jborrero 10/08 musculoskeletal stressors nur240. arthritis degenerative joint disease arthritis=...
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JBorrero 10/08
MusculoskeletalStressors
NUR240
Arthritis
Degenerative Joint Disease Arthritis= joint inflammation. Arthralgia= joint pain Different types of arthritis:
Osteoarthritis Rheumatoid arthritis Gouty arthritis
Osteoarthritis
Most common form of arthritis, noninflammatory, nonsystemic disease
One or many joints undergo degenerative and progressive changes, mainly wt. bearing joints.
Stiffness, tenderness, crepitus and enlargement develop.
Deformity, incomplete dislocation and synovial effusion may eventually occur.
Treatment: rest, heat, ice, anti inflammatory drugs, decrease wt. if indicated, injectable corticosteroids, surgery.
Osteoarthritis- Risk Factors
Age Decreased muscle strength Obesity Possible genetic risk Early in disease process, OA is difficult to dx
from RA Hx of Trauma to joint
OA- Signs and Symptoms
Joint pain and stiffness that resolves with rest or inactivity
Pain with joint palpation or ROJM Crepitus in one or more joints Enlarged joints Heberden’s nodes enlarged at distal IP joints Bouchard’s nodes located at proximal IP
joints
What to assess for:
ESR, Xrays, CT acans Pain Degree of functional limitation Levels of pain/fatigue after activity Range of motion Proper function/joint alignment Home barriers and ability to perform ADLs
Osteoarthritis- Tx
Pharmacotherapy- tylenol, NSAIDS, ASA, Cox-2 inhibitors
Intra-articular injections of corticosteroids Glucosamine- acts as a lubricant and shock
absorbing fluid in joint, helps rebuild cartilage Balance rest with activity Use bracing or splints Apply thermal therapies Arthroplasty- joint replacement can relieve pain and
restore loss of function for patients with advanced disease.
Auto-Immune Disease
Inflammatory and immune response are normally helpful
BUT these responses can fail to recognize self cells and attack normal body tissues.
Called an auto-immune response Can severly damage cells, tissues and organs EG. RA, SLE, Progressive systemic sclerosis,
connective tissue disorders and other organ specific disorders
Rheumatoid Arthritis
Chronic, systemic, progressive inflammatory disease of the synovial tissue, bilateral, involving numerous joints.
Synovitis-warm, red, swollen joints resulting from accumulation of fluid and inflammatory cells.
Classified as autoimmune process Exacerbations and remissions Can cause severe deformities that restrict
function
RA- Risk Factors
Female gender Age 20-50 years Genetic predisposition Epstein Barr virus Stress
Rheumatoid Arthritis- Dx
Rheumatoid Factor antibody- High titers correlate with severe disease, 80% pts.
Antinuclear Antibody (ANA) Titer- positive titer is associated with RA.
C- reactive protein- 90% pts. ESR: Elevated, moderate to severe elevation Arthocentesis- synovial fluid aspirated by
needle
RA – Signs and Symptoms
Joints- bilateral and symmetric stiffness, tenderness, swelling and temp. changes in joint.
Pain at rest and with movement Pulses- check peripheral pulses, use doppler if
necessary, check capillary refill. Edema- observe, report and record amt. and location
of edema. ROM, muscle strength, mobility, atrophy Anorexia, weight loss Fever- generally low grade
RA- Sign and Symptoms
1. Fatigue- unusual fatigue, generalized weakness
2. Morning stiffness lasting longer than 30 minutes after rising, subsides with activity.
3. Red, warm, swollen, painful joints
4. Systemic S&S
5. Pain- at rest and with movement
What should we monitor?
Rheumatoid Arthritis- Tx
Rest, during day- decrease wt. bearing stress. ROM- maintain joint function, exercise –water. Medication- analgesic and anti-inflammatory
(NSAIDS), steroids,Gold therapy, topical meds. Immunosuppressive drugs- Imuran, Cytoxan, methotrexate. Monitor for toxic effects
Biological response modifiers (BRM):Inhibit action of tumor necrosis factor (Humira, Enbrel, Remicade)
Ultrasound, diathermy, hot and cold applications Surgical- Synovectomy, Arthroplasty, Total hip
replacement.
