GENDER: MALES ARE TWICE LIKELY AS FEMALES TO BE BORN
WITH CLUBFOOT
– FAMILY HISTORY: IF EITHER OF THE PARENTS OR THEIR OTHER
CHILDREN HAVE HAD CLUBFOOT, THE BABY IS MORE LIKELY
TO HAVE IT AS WELL
– CONGENITAL CONDITIONS: CLUBFOOT CAN BE ASSOCIATED
WITH OTHER ABNORMALITIES OF THE SKELETON THAT IS
CONGENITAL, SUCH AS SPINA BIFIDA AND HIP DYSPLASIA
RISK FACTOR
– ENVIRONMENT: SMOKING DURING PREGNANCY CAN
SIGNIFICANTLY INCREASE THE BABY’S RISK OF
CLUBFOOT
– NOT ENOUGH AMNIOTIC FLUID DURING PREGNANCY
MAY INCREASE THE RISK OF CLUBFOOT
PATHOPHYSIOLOGY
MUSCLE CONTRACTURES

ATROPHY

THICKENED TENDON SHEATS (ESPECIALLY TIBIALIS POSTERIOR – PERINEAL

TENDONS AND PLANTAR FASCIA)

SHORTENED TIBIA AND FIBULA

ASSESSMENT
FOUR COMPONENTS OF DEFORMITY OF CLUBFOOT:
CAVUS
ADDUCTION
VARUS
EQUINUS
ASSESSMENT
MIDFOOT CAVUS: LONGITUDINAL ARCH
FOREFOOT ADDUCTION: IN TARSOMETATARSAL
JUNCTION
TALIPES VARUS: INVERSION OR BENDING INWARD
TALIPES VALGUS: EVERSION OR BENDING OUTWARD
EQUINUS: FOOT FIXED IN PLANTAR FLEXION AT ANKLE
JOINT
NURSING DIAGNOSIS
1. DIRSTURBED BODY IMAGE RELATED TO PERMANENT ALTERATION IN
STRUCTURE/FUNCTION.
2. DEFICIENT KNOWLEDGE RELATED TO CONDITION/TREATMENT
3. RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION RELATED TO
MECHANICAL COMPRESSION (CAST OR BRACE)
4. RISK FOR IMPAIRED SKIN INTEGRITY RELATED TO CAST/SURGERY
5. RISK FOR IMPAIRED PARENTING RELATED TO MALADAPTIVE COPING
STRATEGIES
DIAGNOSTIC TEST
3D ULTRASOUND
DIAGNOSTIC TEST
RADIOGRAPH
HINDFOOT
VARUS
URES
A
NON-SURGICAL
MANAGEMENT
PONSETI METHOD
PONSETI METHOD
– AIM TO CORRECT THE BEND IN THE FOOT
– PLASTER CAST IS APPLIED FROM TOES TO THE THIGH, TO HOLD
THE FOOT IN POSITION
– ONE SESSION PER WEEK, PLASTER IS CHANGED
– 4-10 TIMES USING NEW CASTS EVRYTIME
MANIPULATION AND CASTING

– GENTLY STRETCH AND MANIPULATED INTO A CORRECTED

POSITION
– STRETCHING
– RE-POSITIONING
– CASTING
– APPROXIMATELY 6-8 WEEKS FOR SIGNS OF IMPROVEMENT
ACHILLES TENOTOMY
ACHILLES TENOTOMY
– APPROXIMATELY 90% OF BABIES WILL REQUIRE A MINOR
PROCEDURE TO RELEASE CONTINUED TIGHTNESS IN THE ACHILLES
TENDON (HEEL CORD)
– THE DOCTOR WILL USE A THIN INSTRUMENT TO CUT THE TENDON
– NEW CAST WILL BE APPLIED TO THE LEG TO PROTECT THE TENDON
AS IT HEALS
– 3 WEEKS FOR THE ACHILLES TENDON TO BE FULLY GROWN AND
CLUBFOOT TO BE FULLY CORRECTED
BRACING (DENIS BROWNE BAR)
BRACING
– TO ENSURE THE FOOT WILL PERMANENTLY STAY IN THE
CORRECT POSITION, THE BABY WILL WEAR A BRACE (BOOTS AND
BAR)
– BRACE KEEPS PROPER ANGLE TO MAINTAIN THE CORRECTION
– FIRST 3 MONTHS, THE BABY WEAR THE BRACE
– BRACING REGIMEN: 3-4 YEARS
 SURGICAL
MANAGEMENT
ANTERIOR TIBIAL TENDON
TRANSFER
– ACHILLES TENDON AT THE BACK OF THE ANKLE OR MOVING THE
TENDON THAT TRAVELS FROM THE FRONT OF THE ANKLE TO THE
INSIDE OF THE MIDFOOT
– JOINTS OF THE FOOT ARE USUALLY STABILIZED WITH PINS AND
LONG LEG CAST WHILE THE SOFT TISSUE HEALS
– AFTER 4-6 WEEKS, PINS AND CAST WILL BE REMOVED
– BRACES WILL BE USED AFTER FOR A YEAR
 NURSING
MANAGEMENT
NURSING MANAGEMENT
REMEMBER CMS FOR CAST CARE
CIRCULATION IN COLOR
MOVEMENT
SENSATION
NURSING MANAGEMENT
– APPLY GENTLE PRESSURE FOR CAST CARE
– ELEVATE EXTREMITY ON PILLOW ABOVE THE LEVEL OF THE HEART
– MONITOR ANY UNTOWARD SIGNS AND SYMPTOMS
– OBSERVE AND ASSESS THE PATIENT EVERY 15-30 MINUTES DURING
THE 24 HOURS
– KEEP THE CAST CLEAN AND DRY
– PARENTS/SO DEMONSTRATE HOW TO INCORPORATE TREATMENT
REGIMEN
Developmental dysplasia of the hip
(DDH) is a condition where the "ball
and socket" joint of the hip does not
properly form in babies and young
children.
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 108
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The Hip Joint

