chapter 63 musculoskeletal problems fall 2019lahc323325.weebly.com/uploads/1/1/0/6/110686185/... ·...

Musculoskeletal Problems •  Osteomyeli*s

•  Low Back Pain & Intervertebral Disc Disease

•  Osteoporosis –Metabolic Bone Disease

•  Common source of pain and disability

•  Variety of problems unrelated to trauma

•  Mobility •  Perfusion •  Pain •  Collabora*on •  Psychosocial *Describe each concept *What nursing physical assessments are involved?

Fall 2019 - Spring 2020 1

OSTEOMYELITIS Severe infec*on of bone, bone marrow, and

surrounding soL *ssue Most common microorganism is Staphylococcus aureus, but can be caused by variety of organisms

What are 3 reasons a person would get osteomyeli*s? Fall 2019 - Spring 2020 2

Case Study •  74-‐year-‐old man brought into the ED

by his daughter •  CC: Fever, nausea, and constant pain

in his leL leg •  PMH: DM and foot ulcers •  Examina*on: LLE indicates

inflamma*on with restricted movement secondary to pain

•  V.R.’s WBC count is elevated •  CT scan reveals severe inflamma*on of

his *bia and surrounding soL *ssue •  He is admiYed to the hospital

²  What previous (oxygena:on) disease increases risk for osteomyeli:s?

•  V.R.’s daughter asks how his bone could get an infec*on.

²  What type of infec*on is in the CC? ²  What could it turn into? ²  How would you explain the disease

process and likely cause?

(©Jupiterimages/Polkadot/Thinkstock)


E*ology and Pathophysiology

•  Direct entry –  Via open wound –  Foreign body presence

•  Microorganisms grow → increase pressure in bone → ischemia and vascular compromise

•  Infec*on spreads through bone → cortex devasculariza*on and necrosis


Clinical Manifesta*ons Acute Osteomyeli*s: < 1 month in dura*on

•  Local manifesta:ons

–  Pain that worsens with ac*vity; is unrelieved by rest

–  Swelling, tenderness, warmth

–  Restricted movement

•  Systemic manifesta:ons –  Fever –  Night sweats –  Chills –  Restlessness –  Nausea – Malaise –  Drainage (late)


Clinical Manifesta*ons Chronic Osteomyeli*s: > 1 month or has failed to respond to ini*al an*bio*c

treatment

•  Con*nuous and persistent or process of exacerba*ons and remissions

•  Systemic manifesta*ons reduced

•  Local signs of infec*on more common –  Pain, swelling, warmth

•  Granula*on *ssue turns to scar *ssue → avascular → ideal site for microorganism growth → cannot be penetrated by an*bio*cs


Case Study

•  Based on V.R.’s history and presenta*on, how would you classify his osteomyeli*s? •  __ __ __ __ __

• What addi*onal lab tests would you expect the health care provider to order?

1.  __ __ __ and __ __ __ 2.  Blood/wound __ __* 3.  Erythrocyte

sedimenta*on rate (ESR) 4.  C reac*ve protein 5.  X-‐ray/__ __/__ __ __ 6.  Bone/SoL Tissue Biopsy 7.  Bone Scans

Fall 2019 - Spring 2020


7

Case Study –ACUTE OSTEOMYELITIS

•  Aggressive, prolonged __ __ an*bio*c therapy – What type of an*bio*cs? – Started in hospital, con*nued at home/ skilled nursing facility

•  Cultures or bone biopsy – What happens when cultures are resulted?

•  Surgical debridement and decompression

•  What treatment would you expect the health care provider to order to treat V.R.’s acute osteomyeli:s?



8

Case Study –CHRONIC OSTEOMYELITIS

•  Casts or braces •  Nega*ve-‐pressure wound therapy (WoundVac)

•  Hyperbaric oxygen therapy •  Removal of prosthe*c devices •  Muscle flaps, skin gra7s, bone gra7s*

•  Amputa*on

•  If V.R.’s infec*on turns into a chronic osteomyeli*s, what treatment op*ons would be available for him?

1. 2. 3.



