Transcript Nursing Care of Clients with Musculoskeletal Disorders

Nursing Care of Clients with
Musculoskeletal Disorders
Chapter 43
1
Gout
Inflammatory response to high levels of uric
acid in body
 Primary gout

–

characterized by elevated uric acid levels from
error of purine metabolism
Secondary gout
–
results from a treatment or disease
 leukemia,
CRF, meds.
2
Gout

Manifestations
–
1. hyperuricemia
–
–
–
–
–
levels 9-10mg/dL
recurrent attacks of inflammation of single joint
tophi in and around the joint
renal disease and stones
2. Acute gouty arthritis
–
–
–
–
single joint - red, swollen, hot, painful
triggered by trauma
elevated WBCs, ESR
last hours to weeks
3
Gout

3. Chronic gout
–
–
–
–

occurs when hyperuricemia not treated
tophi develop in cartilage, synovial membranes
tendons and soft tissue
urate crystals
may lead to kidney disease
Treatment
–
end acute attacks and prevent recurrence
4
Urate Crystals in a tophi
5
Gout Affects many Joints
6
7
Gout

Diagnostic tests
–
–

uric acid above 7.5mg/dL
elevated WBC and ESR
Medications
–
–
–
–
NSAIDs - indocin
cochicine - interrupts the uric crystal cycle
corticosteroids
Zyloprim - lowers serum uric acid levels
8
TABLE 43-6 (continued) Giving Medications Safely: Gout
Gout

Dietary
–
–
–

low-purine diet – avoid liver, meats, seafood,
beans
lose wt
avoid ETOH or foods known to precipitate gout
Other Treatments
–
acute attack
 B/R,
elevate joint with hot/cold compress, increase
fluid intake
11
Gout
Definition
Clinical manifestations
Hyperuricemia
Acute gouty arthritis
Chronic gout
Treatment?
12
Osteoarthritis - Joints affected
13
Healthy Joint
14
15
16
17
18
Degenerative Joint Disease
Osteoarthritis OA
Most common form of all arthritis
 loss of articular cartilage in joints and
hypertrophy of bones at articular margins
 causes are idiopathic or secondary
 Risk Factors

–
–
age
inactivity
excessive wt
repetitive exercise
19
Osteoarthritis

Patho
–
–
degeneration of cartilage lining, bone thickens
and that reducing the ability to absorb energy in
joint load
osteophytes form, change the joint, these spurs
enlarge, break off and lead to synovitis
20
Inflamed Joint Changes
21
Joint Narrowing
22
23
Osteoarthritis OA

Manifestations
–
–
–
–
–
–
–
gradual, insidious
pain, stiffness in one or more joints
pain aggravated by use and relieved by rest
immobility are followed by stiffness
decrease ROM, joint crepitus during movement
joint enlargement
flexion contractures
24
Changes in the hip
25
Patho of Osteoarthritis
26
Changes in the Knee
What might your
client be feeling?
27
Osteoarthritis

Diagnostic tests
–

changes are seen on X-ray
Medications
–
–
–
–
pain management ASA, tyl., NSAIDs, topical creams
celebrex - fewer GI side effects
vioxx - recalled - heart arrhythmia, death
corticosteriod injection of joints
28
Osteoarthritis

Conservative treatment
–
–
–
–
–
P.T
rest of involved joints
using ambulation devices
wt loss
analgesic and anti-inflammatory meds
29
Late Stage Osteoarthritis
30
Osteoarthritis OA

Surgery
–
arthroscopy
 debridement
–
and lavage involved joints
osteotomy
 incision
into bone to realign affected joint
 shift joint load toward areas of less cartilage damage
–
Joint arthroplasty
 reconstruction
or replacement of joint
31
32
Osteoarthritis

Joint Arthroplasty
–
–
usually TJR - replaces both articulating surfaces
Cemented vs uncemented
 most
uncemented, porous, new bone growth 6
weeks, requires longer time of non-wt bearing, lasts
longer
 cemented - inflammation eventually loosen joint
33
Osteoarthritis OA