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Etiology:
- UNKNOWN

Epidemiology:
- is usually reported as approximately 1 case per
1000 individuals
- estimated 80% of persons with DDH are female
- approximately 20% rate of breech positioning in
children in DDH
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Risk Factors:
- Genetic
- Hormonal
- Intrauterine malposition
- First born child

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Pathophysiology:
- dislocated at birth or dislocation after birth
- femoral head is dislocated upward and laterally,
epiphysis is small and ossifies lste.
- femoral neck is excessively anteverted
- acetabulum shallow
- labrum may be folded into the activity
- capsule is stretched, hip muscles undergo adaptive
shortening
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 Clinical Manifestations:
-The leg may appear shorter on the side of the dislocated hip.
-The leg on the side of the dislocated hip may turn outward.
-The folds in the skin of the thigh or buttocks may appear
uneven.

“ -The space between the legs may look wider than normal.

”
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 Assessment Findings:
-Newborn physical examination
-Barlow’s test
-Ortalani test
-Klisics test
“ -Galeazzi’s test
”
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 Barlow’s test- the barlow
manuever identifies the unstable hip that is
in a reduced position that the clinician can
passively dislocate.

Ortalani’s test- perform following Barlow’s

“ test to determine if the hip
is actually dislocated
”
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 Galeazzi’s test- is performed with infant supine,
hips flexed to 45 and knees flexed to 90 with feet
flat on examining surface

Klisic’s test- is performed by placing the index

“ finger on the anterior superior iliac spine and the
middle finger on the greater trochanter.
”
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“
”
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“
”
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“
”
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“
”
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 Diagnostic Test:
-xrays
-ultrasound

“
”
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 Nursing Diagnosis:
- Impaired physical activity
- Impaired social interaction

“
”
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 Non surgical:
- Pavlik harness- a brace that holds the hip in
the correct position

“
”
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“
”
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“
”
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Surgical:
Reduction surgery is done under general anaesthetic
and may be done as either:

“
closed reduction – the femoral head is placed in the hip
socket without making any large cuts
open reduction – a cut is made in the groin to allow the
surgeon to place the femoral head into the hip socket
”
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OSTEOMYELITIS
By: Glowsy Cabral
Painless operation
Life after death
I’ll be there in a minute
0ne way or the other
 Description

- Is an infection of the bone

that results in
inflammation, necrosis, and
formation of new bone
 Classifications

 Hematogenous osteomyelitis
 Contiguous-focus osteomyelitis
 Osteomyelitis with vascular insufficiency
 Risk Factors

• Older adults
• Poorly nourished
• Obese
• Impaired immune system
• Those with chronic illnesses
• Those receiving long-term corticosteroid
therapy or immunosuppresive agents
• Those who use IV drugs
 Pathophysiology
Infection / traumatized tissue

Inflammation, increased vascularity, and edema

Ischemia with bone necrosis

Bone abscess formation

Sequestra formation

Involucrum surrounds the sequestrum

Chronic Osteomeyletis
Clinical Manifestations
 Bloodborne:
- Sudden
- Manifestation of sepsis: chills, high fever, rapid
pulse, general malaise
- Infected area may be painful, swollen,
extremely tender

 Spread of adjacent infection/direct

contamination:
- No manifestation of sepsis
- Area is swollen, warm, painful, and tender to
touch
 Clinical Manifestations

 Chronic osteomyelitis:
- presents with a nonhealing ulcer
- pus
 Diabetic ostemyelitis:
- can occur without any external
wound
An outside chance
Go for it
Highway overpass
 Assessment and Diagnostic Findings
Acute:

 Xray
- demonstrate soft tissue edema
 Radioisotope bone scan and MRI
- help with early definitive
diagnosis
 Blood studies
- Reveal an elevated ESR and
leukocytosis
 Assessment and Diagnostic Findings
Chronic:

 Xray
-demonstrate large, irregular cavities,
raised periosteum, sequestra, or dense bone
formation
 Bone scans
- used to identify areas of infection
 Blood studies- anemia may be evident
 Open bone biopsy
- used to identify the underlying
pathogen
 Medical Management

• Initial goal: control and halt the

infective process
• Provide general supportive
measures
• Area affected is immobilized
 Medical Management

 Pharmacologic Therapy
- antibiotic therapy (3-6 weeks)
 Surgical Management
- surgical debridement
- sequestrectomy
Nursing Diagnosis
 Acute pain related to inflammation
and edema
 Impaired physical mobility related to
pain, used of immobilization devices,
and weight-bearing limitations
 Risk for extension of infection: bone
abscess formation
Nursing Interventions

• Relieve Pain
- immobilized affected area
- monitor skin and neurovascular
status of the affected extremity
- affected extremity must be handled
with great care and gentleness
- elevation
- administer prescribed analgesics
 Nursing Interventions
• Improved physical mobility
- Restrict activity
- Perform gentle ROM to joints
above and below the affected part
-encourage to participate in ADLs
within limitations
 Nursing Interventions

• Controlling the infectious process

- promote good nutrition including
vitamin C and protein
- encourage adequate hydration
- administer and monitor antibiotic
therapy
Thank you!
Too big to ignore
I’m bigger than you
Break in custom
Bone tissue
neoplasms
MARK OLIVA
definition

✗ Osteosarcoma - cells that grow new bone form a cancerous tumor

resulting in bone cancer

157
158
definition

✗ Osteoid Osteoma - benign bone tumor that arises from osteoblasts

✗ Most common in long bones

159
definition

✗ Osteoma - benign bone tumors that typically form on the skull.

