Chapter 46

Linda S. Williams / Paula D. Hopper

Understanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th Edition

Chapter 46

Nursing Care of Patients withMusculoskeletal and Connective Tissue

Disorders

Linda S. Williams / Paula D. HopperUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th Edition

Bone and Soft Tissue Disorders

Strain Sprain Dislocation Bursitis Rotator Cuff Injury

Carpal Tunnel Syndrome Median Nerve Compression in Wrist’s

Carpal Tunnel Occurs with Swelling in Tunnel Finger, Hand, Arm Pain/Numbness

Carpal Tunnel Syndrome (cont’d) Relieve Inflammation and Rest Wrist

Splint Anti-inflammatory Surgery

Teach Prevention

Fractures Break in a Bone Cause

Trauma Pathological (From Disease )

Open – Breaks Skin Closed – Does Not Break Skin

Types of Fractures

Signs and Symptoms Pain Decreased ROM Limb Rotation Deformity, Shortening of Limb Swelling Bruising

Diagnostic Tests X-Ray CT scan

Emergency Treatment Splint It As It Lies! Seek Medical Treatment

Fracture Management Goals

Realignment of Bone Ends Immobilization

Fracture Healing Phases

Closed Reduction Manual Realignment Bandages/Splints Casts Traction

Skin Skeletal

Types of Skin Traction

Balanced Suspension and Skeletal Traction

Fracture Management (cont’d) Open Reduction with Internal Fixation External Fixation

External Fixation

Complications of Fractures Nonunion Neurovascular compromise Hemorrhage Infection Thromboembolitic Complications Acute Compartment Syndrome Fat Embolism Syndrome

Compartment Syndrome

Bivalving Cast

Nursing Diagnoses Acute Pain Impaired Physical Mobility Impaired Walking Ineffective Health Maintenance Risk for Peripheral Neurovascular

Dysfunction

Nursing Diagnoses (cont’d) Risk for Ineffective Tissue Perfusion Risk for Ineffective Skin Integrity

Palming the Cast

Nursing Care Cast Care Traction Care Pain Control Neurovascular Checks Skin Care Nutrition

Nursing Care (cont’d) Self Care Deficits Psychosocial

Patient Education Cast Care Pin Care Nutrition

Osteomyelitis Infection of Bone Prevention is Key! Fever, Redness, Heat, Pain, Swelling, Pain Long-term Antibiotic Therapy Incision and Drainage Amputation

Osteomyelitis (cont’d)

Osteomyelitis (cont’d) Nursing Care

Medication Teaching Hand Hygiene Sterile Dressing Changes

Osteoporosis Low Bone Mass as Bone Loses Density Prone to Fractures Occur Spine, Wrist, Hip Most Common All Bones Affected

Osteoporosis Prevalence 10 Million People

8 Million Females 2 Million Males

Over Age 50 Fractures 1 in 2 Women 1 in 4 Men

Osteoporosis Fracture Effects Hip/Vertebral Fractures

Reduced Quality of Life Increased Disability Risk of Death (During Year After Fracture)

Osteoporosis Prevention Build Bone Through Age 30 Obtain Adequate Calcium and Vitamin D Exercise (Especially Childhood ) Avoid Alcohol and Smoking

Osteoporosis (cont’d) Imbalanced Remodeling Process

Osteoporosis Risk Factors Aging Female Caucasian/Asian Fracture History Family History Petite Body Build Postmenopausal Women

Osteoporosis Risk Factors (cont’d) Low Testosterone and Estrogen Low Calcium Intake Low Vitamin D Excessive Caffeine, Protein, Sodium Sedentary Lifestyle Excessive Alcohol Use Cigarette Smoking

Osteoporosis (cont’d) Signs and Symptoms

Dowager’s Hump Kyphosis Height Decreases Back Pain Fracture

Osteoporosis (cont’d) Body System Effects Functional Effects Emotional effects Socialization

Osteoporosis Diagnostic Tests

Dual-energy X-Ray Absorptiometry Serum Calcium, Vitamin D Decreased Serum Phosphorus Increased Serum Alkaline Phosphatase Increased