Nursing Interventions
Assist with/encourage physical activity Provide a safe environment Utilize progressive muscle relaxation Refer to support groups Emotional support
Complications
Sjogrens’s syndrome Joint deformity Vasculitis Cervical subluxation
Gouty Arthritis Very painful joint inflammation, swollen and reddened Primary-Inborn error of uric acid metabolism- increases production
and interferes with excretion of uric acid Secondary- Hyperuricemia caused by another disease Excess uric acid – converted to sodium urate crystals and
precipitate from blood and become deposited in joints- tophi or in kidneys, renal calculi
Treatment: Meds- colchicine, NSAIDS, Indocin (indomethacin), glucocorticoid
drugs, Allopurinol, Probenecid-reduce uric acid levels Diet- excludes purine rich foods, such as organ meats, anchovies,
sardines, lentils, sweetbreads,red wine Avoid ASA and diuretics- may precipitate attacks
Systemic Lupus Erythematosus
SLE- Chronic Inflammatory disease affecting many systems.
Women between 18-40, black>white, child bearing years
Autoimmune process- antibodies react with DNA, immune complexes form- damage organs and blood vessels.
Includes: vasculitis; renal involvement; lesions of skin and nervous system.
Initial manifestation- arthritis, butterfly rash, weakness, fatigue, wt. loss
Symptoms and tx. depend on systems involved.
Systemic Lupus Erythematosus
Pathologic changes-Autoimmune process
1. Vasculitis in arterioles and small arteries
2. Granulomatous growths on heart valves- non bacterial endocarditis.
3. Fibrosis of the spleen, lymph node adenopathy
4. Thickening of the basement membrane of glomerular capillaries.
5. 90% swelling and inflammatory infiltrates of synovial membrane.
SLE
6. Renal- Lupus nephritis
7. Pleural effusion or PN
8. Raynaud’s phenomenon- about 15% cases
9. Neuro- psychosis, paresis, migraines, and seizures
SLE Dx
ANA- hallmark test, + in 98% pts.Medications- NSAIDS Antimalarial meds- hydroxychloroquine (Plaquenil)
Immunosuppressive agents- pt teaching corticosteroids, methotrexate, cyclophosphamide
AntidepressantsResources:http://www.lupus.orghttp://www.arthritis.org
Systemic Lupus- EducationEncourage to avoid undue emotional/ physical
stress and to get enough rest Alternate exercise + planned rest periods. Teach how to recognize the symptoms of a flare Teach how to prevent and recognize infection Avoid sunlight, use sunscreen Eat a well balanced diet,vitamins and iron. Establish short term goals Teach re: meds. Meds avoid- Pronestyl, Hydralazine.
Charting Chuckles
On the second day, the knee was better, and on the third day, it had completely disappeared.
While in the emergency department, she was examined, X-rated, and sent home
The patient will need disposition, and therefore, we will get Dr. Blank to dispose of him.
Patient was admitted through the emergency department. I examined her on the floor.
Joint Replacement Indications
Rheumatoid arthritis Trauma Congenital deformity Avascular necrosis
Total Hip Replacement
Indications for surgery: Arthritis Femoral neck fractures Congenital hip disease Failed prosthesis
Pre-op management
Assess medication history. Assess Respiratory, neurovascular,
nutritional and integumentary status. Presence of other diseases- COPD, CAD,
Hx. Of DVT or pulmonary embolism. Discuss surgical procedure, informed
consent. Prepare for autologous blood donation.
Pre-op teaching
Presence of drains and hemovac postoperatively.
Pain management (epidural/PCA). Coughing and deep breathing. Use of incentive spirometer ROM exercises to unaffected extremities. Post-op restrictions:Need to avoid bending beyond 90 degreesImportance of leg abduction post-op.
Post-op Management of THR
Assess neurovascular status of involved extremity.
Incision site, wound drains, hemovac. Note excessive bleeding or drainage Respiratory status- elderly population. Position of affected joint and extremity Mental alertness Assess Hgb and Hct Pain management
Total hip replacement-Complications
Dislocation of hip prosthesis Thromboembolism Infection Avascular necrosis Loosening of the prosthesis
Dislocation of prosthesis
Increased pain, swelling Acute groin pain Shortening of the leg Abnormal internal or external rotation Restricted ability or inability to move leg Reported popping sensation in hip.