160
definition

✗ Osteoclastoma - A tumor
of the bone characterized
by massive destruction of
the end (epiphysis) of a
long bone.

161
activity
162
 Bone
cancer 163
Short
Bone 164
osteosarc
oma
166
Risk factors

✗ Age - during growth spurt

✗ Gender - more often in males
✗ Height - taller kids
✗ Treatment - radiation therapy
✗ Health conditions
✗ Family History

✗ Etiology - unknown

167
INCIDENCE

✗ 1/200,000 population

✗ Occurs mostly in males

✗ Teenagers

✗ 15-25 years old

168
Pathophysiology

- Osteoblastic DNA mutation

- Proliferation of malignant osteoblasts

- Formation of osteoid tissue

- Overcrowding tissue in the bone

169
ASSESSMENT FINDINGS

✗ Swelling
✗ Tenderness
✗ Pain
✗ Lump
✗ Redness
✗ Fever

170
Diagnostic tests

✗ Medical Imaging Tests

✗ X-Rays
✗ CT Scans
✗ MRI

✗ Serum tumor marker

✗ Biopsy

171
Activity
173
 There’s gonna be...

ONE LESS LONELY GIRL

_______________________

*Clue for next slide*

174
 LONELY
TUMOR
GIRLS
_____
175
Management

Malignant Tumor

radiotherapy,

chemotherapy,

surgery

176
medical

3 months of chemotherapy/radiation therapy known as neo-adjuvant

therapy followed by surgery

Prescribed drugs will be given

177
Surgery

Amputation

Rotationplasty - surgery for bone cancer near the knee. Removing middle part.
Attaching lower leg to the thigh then putting a prosthetic

Limb Salvage - replaces disease bone and reconstructs a function limb with a
metal implant or bone graft

178
179
180
Surgery

Pre-op
Physcian and client will discuss about expected outcomes of options
and complications and risks.

Refrain from taking medication one week prior to surgery

NPO night before surgery

181
Surgery

Post-op
Monitoring the patient wound

Educate client on protecting the extremity from refraining from lifting,

exercising any major forces

Educate client safety measures at home

182
NURSING DIAGNOSIS

Acute or Chronic Pain

Ineffective coping
Activity Intolerance
Risk for injury

183
NURSING INTERVENTIONS

✗ Monitor vital signs

✗ Assess clients motor functions
✗ Encourage diversional activities
✗ Provide quiet environment
✗ Encourage rest periods and provide comfort measures
✗ Assist client in changing of position
✗ Educate the client on the condition
✗ Give medications as ordered

184
 Last
activity
185
BONE TISSUE
186
The end
187
Thank
s!

188
Herniated Nucleus
Pulposus
By Limytch Diaz
 Before we start

• An intervertebral disk acts as shock absorber

(24 disk)
• protect the nerves that run down the middle of
the spine and intervertebral disks
 What is HNP?
• Herniated nucleus pulposus or HNP is
prolapse of an intervertebral disk through a
tear in the surrounding annulus fibrosus.
Pathophysiology
Predisposing Precipitating
factors factors
• Genetics • Weight
• Age • Occupation
• Smoking

lifting heavy objects

aging-related can lead to a herniated
wear and disk, as can twisting
tear and turning while
lifting

Annulus fissures
predispose to a
weakness, which allows
disc material to bulge
or migrate outside the
which allows disc
annulus margins
material to bulge or
migrate outside the
annulus margins
 ETIOLOGY
• Most disc herniations occur when a person is in their 30’s or
40’s
• After age 50 or 60, osteoarthritic degeneration (spondylosis) or
spinal stenosis are more likely causes of low back pain or leg
pain.
Stages of Disc Herniation
 Signs and Symptoms
• Pain- if disc does press on a nerve, symptoms may
include: Pain that travels through the buttock and
down a leg to the ankle or foot because of pressure
on the sciatic nerve. Low back pain (LUMBAGO) may
accompany the leg pain.
 Signs and Symptoms
• Tingling ("pins-and-needles“ sensation) or
numbness in one leg that can begin in the
buttock or behind the knee and extend to
the thigh, ankle, or foot.
• Weakness in certain muscles in one or both
legs.
• Pain in the front of the thigh.
• Severe deep muscle pain and muscle
spasms.
 Signs and Symptoms
• Long term nerve compression can cause
• Cauda equina syndrome
• Bladder/bowel dysfunction
• Low back pain (Sharp)
• Sciatica / Motor weakness
 Diagnostic Test
• Physical Exam- Straight Leg Raise
• The straight leg raise, also called Lasègue's sign,
Lasègue test or Lazarević's sign, is a test done
during the physical examination to determine
whether a patient with low back pain has an
underlying herniated disk, often located at L5
(fifth lumbar spinal nerve)
 Diagnostic Test
• The test is positive if significant back pain, or
radicular pain in the lower extremity is present.

