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