Impaired physical mobility r/t joint replacement and pain
Maintain bed rest with affected joint abducted with wedge pillow.
Perform passive and teach active ROM to unaffected joints, quad, isometric, gluteal exercises.
Ambulate with assistance, WB restrictions Turn pt. as ordered, monitor skin for
breakdown
Altered Tissue perfusion r/t reduced flow and immobilization
Administer parenteral fluids with electrolytes to increase tissue perfusion.
Monitor VS q4h and prn, I and O. Assess NV status q1h for first 12 hrs., then
q4h. Color, temp., pulse, sensation. Ambulation and exercises Monitor CBC, electrolytes, PT/INR Administer anticoagulants - phlebitis
Pain r/t surgical intervention and impaired mobility
Assess location, intensity, quality pain. Administer analgesics, sedatives, anti-
inflammatories, assess effectiveness, Monitor PCA or continuous epidural Change position frequently, back rubs. Provide diversional activities- reduce
attention on pain. Monitor - severe chest, affected joint pain.
Knowlwdge deficit R/T…
Stress importance of rehab program and exercises, no flexion greater than 90 degrees.
Discuss and demonstrate incision care Medication teaching- especially
anticoagulants, instruct pt to be checked, observe for bleeding, etc.
High protein, high fiber and increased fluid to prevent constipation.
Pain Management
Discharge/home care
Safety: stairs with hand rails, no scatter rugs, grab bars tub and toilet, good light.
Height of bed and chair for easy transfer. Elevated toilet seat, fracture pan, urinal Ability to care for wound, correct supplies and
hand washing technique. Correct transfer techniques, ability to follow
rehab plan and exercises.
Arthroscopy
Pre-op: lab work- Hgb, Hct, Pt/PTT, urine, PT,exercises
History of underlying problem, meds. Post-op- N/V assessment, pulses distal to
Joint. Teach: ROM to unaffected extremities,
limitations post-op, crutch walking prn, pain management, reinforce explanation of procedure.
Total Knee Replacement
Indications:Osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, bleeding into joint.
Post-op compression bandage and ice. Assess N/V status of leg, active flexion q1h.
While awake, CPM machine. Wound suction drain OOB within24 hrs., knee immobilizer and
elevated while sitting.
Care of the patient undergoing an amputation
Pre-op monitor N/V status both extremities Observe for ulceration, edema, necrosis. Baseline VS and lab data, doppler studies,
angiography, ECG, chest x-ray. Time for verbalization fears, anxieties. Teach re; overhead trapeze, C and DB,
incentive spirometer. http://www.diabetesresource.com/
Post-op: amputation Stump dressing, amt. and color of drainage,
hemovac drain. Respiratory status and VS. Presence of phantom limb pain. Monitor for complications; infection, hemorrhage,
phantom pain, contractures, scar formation, abduction deformity.
PT, diet, rest, activity, wound care Pain management Phantom limb pain Immobility complications
Body image disturbance r/t loss body part
Allow time for pt. to grieve, assess need for counseling.
Encourage pt. to discuss and view stump Assist in identifying positive coping strategies,
praise strengths observed. Provide a supportive environment. Demonstrate positive regard for pt. and acceptance
of personal appearance. Assess religious beliefs re: care of amputated limb Verbalize feelings re: change in role, job, family,
sexual perosn
Discharge/ Home care planning
Environmental/safety status: Hand rails- tub toilet, stairs, no scatter rugs. Wide doorway to accommodate wheelchair,
walker, Ht. of bed, chair ok. Ability to care for wound and has correct
supplies. Ability and desire to follow prescribed rehab
plan and exercises. Prosthesis fitting with orthotist
Osteoporosis Primary or Secondary Metabolic bone disorder- progressively porous,
brittle, fragile bones, low bone density, susceptible to fractures
Occurs in postmenopausal women Bone resorption (osteoclast) > bone formation
(osteoblast) activity Dowager’s hump – progressive kyphosis – gradual
collapse of vertebrae. Post menopausal lose height, c/o fatigue. Osteopenia, precursor to osteoporosis Dx tests: Radiographs, Dexa scans
Osteoporosis- Risk Factors
Gerontologic- over 80 yrs. old, 84% have osteoporosis.