Osteoporosis Therapeutic Interventions

Reduce Risk Factors Calcium Supplements Vitamin D Supplements Medications

Antiresorptive Medications Bisphosphonates

Alendronate (Fosamax) Ibandronate (Boniva) Risedronate (Actonel) Zoledronic acid (Reclast)

Calcitonin (Fortical, Miacalcin)

Antiresorptive Medications (cont’d)

Selective Estrogen Receptor Modulator Raloxifene (Evista)

Estrogen Therapy

Anabolic (Bone Forming) Teriparatide (Forteo)

Osteoporosis Nursing Care Pain Relief Symptom Management Education

Diet: Increase Calcium, Vitamin D Exercise Medication

Fall Prevention

Paget's Disease Increased Bone Loss Disorganized Bone Deposits No Obvious Symptoms Usually X-Ray, Bone Scan Calcitonin (Calcimar) Relieve Pain, Teach, Promote Life Quality

Bone Cancer Primary Malignant Tumors

Osteosarcoma Most Common 50% Occur in Distal Femur in Young Men Metastasizes to Lung Within 2 Years

Bone Cancer (cont’d) Primary Malignant Tumors

Ewing’s Sarcoma Most Malignant

Chrondrosarcoma Cancer of Cartilaginous Cells Better Prognosis

Primary Bone Cancer Therapeutic Interventions

Surgery, Chemotherapy, Radiation

Nursing Care Postoperative Care Supportive

Metastatic Bone Disease Bone-seeking Cancers

Prostate, Breast, Lung, Thyroid

Pathological Fractures Severe Pain Therapeutic Interventions

Radiation

Metastatic Bone Disease (cont’d) Nursing Care

Supportive Care as with Other Cancers

Gout Pathophysiology

Systemic Connective Tissue Disorder Uric Acid Build Up Urate Crystals Deposited in Joints/Connective

Tissues Severe Inflammation

Causes and Types Primary – Inherited Problem with Purine

Metabolism Secondary – Another Health Problem

Signs and Symptoms Acute

Swollen, Red, Hot, Painful Inflamed Joints Great Toe

Chronic Gout Urate Deposits Under Skin Renal Stones

Diagnostic Tests Serum Uric Acid Joint Fluid – Uric Acid Crystals

Therapeutic Interventions Medication

Colchicine NSAIDs Allopurinol (Zyloprim) Probenecid (Benemid)

Nursing Care Teaching

Diet: Avoid Foods High in Purines Avoid Aspirin, Diuretics, Alcohol Increase Fluids

Systemic Lupus Erythematosus

Autoimmune Disease Genetic Link Remissions and Exacerbations Systemic Type Skin Type – Discoid Lupus Erythematosus

Pathophysiology Abnormal Antibodies Immune Complex Formation Complement System Activation Affects Connective Tissue

Signs and Symptoms Butterfly Rash Photosensitive Fever Fatigue, Malaise Arthralgia, Myalgia Weight Loss

Signs and Symptoms (cont’d) Mucosal Ulcers Alopecia Skin Lesions

Diagnostic Tests Biopsy Erythrocyte Sedimentation Rate Immunological Tests

Antinuclear Antibody Titers Antibodies Against SR Proteins

Therapeutic Interventions NSAIDs Corticosteroids Antimalarials Immunomodulating Drugs Topical Cortisone Chloroquine (Aralen)

Nursing Diagnoses Acute Pain Chronic Sorrow Fatigue Disturbed Body Image

Nursing Diagnoses (cont’d) Ineffective Coping Ineffective Health Maintenance Powerlessness Risk for Impaired Skin Integrity Self-care Deficit

Patient Education Skin Care Avoid Prolonged Exposure to Sunlight Exercise Immunization Stress Reduction Community Support Groups

Scleroderma Inflammation Develops into Fibrosis and

Sclerosis of Tissues Autoimmune Response Progress Very Rapidly Remissions and Exacerbations Poor Prognosis