• A positive test may indicate sciatic or lumbosacral

nerve root irritation, for example due to a prolapsed
lumbar disc
 Diagnostic Test
• Imaging
• X-RAY
• COMPUTED TOMOGRAPHY
• MAGNETIC RESONANCE IMAGING
• MYELOGRAM
Xray
COMPUTED TOMOGRAPHY
MRI
Myelogram
 Diagnostic Test
• Electromyogram and Nerve conduction studies
(EMG/NCS) These tests measure the electrical impulse
along nerve roots, peripheral nerves, and muscle
tissue.
• This will indicate whether there is ongoing nerve
damage, if the nerves are in a state of healing from a
past injury, or whether there is another site of nerve
compression.
 Treatments
• MEDICATION
• Acetaminophen (paracetamol)
• NSAIDs
• Muscle relaxants
• Antidepressants
• Antiseizure drugs
 Treatments
• NON SURGICAL
• Education on proper body mechanics
• Physical therapy, to address mechanical factors, and
may include modalities to temporarily relieve pain
(i.e. traction, electrical stimulation, massage)
• Weight control
• Traction Belt
• Pelvic Girdle traction
 Treatments
• SURGICAL
• Discectomy
• Lumbar Discectomy
• Neck Discectomy
Nursing Management
fracture
• A fracture is a break in the continuity of bone and is defined
according to its type and extent.
• Fracture is abreak in any bone in the body.
fracture
• A fracture is a break in the
continuity of bone and is
defined according to its type
and extent.

• Fracture is a break in any

bone in the body.
Causes
of
fracture
• Direct blows

• Crushing forces
• Sudden twisting motions • Extreme muscle contractions
Types of fractures
• Closed fractrure • Open fracture
Classification according to the anatomical
placement
Greenstick fracture
• A fracture in which one side of
a bone is broken while the
other is bent (like a green
stick)
Spiral fracture
• A fracture, sometimes called
torsion fracture in which a
bone has been twisted apart
Comminuted fracture
• A fracture in which bone is
broken, splintered or crushed
into a number of pieces
Transverse fracture
• A fracture in which the break
is across the bone, at a right
angle to the long axis of the
bone
Compound fracture
• A fracture in which the bone is
sticking through the skin. Also
called an open fracture
Compression fracture
• A fracture caused by
compression, the act of
pressing together.
Compression fractures of the
vertebrae are especially
common with osteoporosis
Other fracture
• Avulsion • Depressed
> Fracture which occurs when a > A fracture in which fragments
fragment of bone tears away are driven inward (seen
from the main mass of bone frequently in fractures of skull
and facial bones)
Other fracture
• Epiphyseal • Pathologic
> A fracture through the It occurs through an area of
epiphysis diseased bone (eg,
osteoporosis, bone cyst, bony
metastasis, tumor);
Can occur without trauma or
fall
Other fracture
• Stress
> A fracture that results from
repeated loading without bone
and muscle recovery
pathophysiology
Due to any etiology (crushing movement)

Fracture occurs, muscle that were attached

to bone are disrupted and cause spasm

Proximal portion of bone remains in place, the distal portion can

become displaced in response to both causative force and spasm in
the associated muscles

In addition, the periosteum and blood

vessels in the cortex and marrow are
disrupted

Soft tissue damage occurs, leads to

bleeding and formation of hematoma
between the fracture fragment and
beneath the periosteum
Bone tissue surrounding the fracture site
dies, creating an intense inflammatory
response

Release of chemical mediators (histamins,

prostaglandins)

Resulting in vasodilation, edema, pain, loss of function, leukocytes,

and infiltration of WBC
Clinical manifestations
• Pain
• Loss of function
• Deformity
• Shortening
• Crepitus
• Swelling and discoloration
manageme
nt
MEDICAL /SURGICAL MANAGEMENT OF
FRACTURES:
• Reduction
Reduction of a fracture (“setting” the bone) refers to restoration
of the fracture fragments to anatomic alignment and rotation.
Open reduction
It’s a surgical approach, the fracture fragments are reduced.
External/Internal fixation devices (metallic pins, wires, screws,
plates, nails, or rods) may be used to hold the bone fragments
in position until solid bone healing occurs
MEDICAL /SURGICAL MANAGEMENT OF
FRACTURES:
• Internal fixation
MEDICAL /SURGICAL MANAGEMENT OF
FRACTURES:
• External fixation
Closed reduction
• closed reduction is accomplished by bringing the bone
fragments into apposition (ie, placing the ends in contact)
through manipulation and manual traction.
• Extremity is held in the desired position while the physician
applies a cast, splint, or other device.
• X - rays are obtained to verify that the bone fragments are
correctly aligned.
• Traction (skin or skeletal) may be used to effect fracture
reduction and immobilization.
immobilization
• Immobilization may be accomplished by external or internal
fixation.
• Methods of external fixation include bandages, casts, splints,
continuous traction, and external fixators.
• Metal implants used for internal fixation serve as internal splints
to immobilize the fracture
traction
• Traction is the use of weights, ropes and pulleys to apply force
to tissues surrounding a broken bone.
traction
• Skin traction
-Bucks traction used for knee,hip bone fracture
Weight usually 5-7 pounds attach to skin
Skeletal traction
Needs invasive procedure
Weight is upto 10 kg attached to bone
SPLINTING
• Splinting is the most common procedure for immobilizing an
injury.