Family hx, thin, lean body build Postmenopausal estrogen deficiency Hyperparathyroidism – increases bone
resorption Hx of low Ca intake and low levels of Vit D Long tem corticosteroid use Lack of physical activity/ prolonged immobility Hx of smoking, high alcohol intake
Osteoporosis
Diagnosis:
Physical assessment:
Psychosocial assessment:
Pt. teaching- osteoporosis
Adequate dietary calcium- 1200mg/day with fluids
Exercise, wt. bearing beneficial. Walking outdoors- vitamin D absorption. Good body mechanics Safe home environment, fall prevention Balanced diet- protein, Mg, Vit K & D, Ca Modify lifestyle choices- smoking, alcohol
and caffeine intake and sedentary lifestyle.
Patient teaching- Meds
HRT-Raloxifene (Evista) PTH- Forteo Subcut Bisphosphonates- Fosamax,Boniva, Actonal
Reclast, Zometia Calcitonin, Vit D NSAIDs
Osteomyelitis Infection of the boneEndogenous: Extension of soft tissue infection- infected pressure
ulcers or incision. Blood borne (spread from other body sites) At risk- poorly nourished, elderly, obese, impaired
immune systems, corticosteroid therapy, chronic illnesses.
Prevention- proper tx. of infections, aseptic post op wound care
Exogenous: Organism enters from outside the body. Eg. Open fx
Osteomyelitis
Signs and symptoms- High fever, chills, increased HR, general
malaise, swelling, tenderness, heat and erythema, painful movement.
Draining ulcers, bone pain Dx- increased WBCs, elevated ESR, positive
blood cultures, X-rays, bone scan, MRI.
Osteomyelitis Tx
Long term IV antibiotics Hickman or other CVAD catheter Strict sterile technique for tx Hyperbaric oxygen tx Surgery- bone exposed and necrotic tissue
removed, debridement, bone grafts, amputation
Contusions, Strains, Sprains
Contusion-soft tissue injury, hematoma, ecchymosis.
Strain- “muscle pull” over use over stretching. Sprain – an injury to ligaments surrounding
joint, caused by twisting. Management- RICE = rest, ice, compression,
elevation.
Orthopedic Injuries
Joint dislocation- out of joint. If not treated promptly, avascular necrosis can occur.
Reduced- put back in place = closed reduction. Neurovascular status- check.
Rotator cuff injury/tear Tennis elbow Ligament injuries
Fractures (Fx)
Complete- a break across the entire cross- section and is frequently displaced.
Incomplete (Greenstick)-break occurs through only part of the cross-section of the bone.
Closed Fracture (simple)- doesn’t break through the skin.
Open fracture (compound) - extends through the skin Comminuted- splintered into fragments Depressed- fragment(s) is(are) indriven Pathologic- through an area of diseased bone
Fractures-Signs and Symptoms
Pain- continuous and increases in severity after injury.
Swelling- usually over affected area, but can also occur in adjacent structures.
Reduction- open or closed Treatment- Casting and/or traction
Fracture complications
Shock Fat embolism Compartment syndrome DVT, thromboembolism or pulmonary
embolism. DIC Infection Avascular necrosis
Casts
Used to immobilize a body part so that a fracture of a bone or dislocation can heal.
Pressure from hard casting materials can produce complications such as:
Pain Decreased sensation Skin breakdown
Casting materials- plaster or fiberglass.
Casts-Indications
Provide protection and healing of fractures Maintain therapeutic alignment- body parts Protect soft tissue injuries Provide support after orthopedic surgery Correct skeletal malformations.
Casts
While cast is drying, check C/M/S or NV status hourly and then q4-8h
Circulation/ vascular checks- Warmth, color, pulses, capillary refill, swelling.
Motion checks- ask pt. to wiggle fingers or toes. Sensation checks- can pt. feel pressure, ask about
pain, this may detects if cast is too tight. Check for odor and drainage
Electrical Bone Stimulation
Application of electrical current at fracture site, invasive or non-invasive.
Stimulates osteogenesis to fracture site. Invasive- inserts cathode to site. Non-invasive- Coil encircles cast or skin,
attached to external generator, used 3-10 hrs. per day.