9

AMPUTATION –AEA, BEA, AKA, BKA

•  Residual limb (stump) – With skin flap – Guillo*ne – Prevent flexion contractures

•  Phantom pain •  Hemorrhage •  Sterile dressing changes •  Prosthesis –  Immediate – Delayed

•  Promote ac*vity

•  Removal of body extremity by trauma or surgery

•  Most done due to PVD, DM, and peripheral neuropathy that progresses to ulcers and gangrene

Preopera*ve Care Ø  Surgicaurgic/Anesthesia

consent Ø  Pre-‐op labs/x-‐rays Ø  Medical clearance* Ø  Teaching General principles of post-‐operative nursing care

Fall 2019 - Spring 2020 10


•  Immobiliza*on/Proper posi*oning/support of extremity

•  Assess and treat pain •  Dressing care –sterile technique •  Pa*ent teaching adverse and toxic reac*ons to an*bio*c therapy –  Ototoxicity, impaired renal func*on, neurotoxicity (older, impaired renal, liver failure)

–  Hives, severe or watery diarrhea (Candida albicans and Clostridium difficile), bloody stools, throat and mouth sores

•  Monitor peak and trough levels –trough common for Vancomycin ² When should RN have it drawn? Explain what the trough is

•  During V.R.’s hospitaliza*on, what is the nurse’s focused assessment related to his leL leg?

1. 2. 3. “SIRS ALERT”èSEPSIS



11


1.  __ __ __ __ 2.  Wound care 3.  Physical and psychologic

support

•  V.R. is discharged to home to complete his IV an*bio*c therapy. ² What type of venous access devise will he need? Explain. ² What important teaching must be done before he is discharged? ² What resources might be helpful for him at his home?



12

Nursing Diagnoses

Nursing Implementa:on •  Health Promo*on – Control other current infec*ons – Persons at risk

•  Are immunocompromised •  Have diabetes, orthopedic prosthe*c devices, vascular insufficiencies

– Encourage to call HCP about local signs

•  Acute pain •  Ineffec*ve health

management •  Impaired physical

mobility

Fall 2019 - Spring 2020 13

Planning –Overall Goals: Evalua*on

•  The pa*ent will – Have sa*sfactory pain management

– Follow treatment regimen – Verbalize confidence in ability to implement treatment plan

– Demonstrate increase in mobility/ range of mo*on

•  Have sa*sfactory pain and fever management

•  Do not experience any complica*ons associated with osteomyeli*s

•  Adhere to treatment plan

•  Maintain a posi*ve outlook on outcome of disease

Fall 2019 - Spring 2020 14

LOW BACK PAIN •  Low back pain common because lumbar region –  Bears most of body weight –  Is most flexible –  Contains nerve roots –  Has poor biomechanical structure

•  Causes –  Lumbosacral strain/instability –  Degenera*ve disc disease/hernia*on –  Osteoarthri*s

•  Direct pa*ent care workers –  the future YOU

•  Leading cause of job-‐related disability –  industrial accident (IA)

•  Major contributor to missed work days

•  Localized •  Diffuse •  Radicular pain •  Referred pain

Fall 2019 - Spring 2020 15

The Concept of Mobility


Altera:on Descrip:on Manifesta:ons Interven:ons and Therapies

Herniated disc

A spinal disc that slips out of place or ruptures

•  Back pain that spreads to the buYocks and legs (herniated disc in lower back)

•  Tingling or numbness

•  Muscle spasms or weakness

•  Limited mobility

•  Rest •  Pharmacologic

therapy to manage pain and prevent muscle spasms

•  Physical therapy •  Complementary

health approaches

•  Surgery to remove or replace the disc

16


Fall 2019 - Spring 2020 17

Low Back Pain

Acute Low Back Pain •  Lasts 4 weeks or less •  Caused by trauma or undue

stress •  Symptoms usually appear

within 24 hours –  Muscle ache to shoo*ng/stabbing

pain –  Limited flexibility/ROM –  Inability to stand upright

Chronic Low Back Pain •  Lasts longer than 3 months or

involves a repeated incapacita*ng episode

•  OLen progressive •  Various causes

–  Degenera*ve or metabolic disease

–  Weakness from scar *ssue –  Chronic strain –  Congenital spine problems

Clinical Manifesta*ons: Pain, decreased mobility

Consider psychosocial ramifica*ons Fall 2019 - Spring 2020 18

Low Back Pain

Acute Low Back Pain •  Few defini*ve diagnos*c

abnormali*es •  Straight-‐leg raising test

–  Posi*ve for disc hernia*on when radicular pain occurs

•  X-‐ray, CT, MRI only for trauma or suspected systemic disease

Chronic Low Back Pain •  Spinal stenosis

–  Narrowing of spinal canal (lumbar vs. cervical)