Signs and Symptoms Arthritis, Fatigue Scleroderma

Pitting Edema, Tightening, Hardening, Thickening of Skin Tissue

Loss of ROM Contractures

Diagnosis History Physical

Therapeutic Interventions Steroids Immunosuppressant Antacids, Histamine Blockers Rehabilitative Therapy

Nursing Care Pain Control

Bed Cradle Sock/Gloves

Skin Protective Mild Soaps and Lotions

Nursing Care (cont’d) Small, Frequent, Bland Meals

Cut Food into Small Pieces Thicker Liquids

Osteogenesis Imperfecta Congenital Abnormality Characterized by

Skeletal Bone Fragility Brittle Bones Disease Pathological Fractures Collagen Synthesized Abnormally

Osteogenesis Imperfecta (cont’d) Signs and Symptoms

Fragile Bones Triangular Shaped Face Potential Hearing Loss Scoliosis Loose Joints

Osteogenesis Imperfecta (cont’d) Signs and Symptoms (cont’d)

Alterations in Muscle Tone or Development Blue, Purple, Grey Tint to Sclera Brittle or Discolored Teeth Smooth, Thin Skin

Osteogenesis Imperfecta (cont’d) Diagnosis

History of Fractures Physical Skin Biopsy

Osteogenesis Imperfecta (cont’d) Therapeutic Interventions

No Treatment Fracture Care

Osteogenesis Imperfecta (cont’d) Nursing Care

Careful Handling Teaching Support Groups

Osteogensis Imperfecta Foundation

Polymyositis Diffuse Inflammation of Skeletal Muscle Dermatomyositis – with Rash Progressive Remissions and Exacerbations Women Greater Than Men Treatment: Prednisone

Polymyositis (cont’d) Nursing Care

Supportive Care Education

Muscular Dystrophy Group of Nine Disorders Loss of Muscle Tissue Progressive Muscle Weakness Genetic Skeletal Muscle Fibers Degenerate,

Atrophy

Therapeutic Interventions Supportive Care Prevention of Complications Gene Therapy Research

Nursing Diagnoses Impaired Physical Mobility Ineffective Breathing Pattern Self-care Deficits Deficient Knowledge

Osteoarthritis Degenerative Joint Disease (DJD) Common

Pathophysiology Articular Cartilage/Joints Bone Ends

Deteriorate Joint Space Narrows, Bone Spurs Develop,

Joint Inflamed Joint Deformities, Pain, Immobility Weight-bearing Joints

Joints Affected by Osteoarthritis

Causes Unknown Risk Factors

Aging Obesity Excessive “Wear and Tear” on Synovial Joints

Signs and Symptoms Joint Pain

Intensifies After Physical Activity

Stiffness Heberden’s and Bouchard’s Nodes

Bony Nodes on Joints of Fingers

Diagnostic Tests X-Rays CT scan MRI Synovial Fluid Analysis

Therapeutic Interventions No Cure Medication

NSAIDs

Rest and Exercise Heat or Cold Weight Control

Therapeutic Interventions (cont’d) Complementary Therapies

Imagery, Music Therapy, Acupressure, Acupuncture

Surgery Total Joint Replacement

Nursing Diagnoses Chronic Pain Activity Intolerance Chronic Sorrow Disturbed Body Image Impaired Physical Mobility

Nursing Diagnoses (cont’d) Self-care Deficit Ineffective Health Maintenance

Patient Education Protect Joints Conserve Energy

Rheumatoid Arthritis Chronic, Progressive, Systemic

Inflammatory Disease Destroys Synovial Joints and Other

Connective Tissues Includes Major Organs

Rheumatoid Arthritis (cont’d)

Pathophysiology Synovitis Synovium Thickens, Fluid Accumulates Destructive Pannus Erodes Joint Cartilage,

Destroys Joint Bone Pannus Converted to Bony Tissue

Pathophysiology (cont’d) Joint Deformity Other Connective Tissue Affected

Etiology Unknown Genetic Predisposition Environmental Autoimmune Response – Antibodies