WHY DO WE SPLINT?
To stabilize the extremity
To decrease pain
Actually treat the injury
Possible items for splinting
• Soft materials. Towels, blankets, or pillows, tied with bandaging
materials or soft cloths.
• Rigid materials. A board, metal strip, folded magazine or
newspaper, or other rigid item.
Soft splints
• Splinting Using a Towel
• Splinting using a towel, in which the towel is rolled up and
wrapped around the limb, then tied in place.
Guidelines for splinting
1. Support the injured area.
2. Splint injury in the position that you find it.
3. Don’t try to realign bones.
4. Check for color, warmth, and sensation.
5. Immobilize above and below the injury.
Maintaining and restoring function
• Restlessness, anxiety, and discomfort are controlled with a
variety of approaches, such as reassurance, position changes,
and pain relief strategies, including use of analgesics.
• exercises are encouraged to minimize disuse atrophy and to
promote circulation.
• Participation in activities of daily living (ADLs) is encouraged to
promote independent functioning and self-esteem.
Treating an Open Fracture
• Do not draw exposed bones back into tissue.
Treating an Open Fracture
DO:
• Cover wound.
• Splint fracture without disturbing wound.
• Place a moist 4" x 4" dressing over bone end to prevent drying.
• Assist the surgeon in debridement of wound
Complication of fracture
• Early complications
• Shock
• fat embolism
• compartment syndrome
• deep vein thrombosis
• disseminated intravascular coagulopathy
• infection
• Delayed complications
• delayed union and nonunion
• avascular necrosis of bone
• reaction to internal fixation devices
Compartment syndrome
• develops when tissue perfusion in the muscles is less than that
required for tissue viability.
• patient complains of deep, severe pain, which is not controlled
by opioids.
• Reduction in size of muscle compartment
• It increase pressure in the muscle compartment
• Reduce microcircualtion,leads to muscle and nerve anoxia and
necrosis
Fat embolism syndrome
• occurs most frequently in young adults
• fat globules may move into the blood because the marrow
pressure is greater than the capillary pressure
• usually occurring within 24 to 72 hours
NURSING MANAGEMENT
• Patients with closed fractures
• Encourage patient not to mobilize fracture site. • exercises to
maintain the health of unaffected muscles for using assistive
devices (eg, crutches, walker).
• teach patients how to use assistive devices safely. • Patient
teaching includes self-care, medication information, monitoring
for potential complications, and the need for continuing health
care supervision.
• Patients with open fractures
• administers tetanus prophylaxis if indicated. • wound irrigation
and debridement in the operating room are necessary. •
Intravenous antibiotics are prescribed to prevent or treat
infection. • wound is cultured.
• fracture is carefully reduced and stabilized by external fixation or
intramedullary nails. • Any damage to blood vessels, soft tissue,
muscles, nerves, and tendons is treated. • Heavily contaminated
wounds are left unsutured and dressed with sterile gauze to
permit swelling and wound drainage.
Care of client with cast
• Before application of a cast preparation of the client includes:
• Detailed explanation of the procedure
• Skin preparation involves through cleansing of the skin
• Presence of unremovable particle or dust should be reported to
the physician
• Roll the cast material are individually submerged in clean water
and excess water is squeezed from the roll ,apply bandage is
applied to encircle the injured the body parts
• As the water evaporates the cast will dry
• plaster cast generates while drying so instruct patient for heat
sensation
• Do not cover the cast
• Windowing or bivalving a cast means cutting a cast along both
sides then splitting it to decrease pressure on underlying tissue.
• Window may also be cut into cast to allow the physician or
nurse to visualize wounds under the cast or removes drains.
• Neurovascular assessment:
• It should be performed every 30 minutes for 4 hours.
• Assess the cast extremity for color, warmth, pulse distal to the
cast, capillary refill.
• Movement of the distal fingers or toes, awareness of light touch
distal to the cast, change in the sensation.
• Assessment of the pain: Assess the degree of pain
• Assessment of the cast: The skin around the cast edges should
be observed for damage or swelling.
• “Hot spots” areas of the cast that feel warmer than other section
may indicate tissue necrosis or infection under the cast.
• “Wet spots” may indicate drainage under the cast
Care of external fixation
• Assessment-
• pain, nerve supply,infection,pin site etc.
• Small bleeding from pin site is normal
• Critical, If extend more than 24 hours
• Administer antibiotics, analgesic medication
Care of traction
• Assessment
skin breakdown, pain, neurovascular ,constipation
Stool softner
Plenty of fluids
Provide bedpan and urinals for elimination
Encourage clients activity
Nursing
diagnosis
• Acute pain related breakdown of continuity of the bone as
evidenced by facial expressions and verbalization of patient.
• Goals: Patient will not feel pain
• Intervention:
Assess the onset, duration, location, severity and intensity of
pain.
Administer the analgesic according to physician order. •
Provide comfort devices like sand bags for immobilization of
affected parts.
Provide diversion therapy
• Impaired physical mobility related to application of traction or
cast as evidenced by assessment
• Goal: Patient will able to move unaffected area.
Intervention:
Provide range of motion exercises to the patient.
Assist the patient in ambulation after recovery of fracture.
Provide assistance while using walker or crutches if required.
Prevent from complication which usually occurs due to
immobility.
• Self care deficit related to fracture as evidenced by poor
personal hygiene.
• Goal: Patient will maintain the personal hygiene
Intervention:
 Assess the need of self care
 Encourage the patient or relatives to do self care activity
 Head to foot care to be provided to the patient.
 Educate about importance of maintaining personal hygiene.
SPINAL CORD INJURY
INCIDENCE

o 200,000 people in the United States live each day with a disability from
SCI, and an estimated 11,000 new injuries occur each year

o SCI is primarily an injury of young adult males and 50% of those injured
are between 16 and 30 years of age.