–  Pain in low back, radiates to buYock and leg

–  ↑ With walking/ prolonged standing

–  Numbness, *ngling, weakness, heaviness in legs and buYocks

–  Pain ↓ when bends forward or sits down

Fall 2019 - Spring 2020 19

Interprofessional Care –ACUTE LOW BACK PAIN

•  Pharmacologic: –  NSAIDs, muscle relaxants –  Severe pain -‐ cor*costeroids, opioids

•  Non-‐pharmacologic: – Massage –  Acupuncture –  Back manipula*on –  Cold and hot compresses –  Transcutaneous electrical nerve s*mula*on (TENS)

–  Brace •  Ac*vity Restric*ons:

–  Brief period of rest may be necessary; Avoid prolonged bed rest*

–  No LiLing, bending, twis*ng, prolonged siqng

Health Promo*on: •  Proper body mechanics •  “Back School” •  Appropriate body weight •  Proper sleep posi*oning;

firm maYress •  Stop smoking •  Ways to prevent addi*onal

episodes •  Strengthening and stretching

exercises (PT/OT)

Goal is to make an episode of acute low back pain an isolated incident

Fall 2019 - Spring 2020 20

Low Back Pain Pa*ent Teaching •  Do:

–  Sleep in a side-‐lying posi*on with knees and hips bent

–  Sleep on back with a liL under knees and legs or back with 10-‐inch-‐high pillow under knees to flex hips and knees

–  Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing

–  Maintain appropriate body weight –  Exercise 15 minutes in the

morning and evening regularly –  Carry light items close to body –  Use local heat and cold applica*on –  Use a lumbar roll or pillow for

siqng

•  Do Not:

Fall 2019 - Spring 2020 21

Interprofessional Care –CHRONIC LOW BACK PAIN

•  Pharmacologic: – Mild analgesics (NSAIDs, muscle relaxants)

– An*depressants: duloxe*ne (Cymbalta)

– An*seizure: gabapen*n (Neuron*n) –  Epidural cor*costeroid injec*ons –  Implanted devices to deliver analgesia

•  Non-‐pharmacologic –same as acute

•  Surgery *

•  Weight reduc*on •  Sufficient rest periods •  Local heat and cold

applica*on •  Physical therapy •  Exercise and ac*vity

throughout day •  Complementary and

alterna*ve therapies •  “Back School”

Fall 2019 - Spring 2020 22

When caring for a pa*ent following a lumbar laminectomy, the nurse should a.  Place a pillow between the pa*ent’s legs before

turning to the side. b.  Elevate the head of the bed 30 degrees and then turn

the pa*ent to the side. c.  Ask the pa*ent to flex the knees and push the heels

into the bed during turning. d.  Have the pa*ent grasp the side rail on the opposite

side of the bed to help with turning.

Audience Response Question

Fall 2019 - Spring 2020 23

Interprofessional Care –CHRONIC LOW BACK PAIN SURGICAL CANDIDATE

•  Degenera:ve disc disease (DDD) – Loss of elas*city, flexibility, and shock-‐absorbing capabili*es

– Disc becomes thinner as nucleus pulposus dries out → load shiLed to annulus fibrosus → progressive destruc*on →pulposus seeps out (herniates)

•  Herniated disc (slipped disc) – Age, repeated stress, trauma – Osteoarthri*s

L4-‐5 and L5-‐S1*Radiculopathy

Fall 2019 - Spring 2020 24

Interprofessional Care –CHRONIC LOW BACK PAIN SURGICAL CANDIDATE Clinical Manifesta*ons: •  Low back pain most

common •  Radicular pain •  + Straight leg raise •  ↓ or absent reflexes •  Paresthesia •  Muscle weakness