(Rheumatoid Factor) Local and Systemic Inflammation

Signs and Symptoms Remissions and Exacerbations Varies by Individual

Signs and Symptoms (cont’d) Early Symptoms

Bilateral, Symmetrical Joint Inflammation Reddened, Warm, Swollen, Stiff, Painful Stiffness After Resting Activity Decreases Pain and Stiffness Low Grade Fever, Weakness, Fatigue,

Anorexia

Signs and Symptoms (cont’d) Late Symptoms

Joint Deformity Secondary Osteoporosis

Joint Abnormalities in Rheumatoid Arthritis

Diagnosis Rheumatoid Factor (RF) Red Blood Cell (RBC) C4 Complement Decreased

Erythrocyte Sedimentation Rate (ESR) Antinuclear Antibody (ANA) C-reactive Protein (CRP)

Therapeutic Interventions Medication

Disease-modifying Antirheumatic Drugs Leflunomide (Arava) Etanercept (Enbrel)

Therapeutic Interventions (cont’d) Medication (cont’d)

Methotrexate Gold Prednisone NSAIDs

Therapeutic Interventions (cont’d) Heat/Cold Balanced Rest and Activity Surgery – Total Joint Replacement

Nursing Diagnoses Acute Pain Disturbed Body Image Fatigue Self-care Deficit Impaired Physical Mobility Deficient Knowledge

Patient Education Disease Process Medication Management Rest and Exercise Vocational Counselor Community Resources

Total Hip Replacement Acetabular Cup Inserted Into Pelvic

Acetabulum Femoral Component Inserted Into Femur

Total Hip Replacement (cont’d) Preoperative Care

Total Joint Education Programs Autologous Blood Donation

Total Hip Replacement (cont’d) Postoperative Care to Prevent

Complications Hip Dislocation

Prevent Adduction or Hyperflexion

Skin Breakdown Prevent Pressure Ulcers

Abductor Pillow

Hip Flexion After Total Hip Replacement

Total Hip Replacement (cont’d) Pain

Provide Pain Relief

Infection Prophylactic Antibiotics

Coughing and Deep Breathing Incisional Care

Total Hip Replacement (cont’d) Bleeding

Monitor Incision/Drainage from Drain

Neurovascular Compromise Neurovascular Checks

Total Hip Replacement (cont’d) Ambulation

Physical Therapy Use Walker/Crutches

Total Hip Replacement (cont’d) Thromboembolitic Complications

Compression Devices Leg Exercises

Enoxaparin (Lovenox)

Total Hip Replacement (cont’d) Self-care

Assistive Dressing Devices Raised Toilet Seat Rehabilitation

Total Knee Replacement Femoral Component, Tibial Component,

Patellar Button Dislocation Not a Concern Care like Total Hip Replacement Continuous Passive Motion Machine

Continuous Passive Motion Machine

AmputationRemoval of a body part

Amputation (cont’d) Surgical Amputations

Ischemia from Peripheral Vascular Disease Bone Tumor, Frostbite, Congenital Problems,

Infections

Amputation (cont’d) Traumatic Amputations

Accidents

Amputation (cont’d) Replantation

Wrap Severed Body Part in Cool, Slightly Moist Cloth

Place in Sealed Plastic Bag Submerged in Cold Water

Transported to Hospital

Amputation (cont’d) Levels of Amputation

Below-the-knee (BKA) Above-the-knee (AKA) Below-the-elbow (BEA) Above-the-elbow (AEA)

Amputation Nursing Care Preoperative Nursing Diagnoses

Deficient Knowledge Teach Preoperative Procedures

Disturbed Body Image Begin Support Services

Amputation Nursing Care (cont’d)

Postoperative Hemorrhage Prevention Infection Pain Control

Phantom Pain

Mobility and Ambulation

Bandaging for Above-the-Knee Amputation

Amputation Nursing Care (cont’d)

Postoperative Nursing Diagnoses Prosthesis Lifestyle Adaptation

Chapter 46

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