o Patients over the age of 60 years account for 10% of SCIs, and this figure
has steadily risen over the past 25 years

o Motor vehicle crashes account for 48% of reported cases of SCI, with falls
(23%), violence primarily from gunshot wounds (14%), recreational
sporting activities (9%), and other events accounting for the remaining
injuries.
PREDOMINANT FACTORS

o YOUNG AGE

o MALE GENDER

o ALCOHOL AND DRUG USE

 PATHOPHYSIOLOGY

DAMAGE IN SCI RANGES

o Transient concussion (from which the patient fully recovers)

o Contusion
o Laceration
o Compression of the spinal cord substance (either alone or in combination)
o Complete transection (severing) of the spinal cord (which renders the patient
paralyzed below the level of the injury)
 PRIMARY INJURY SECONDARY INJURY
Result of the initial insult or trauma and Usually the result of a contusion or tear
are usually permanent injury, in which the nerve fibers begin to
swell and disintegrate.
Primary concern for critical care nurses
Principal cause of spinal cord
degeneration at the level of injury and
that it is reversible
during the first 4 to 6 hours after injury
Incomplete spinal cord lesions (the sensory or motor fibers, or both, are preserved below
the lesion) are classified according to the area of spinal cord damage: central, lateral,
anterior, or peripheral.

A complete spinal cord lesion (total loss of

sensation and voluntary muscle control below the lesion)
can result in paraplegia or tetraplegia.
 Assessment and Diagnostic Findings

o Detailed neurologic examination is performed

o Diagnostic x-rays (lateral cervical spine x-rays) and CT scanning are usually
performed initially
o MRI scan may be ordered as a further workup if a ligamentous injury is
suspected, because significant spinal cord damage may exist even in the
absence of bony injury
o Myelogram may be used to visualize the spinal axis
o Continuous electrocardiographic monitoring may be indicated if a spinal cord
injury is suspected
Medical Management (Acute Phase): goals of management are to prevent secondary
injury, to observe for symptoms of progressive neurologic deficits, and to prevent
complications.

Pharmacologic Therapy

• Administration of high-dose IV corticosteroids or methylprednisolone sodium

succinate in the first 24 or 48 hours

Respiratory Therapy

• Oxygen is administered to maintain a high partial pressure

of oxygen (PaO2), because hypoxemia can create or worsen
a neurologic deficit of the spinal cord.

• Diaphragmatic pacing (electrical stimulation of the phrenic

nerve) attempts to stimulate the diaphragm to help the patient
breathe
Skeletal Fracture Reduction and Traction

o Management of SCI requires immobilization and reduction

o of dislocations (restoration of normal position) and stabilization
o of the vertebral column.

o Cervical fractures are reduced, and the cervical spine is

o aligned with some form of skeletal traction, such as skeletal
o tongs or calipers, or with use of the halo device

o The Gardner- Wells tongs require no predrilled holes in the skull. Crutchfield and
Vinke tongs are inserted through holes made in
o the skull with a special drill under local anesthesia.

o Traction is applied to the skeletal traction device by

o weights, the amount depending on the size of the patient
o and the degree of fracture displacement.
 CERVICAL COLLAR

RORO BED

HALO AND VEST

Surgical Management

THE GOALS OF SURGICAL TREATMENT ARE TO PRESERVE NEUROLOGIC

FUNCTION BY REMOVING PRESSURE FROM THE SPINAL CORD AND TO
PROVIDE STABILITY

Surgery is indicated in any of the following situations:

• Compression of the cord is evident.

• The injury results in a fragmented or unstable vertebral body.
• The injury involves a wound that penetrates the cord.
• Bony fragments are in the spinal canal.
• The patient’s neurologic status is deteriorating.
Management of Acute Complications of Spinal Cord Injury

Spinal and Neurogenic Shock

• Neurogenic shock develops as a result of the loss of autonomic

nervous system function below the level of the lesion
• The vital organs are affected, causing decreases in blood pressure, heart rate, and
cardiac output, as well as venous pooling in the extremities and peripheral
vasodilation.
• The patient does not perspire in the paralyzed portions of the body, because
sympathetic activity is blocked; therefore, close observation is required for early
detection of an abrupt onset of fever.

Deep Vein Thrombosis

• Potential complication of immobility and is common in patients with SCI

• Low-dose anticoagulation therapy usually is initiated to prevent DVT and PE, along
with the use of anti-embolism stockings or pneumatic compression devices.
NURSING PROCESS

• Ineffective breathing patterns related to weakness or paralysis of abdominal and

intercostal muscles and inability to clear secretions
• Ineffective airway clearance related to weakness of intercostal
muscles
• Impaired bed and physical mobility related to motor and sensory impairments
• Disturbed sensory perception related to motor and sensory impairment
• Risk for impaired skin integrity related to immobility and sensory loss
• Impaired urinary elimination related to inability to void spontaneously
• Constipation related to presence of atonic bowel as a result of autonomic disruption
• Acute pain and discomfort related to treatment and prolonged immobility
POTT’S DISEASE
 This entity was first described by Dr. Percivall Pott. He noted this as a
painful kyphotic deformity of the spine associated with paraplegia.

 Tuberculosis of the spine is one of the oldest diseases afflicting

humans.
PREDISPOSING FACTORS
 Malnutrition
 Poor Sanitation
 Over Crowding
 Close contact with TB patient
 Immunodeficiency state
NEUROLOGICAL COMPLICATIONS
 ETIOLOGY

 INFLAMMATORY: Inflammatory edema

 MECHANICAL: Tubercular debris, cord constriction due to vertebral canal
stenosis, localized pressure
 INTRINSIC: Infective thrombosis
INCIDENCE
 3% are suffering from skeletal TB, 50% of this suffer from spinal
lesion and almost 50% are from pediatric group.