Contraindicated in presence of infection.
Factors inhibit fracture healing
Extensive local trauma Bone loss- demineralization, osteoporosis Inadequate immobilzation Space/tissue between bone fragment Infection, malignancy, bone disease Irradiated bone (radiation necrosis) Avascular necrosis Age- impaired healing process Corticosteroids inhibit repair rate
Traction- Indications
1. Used to minimize muscle spasm2. Used to reduce, align, and immobilize fractures 3. Used to correct/prevent deformity4. Tx of dislocated, degenerated, rutured
intravetebral discs and sc compressionNursing goals: Maintain line of pull. Pt. is in center of bed, with good alignment Weights hanging freely. Prevent complications
Types of traction
1. Skin traction (straight) - Buck’s, Bryant’s, pelvic girdle. The pull is transmitted to muscle structure, indirect traction.
2. Skeletal traction – pins or wires inserted in bone and attached to traction, may be used to treat fractures of humerus, tibia, fibula
3. Continuous- for fractures4. Intermittent- for back muscle sprains
Traction
Ropes unobstructed and in straight alignment. Skin care- check skin traction for intact skin, pin
care for skeletal traction. Circulation- fat emboli, thromboembolism. Respiratory- pneumonia, exercise, ROM. GI- high fiber diet, increased fluids. Renal- to prevent stones- increase fluids. MS- isometric exercises Pain management Diversion activities
5P’s Assessment for Orthopedic Patients
Symmetric comparison: Pain- location, severity Pulse- distal to injury, check bilaterally. Parasthesias- numbness, tingling, compare
bilaterally. Sensaton check Pallor- check skin color and temp. Paralysis- Assess mobility, watch for foot
drop, compartment syndrome.
Documentation
Amt traction, type, weight, changes in tx Pt tolerance and pain Pt assessment of NV checks, skin condition,
respiratory status, elimination pattern Note condition of any pin sites and any care
given
Hip fractures
High incidence in elderly due to risk for falls, osteoporosis.
Intracapsular- fx. Neck of femur, may damage blood supply, aseptic necrosis.
Extracapsular- base of neck and lesser tronchanter of femur- heals more easily.
ORIF- open reduction with internal fixation.
Symptoms of Fractures
Deformity Swelling Bruising Muscle spasms Tenderness Pain
Impaired sensation Loss of normal
function Abnormal mobility Crepitus Shock Abnormal Xrays
Nursing Diagnoses
Risk for injury r/t subluxation or dislocation Pain related to surgical incision Risk for infection r/t impaired skin integrity Impaired physical mobility Risk for Peripheral Neurovascular
Dysfunction
Back Pain
Review of anatomy Cervical Disc Low back pain Signs and Symptoms Etiology
Back Pain- Assessment and Dx Evaluation
Posture and gait Cervical Disc Pain and stiffness Loss of muscle strength Assess bowel and bladder control MRI, CT scan, Neuro exam Electromyelography and Nerve conduction
studies
Back PainConservative Management
Positioning Firm mattress and back board Exercise and physical therapy Pharmacology Heat and Ice Diet Therapy PT with manipulation, shoes insoles, back
braces Complementary and alternative therapies
Operative Procedures
Conventional open Procedures: Diskectomy Laminectomy Diskectomy with fusionMinimally Invasive Surgeries: Percutaneous lumbar diskectomy Microdiskectomy Laser assisted laparoscopic lumbar diskectomy Interbody cage fusion Direct current stimulation for bone fusion
Postoperative Care
Body mechanics Neurovascular assessment CSF leakage Fluid volume deficit Acute urinary retention Paralytic ileus Fat embolism Infection Persistant or progressive lumbar radiculopathy
Back Surgery- Patient Education
Takes 6 weeks for ligaments to heal Schedule rest periods Avoid heavy labor 2-3mos postop Back exercises
Cervical Disc Herniation or Rupture
Usually occurs at C5, C6, or C7 interspaces Surgical tx is MIS cervical diskectomy with or
without fusion using an anterior or posterior approach
Complications:
Postop Care- Cervical Diskectomy
ABC Check dsg for CSF Check for hoarseness and inability to cough Check for swallowing ability Assess pt ability to void Assist with ambulation Manage pain Assess for complications
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