Complications
–
–
–
–
–
infections
dislocation
loosening of prosthesis
impaired circulation
thromboembolism
34
Osteoarthritis OA

Total Hip Replacement THR
–

Total knee replacement
–

articular surfaces of acetabulum and femoral
head are replaced success rate >90%
vigorous rehab, success rate > 80%
Total shoulder and elbow
–
indicated for unremitting pain and limited ROM
35
Total hip replacement
36
Total Joint Replacement Knee
37
Nursing Care
Promote comfort
 Maintain mobility
 Assist with adaptation of life-style
 Health Promotion

–
–
maintenance of normal wt.
Regular moderate exercise
38
Gout vs. arthritis? Which is it?
39
Autoimmune and Inflammatory
Disorders - Rheumatoid arthritis

Chronic systemic disease causing
inflammation to connective tissue in joints
–
–
–
–
3x more likely in females
onset 20-40 years
course and severity variable
cause unknown - genetic, environmental,
hormonal, infectious agents - Epstein barr
40
41
Rheumatoid Arthritis
42
Rheumatoid arthritis

Patho
–
synovial membrane damaged
from inflammatory and immune
processes, leads to erosion of
articular cartilage and
inflammation of ligament and
tendons
43
Rheumatoid arthritis

Joint Manifestations
–
Onset
 insidious

or after a stressor
Systemic
–
fatigue, anorexia, wt loss, non-specific aching and
stiffness precede joint involvement
 Joint
–
–
swelling, stiffness, warmth, tenderness and pain, multiple
joints and symmetric involvement
fingers, wrists knees, ankles and toes
44
Rheumatoid arthritis

Extra-articular
–
–

low grade fever, anemia, rheumatoid nodules in
subcutaneous tissue
pleural effusion, pericarditis, splenomegaly
Collaborative Care
–
–
–
relief of pain and inflammation
slow or stop joint damage
improve well-being and ability to function
45
47
Arthritic hands
48
Early and Late Stages
Swan neck deformity
Ulnar deviation
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50
Knee
51
Arthritic Hip
52
Rheumatoid arthritis

Diagnostic tests
–
–
–
–
–
Rheumatoid factors (RF) autoantibodies to IgG
ESR - indicator of inflammation - often used to
evaluate effectiveness of treatment plan
synovial fluid
X-rays
CBC
53
Rheumatoid arthritis

Medications
–
ASA, NSAIDs
 tx
symptoms, no effect on disease progression,
many GI side effects
–
corticosteroids
 reduce
pain, inflammation, slows progression
 long-term side effects
54
Rheumatoid arthritis

Disease-modifying - antirheumatic drugs
–
gold compounds
 weekly,
IM injections
 watch for toxic reactions
–
–
antimalarial agents, sulfasalzine
Immunosuppressive and cytoxic drugs
 methotrexate
–
intra-articular corticsteroids
55
Rheumatoid arthritis

Treatments
–
balanced program of rest and exercise
 rest
with exacerbation - utilize splints
 exercise to maintain ROM, muscle strength
 low impact exercises
–
–
–
P.T. and O.T
heat and cold
assistive devices and splints
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Rheumatoid arthritis
–
Diet
 well-balanced,
–
omega-3 fatty acids
Surgeries
 synovectomy,
arthodesis, joint fusion, arthoplasty,
TJR

Nursing Diagnosis
–
Chronic pain, Fatigue, Ineffective Role
Performance, Disturbed Body Image
57
Normal - Rheumatoid - Osteo - Joint
58
Rheumatoid Arthritis
What is it?
How is it different from osteoathritis?
How would you assess for it?
What’s the treatment?
Nursing care?
59
60
Aids to promote usual ADL’s
61
Septic Arthritis
Occurs when joint space invaded by
pathogens - staph, strep, E. coli,
pseudomonas
 Risk factors