 An estimated 2 million or more patients have active spinal tuberculosis

Pathophysiology
 Tuberculosis infiltrates the spine via hematogenous spread through the
dense vasculature of the of cancellous bone of the anterior vertebral
bodies
 Lymphatic spread from para-aortic lymph nodes possible but rare
 Up to 75% of infected individuals develop a soft tissue infection
 If left untreated, degeneration and inflammation of the vertebrae
causes herniation into the cord space, cord compression
 Kyphosis, gibbous
 Paraplegia
Assessment findings
 Physical general examination
 Gait – patient walks with short steps in order to avoid jerking the
spine
 Attitude and deformity – tb of cervical spine patient has stiff, straight
neck. In dorsal spine TB, part of the spine becomes
 Para-vertebral swelling
 Tenderness
 Movement
Diagnostic Test/Findings
 Radiologic Studies
 PlainRadiograpgh
 CT Scan

 MRI

 Bone scan

-TB bacilli are rarely found in CSF, therefore imaging plays an important role
in the suggesting diagnosis
Laboratory Studies
 Tuberculin Skin test demonstrates a positive finding in a positive
finding in 84-95% of patients who are non HIV positive
 Erythrocyte Sedimentation Rate may be markedly elevated
 The enzyme-linked immunosorbent (ELISA) has a reported sensitivity of
60-80%
 A brucella compliment fixation test
TREATMENT
 Aim of treatment is to achieve healing of disease and to prevent,
detect early & promptly any complication like paraplegia
Medical Management
 Treatment goals
 Confirm Diagnosis
 Eradicate Infection

 Identify and Remove Causative Pathogen

 Recover/Maintain Neurological Function

 Recover/Maintain Mechanical Spine Stability

 Correct or Prevent Spinal Deformity and Possible Sequelae

 Functional Return to Activities of Daily Living

 Treatment Techniques
 Anti-TuberculosisChemotherapy
 Surgical Drainage of Abscess

 Surgical Spinal Cord Decompression

 Surgical Spinal Fusion

 Spinal Immobilization

 Anterior Decompression and Spinal Fusion

Nursing Management
 Apply a properly sized cervical collar i cervical injury is suspected
 Offer the patient comfort and reassurance
 Provide firm mattress and small pillows
 Encourage and assist client in changing of position
 Watch closely for neurologic changes
 If the patient is able to ambulate, request a therapy consultation for
ambulation
REFLECTIVE JOURNALS
Reflection Paper on POC rotation
Emmanuel John Enojado RR41

POC rotation for me was a bit tiring because I wasn’t used to the way we did things. Before the POC rotation, our
psyche duty was a bit chill compared to the ortho duty. I was surprised on how time was efficiently used during the
duty. No time was wasted on the duty even if it was online, I felt the hype in the duty. I was happy on how my group
really helped each other to finish our tasks on time. Even if some of our outputs lacked in some parts we did our
best to send an output that we can be proud of. I was sure that I did my part but I also know that I was lacking in
some parts of the duty, good thing my groupmates helped me throughout the duty. In the future I know what I will
be able to do my part and be able to do my best in every part of the duty.
It was a nice experience that we are able to experience this new setting of affiliation even though it was only online,
still we are able to feel what is being done and discuss during the affiliation.

At first I didn't feel that this would be a good idea as having it on online affiliation but then as we had our first
rotation sir Dennis made us really experience the psyche ward and as well the activities being done to the area.
Then we had the Philippine Orthopedic Center (POC) as our 2nd rotation with that experience. I am glad because
maim France gives us all the topic and activities to be done during the duty in that area. Though it wasn’t all the
activities but still we are able to accomplish it plus we got to remember some of the types of fractures and
procedures done in this area.
I am blessed that ma'am France is the clinical instructor assigned to this topic and that she was able to let us
recall, memorize and teach the topics well to us. I also thanked my classmate for doing their best all throughout this
summer affiliation. I admire their dedication and love what they are doing.

Hsin tan hsu

Today was the last day the 2nd rotation of our online Affiliation. I have to say, It was harder than expected. We were
bombarded with reports, Case studies, lessons and Exam/Quizzes but we know it was for our own good it was to
train us on the upcoming boardexams im glad to have this affiliation even though it was just a online affiliation this
POC rotation has refreshed me on the lessons about ortho it also made me realize that this affiliation is the last
time our Ci’s will teach us or scold us about anything and that makes me sad.
This past years has been wonderful and terrible. I’ve been thanked profusely and I’ve been disparaged. I’ve formed
meaningful relationships with patients, and I’ve struggled with building rapport. I’ve felt incompetent and I’ve felt
proud. I’ve been impressed by nurses, doctors, physical therapists, social workers, and many others so incredibly
skilled at what they do. I’ve been ashamed by inefficiency and waste. I’ve imitated and I’ve developed my own
style. I’ve been comforted. I’ve been able to comfort. I’ve laughed. I’ve been moved, scared, confident, anxious,
overwhelmed, overjoyed, insecure, humbled, sad. And as for this last day of this Rotation I Thank you Ma’am
France and to all other Ci’s for teaching and supporting us through everything thank you :D