•  Mul*ple nerve root (cauda equina) compression –  Sever low back pain –  Progressive weakness –  Increased pain –  Bowel and bladder incon*nence

MEDICAL EMERGENCY

Fall 2018

25


•  Laminectomy –  Surgically remove disc through excision of

part of vertebra •  Diskectomy

–  Surgically decompress nerve root •  Ar:ficial disc replacement

–  Surgically placed in spine through small incision aLer damaged disc is removed

–  Allows for movement at level of implant

SURGICAL THERAPY (Outpa:ent/Inpa:ent): Preopera*ve Care Ø  Surgical/Anesthesia

consent Ø  Pre-‐op labs/x-‐rays Ø  Medical clearance *RN preopera*ve “Baseline” physical assessment

Fall 2019 - Spring 2020 26

Intervertebral Disc Disease Surgical Therapy

•  Spinal fusion – Spine is stabilized by crea*ng an ankylosis (fusion) of con*guous vertebrae

– Uses a bone graL from pa*ent’s fibula or iliac crest or from a donated cadaver bone

– Metal fixa*on can add to stability

– Bone morphogene*c protein (BMP) to s*mulate bone grown of graL

Fall 2019 - Spring 2020 27


•  Maintain proper alignment

•  Allowed ac*vity varies •  Post lumbar fusion – Pillows under thighs when supine

– Between legs when side-‐lying

•  Reassure pa*ent

Fall 2019 - Spring 2020 28


•  Frequent neurovascular checks Q2-‐4 hours during first 48 hours post-‐op – What does this include?

•  Compare with preopera*ve status

•  Pain management – Opioids for 24 to 48 hours – Pa*ent-‐controlled analgesia (PCA)

– Switch to oral drugs when able – Muscle relaxants

SURGICAL THERAPY: Postoperative Care –Spinal Surgery Ø  General principles of post-‐

operative nursing care Ø  CBC,F&E ,I&O, IVF Ø  Hemovac drains, JP, FC Ø  Diet Ø  Activity Ø  VTE prophylaxis Ø  Prevent complications of

immobility

Fall 2019 - Spring 2020 29


•  Prolonged limited ac*vity •  Thoracic –lumbar-‐sacral orthosis (TLSO brace) – Verify and teach how to apply

SURGICAL THERAPY: Postoperative Care –Spinal Surgery •  Ac*vity Order: OOB w/

TLSO brace on at all *me, okay to be off while in bed •  Apply and remove while

logrolling in bed •  Apply brace while siqng

or standing posi*on

Fall 2019 - Spring 2020 30


•  Spinal Surgery Complica*ons: – Poten*al for cerebrospinal fluid (CSF) leakage è headache or slightly yellow drainage on dressing; + For glucose

•  GI and bowel func*on (paraly*c ileus) – Administer stool soLeners

•  Bladder emptying – Loss of tone may indicate nerve damage

•  No*fy surgeon immediately if bowel or bladder incon*nence

SURGICAL THERAPY: Postoperative Care –Spinal Surgery •  Assess bone graft donor site

Fall 2019 - Spring 2020 31


1.  Follow up ______________ 2.  Diet 3.  A_______________ 4.  I__________C__________ 5.  Medica*ons –what type?

Important teaching? 6.  When to seek medical

emergency:

Postoperative Care –Spinal Surgery Discharge Instructions ²  What post-‐operative mile

stones will lead the nurse to anticipate discharge?

²  What topics will the nurse discuss upon discharge?

Fall 2019 - Spring 2020 32

OSTEOPOROSIS The “Silent Thief”

Chronic, progressive metabolic bone disease marked by Low bone mass

Deteriora*on of bone *ssue Leads to increased bone fragility

ADD PICTURE

Fall 2019 - Spring 2020 33


•  What is this pa*ent at risk for?

•  Preven*ve factors –  Regular weight-‐bearing exercise

–  Fluoride –  Calcium –  Vitamin D (Why?)