Limtch Diaz
Glowsy C. Cabral
RR41
POC

Reflective Journal

Admittedly, I was reluctant to have this online summer affiliation. I am worried that we cannot get the real essence of
clinical experience. However, for the last 2 weeks of the online affiliation, I am contented with the process. This
method has provided us with new learning experience that is beneficial in our future endeavors.
At first, all of us seemed to be unmotivated due to the fact that everyone was burnt out from all the stress that this
online educational platform has been giving the students. It felt like we were being pushed to do things with half-
hearted efforts. However, we somehow started to awaken to the fact that we may need to give our fervent efforts in
this endeavor due to the concern and encouragement of our CI. After expressing the concerns and apprehensions of
the group, I noticed that for the remaining days of the rotation all of us were trying hard to show our enthusiasm. It
may be a draining week for all of us but I can say that we have tried to put all of our hard work to make the POC
rotation fruitful.
To summarize this POC experience, I am satisfied with the knowledge that I have gained from all the topics
discussed. It became a refresher of the past lessons that will definitely be useful in our review for the board exam.
Our knowledge in the anaphy of the musculoskeletal system; the different tractions, cast, braces, and ortho
hardwares; and the different diseases of the bones was enhanced. Moreover the sincere concern and assistance to
students are helpful traits of the CI that brought focus and motivation upon us. This experience may not be the
same as to the face to face affiliation where we can handle patients but the considerable amount of knowledge that
we got from the online affiliation is enough for us to keep moving forward.
Ateneo de Naga University
College of Nursing
Naga City

REFLECTION PAPER

Submitted by: Anna Dominique B. Calimlim

June 25, 2021

Friday

Today was the last day for our duty in the Philippine Orthopedic Center via google meet. My experience for this
week's rotation for the affiliation was memorable because it was the first time that I ever got to be exposed to the
type of activities conducted in the Philippine Orthopedic Center. Everyday is jam packed with things to do and no
time is wasted because every activity has been scheduled. Even though our duty was online, I felt the experience of
being inside the Philippine Orthopedic Center. Not only did I get a refresher on musculoskeletal conditions and BST,
but I also got to learn more about the different casts, tractions, splints, hardware, gadgets etc. During the entirety of
the week, I felt the fatigue, the stress, the joy, and other emotions that came with the daily activities as we carried
out the schedule for the day. Maybe the reason why I felt so tired by the end of the day is because before the
pandemic, we had actual duties in the hospital and although it was tiring, I still had energy at the end of the duty.
Compared to this online affiliation, I get exhausted quite quickly. I was also stressed because there were a lot of
things to do and prepare for. At the start of the week, it was kind of difficult for me to adjust myself according to the
schedule.
As for myself, I think I did pretty well for this rotation. Although the only difficulty I had was my internet connection, I
still managed to come to class on time. I still regret not participating in the jamboard activities because my laptop’s
outdated but at least I found a way to contribute to my group via messenger. Technology really is a blessing. As for
my classmates, teamwork is truly evident in our group because we helped each other a lot in this rotation. We
made sure that nobody gets left behind in our daily activities. Even when we all felt stressed and tired, we still
managed to encourage each other to keep going and finish every activity this week. For my clinical instructor, I am
grateful that she never fails to be patient and considerate with us. Even though sometimes we feel unmotivated and
stressed with the requirements for this affiliation, she will still try to motivate us to do our tasks. The start of the
week didn’t go quite well but in the end, we made it with the help of our clinical instructor. But even though the
pandemic is still ongoing, we all made it possible to conduct this online affiliation and I’m really happy to have
experienced this and it will be a memory that I will truly remember and carry with me forever.
ELLA MAY B. TERBIO
REFLECTIVE JOURNAL: POC ROTATION

I had my second week online affiliation at POC under the care of our clinical instructor, Ma’am France. During our first
week, I do not know on how an online affiliation can take place. But as the weeks past, everyone was trying to adjust and bring
face-to-face affiliation into us. I was not prepared at first to be honest. Emotionally, mentally and physically I am tired and
exhausted. But my Clinical Instructor help me to realize and gather up my compassion and determination to continue the path I want
to be in the near future.
I would really like to thank my Clinical Instructor for putting an effort to bring our affiliation closer and memorable to us.
They do not teach alone, but they also care for the welfare of the students. They are doing their best to have our affiliation as
productive and engaging as possible. The task they prepared for the whole week were successfully done. The task they make has
given me new knowledge and exercise my comprehension for the different diseases that we tackle.
This online affiliation gave as an opportunity to gain new information and on how we can give care to the patients who had
these diseases. It also refreshes our knowledge during our anatomy and physiology. Since technology is part of our classroom in
today’s world. We should always use the technology productively. This week challenges me to dig deeper into how distance learning
can be successful even with this new normal.
I had intended to do a deeper dive and reflection for the past few weeks. I have to show how determined I am to pass and
focus more on school. I had cried a lot and I almost lose hope in continuing. But just a little bit more time and all is going to be well. I
just need to stand up and try all over.
This POC rotation challenges me to fight for what I had started. To fight and be stronger. Stronger enough to make my
parents proud and happy. This rotation also helps me to remember on what I am really here for. It maybe online, nut the cases that
my CI had given to us is a great help. She chooses real life cases that will eventually help us out.
This online affiliation may be the first time, but it was not bad at all. We can also gain new knowledge and learn form this
experience.
I am the type of person who does not trust easily. I am very skeptic and doubtful. I always question other people’s
intention and end up not trying to gain friends. I am okay without best friends, since I consider to not have any. I
have friends yes, colleagues, and classmates but then I have a hard time trusting other people.

But there were certain individuals that I am comfortable with, and you are one of those, Ma'am France, which
made the POC rotation much more memorable. You never get tired to support everyone and to present to us
realities and actual roles of nurses. You taught me to never slack, but rest if I must. I can truly say that you
motivate me one way or another and I am glad that I was able to somehow open up myself to you.

Once again, thank you very much. People like you, Ma’am, makes the world a better place 

GAB DE LA CRUZ