•  Remodeling –  Osteoblasts – deposit bone –  Osteoclasts – resorb bone

•  In osteoporosis, bone resorp*on exceeds bone deposi*on

34


Which pa*ent would be at greatest risk for developing osteoporosis? a.  A 73-‐year-‐old man who has five alcoholic drinks per week and

limits sun exposure to prevent recurrence of skin cancer. b.  An 84-‐year-‐old man who has recently been diagnosed with

hypothyroidism and is prescribed levothyroxine (Synthroid). c.  A 69-‐year-‐old woman who had a renal transplant 5 years ago

and has been taking prednisone to prevent organ rejec*on. d.  A 55-‐year-‐old woman who recently had a hysterectomy with

bilateral salpingo-‐oophorectomy and refuses estrogen therapy.

Fall 2019 - Spring 2020 35

OSTEOPOROSIS Why is it more common in women? •  Lower calcium intake •  Less bone mass •  Bone resorp*on begins

earlier and becomes more rapid at menopause

•  Pregnancy and breasyeeding

•  Longevity Screening Guidelines: •  Ini*al bone density test in

women over age 65 •  Currently no evidence of

benefit for screening in men

Fall 2019 - Spring 2020 36

Interprofessional Care –OSTEOPOROSIS Focus on

1.  Proper nutri*on 2.  Calcium supplements 3.  Exercise 4.  Preven*on of fractures 5.  Drug therapy

Clinical Manifesta:ons: •  Occurs most commonly in

spine, hips, and wrists •  Back pain •  Spontaneous fractures •  Gradual loss of height •  Kyphosis or “dowager’s hump “ Diagnos:c Studies: •  History and physical exam •  X-‐ray and lab studies not

diagnos*c •  Bone mineral density

(BMD)Quan*ta*ve ultrasound (QUS)Dual-‐energy x-‐ray absorp*ometry (DXA)

Fall 2019 - Spring 2020 37

Interprofessional Care -‐OSTEOPOROSIS Adequate calcium intake: •  1000 mg/day for

–  women ages 19-‐50 years –  Men ages 19-‐70 years

•  1200 mg/day for –  Women 51 years or older –  Men 71 years or older


Supplemental calcium: •  Take in divided doses •  Calcium carbonate

–  40% elemental calcium –  Take with meals

•  Calcium citrate –  20% elemental calcium –  Less dependent on stomach acid

•  Vitamin D necessary for calcium absorp*on/func*on; bone forma*on

•  Sunlight for 20 minutes adequate •  Supplemental (800-‐1000 IU/day)

–  Postmenopausal –  Older adults –  Homebound/long-‐term care –  Minimal sun exposure

38

Interprofessional Care -‐OSTEOPOROSIS •  Weight-‐bearing exercise:

–  Build up and maintain bone mass

–  Increase strength, coordina*on, balance

– Walking, hiking, weight training, stair climbing, tennis, dancing

•  Preven:on of Fracture: –  Quit smoking –  Decrease alcohol intake

Drug therapy to inhibits bone resorp:on: •  Bisphosphonates

–  Side effects: anorexia, weight loss, gastri*s

–  Proper administra*on •  Take with full glass of water •  Take 30 minutes before food or

other meds •  Remain upright for at least 30

minutes •  Calcitonin

–  Give IM form at night to minimize side effects

–  Alternate nostrils when using nasal form –  Calcium supplementa*on is needed

•  Selec*ve estrogen receptor modulators –  Raloxifene (Evista) –  Reduces bone resorp*on

Fall 2019 - Spring 2020 39


Alendronate (Fosamax) is prescribed for a pa*ent with osteoporosis. The nurse teaches the pa*ent that a.  The drug must be taken with food to prevent GI side

effects. b.  Bisphosphonates prevent calcium from being taken

from the bones. c.  Lying down aLer taking the drug prevents light-‐

headedness and dizziness. d.  Taking the drug with milk enhances the absorp*on of

calcium from the bowel.

Fall 2019 - Spring 2020 40

chapter 63 musculoskeletal problems fall 2019lahc323325.weebly.com/uploads/1/1/0/6/110686185/... ·...

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