–
–
–
persistent bactermia
previous joint damage
arthroscopic surgery and TJR
62
Septic
arthritis
63
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Septic Arthritis
–
Onset
 abrupt
with pain and stiffness, joint is red, swollen,
hot and tender to touch
 systemic - chills and fever

Collaborative Care
–
–
requires prompt treatment to preserve joint
function
joint aspiration and X-ray
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Septic Arthritis

Treatment
–
rest, immobilization and elevation
antibiotics
recurrent joint aspiration
P.T.
–
Nursing Care - education, prevent disease
–
–
–
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Osteoporosis
- loss of bone mass, increased bone
fragility, increased risk for fx
 Risk Factors

–
–
depends on amount of bone mass achieved
between 25-35 yrs old
Unmodifiable
 aging
 gender
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–
–

Ethnicity
Endocrine disorders affecting metabolism
Modifiable risk factors
–
–
–
–
–
calcium
menopause, decreasing estrogen
cigarette smoking
excessive ETOH intake
sedentary life style
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Osteoporosis
69
Osteoporosis
70
Osteoporosis

Patho
–
–
–
diameter of bone increases, thinning outer
supportive cortex
spongy tissue lost and outer cortex thins
minimal stress leads to fx
71
Cross Section of Bone
72
Bone X-ray
73
Osteoporosis of the Spine
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Osteoporosis

Manifestations
–
–
–
–
–
“silent disease”
loss of height
progressive curvature of spine
low back pain
fx of forearm, spine or hip
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Osteoporosis

Complications
–
fx
 may
be spontaneous or resulting from every day
activities
–

persistent pain and posture changes
Diagnostic Tests
–
–
X-ray
DEXA - measure bone density mass
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How Injuries can occur
77
Osteoporosis

Medications
–
estrogen replacement therapy
 reduces
bone loss
 increases bone density in spine and hip
 controversial - increase risk of endometrial and
breast cancer, cardiovascular disease
–
–
Biphosphonates - fosamax
Calcitonin - can be nasal spray
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Osteoporosis

Health Promotion
–
–
Calcium intake
Exercise
 activity
–
that is wt. Bearing
Health related behaviors
 no
smoking
 limit ETOH, caffeine, soda
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Ospeoporosis
80
Osteoporosis
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Paget’s Disease - bone enlarging
and softening
83
Paget’s Disease

Progressive skeletal disorder where bones
become larger and softer
–

femur, pelvis, vertebrae, sternum, skull
Manifestations
–
–
bone pain, aggravated by pressure and wt.
Bearing and noticed at night
warmth over bones
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Paget’s Disease

Complications
–
–

osteoarthritis
pathological fx
Treatment
–
–
hip or knee replacement
braces
85
Osteomalacia
Is a metabolic bone disease
Affects the structure and integrity of
bone
 Known as adult rickets

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Osteomalacia

Caused by inadequate mineralization of
bone
–
–
–
–
Insufficient amounts of calcium or phosphate
Bone does not harden
Bone is deformed and unable to bear weight
Pathologic fractures occur
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Osteomalacia

Pathophysiology
–
Lack of vitamin D
 Obtained
by certain foods and radiation from the sun
 Vitamin D is necessary to maintain calcium and
phosphate levels

Risk factors
 Inadequate
intake and/or impaired absorption
 Chronic kidney or liver disease
88
Osteomalacia

Manifestations
–
–
–
–
–
–
Bone pain
Difficulty changing positions
Muscle weakness
Waddling gait
Dorsal kyphosis
Pathologic fractures
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Osteomalacia

Diagnostic tests
–
–

Bone x-rays
Lab tests – calcium and alkaline phosphatase
Treatment
Adequate vitamin D, calcium, and phosphate intake
or supplements
Bisphosphonates and calcitonin
Teach exercise and how to prevent falls
90
Paget’s - bone enlarging and
softening
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Lets Review
Osteoporosis
definition
risk factors
clinical manifestations
#1 complication
92
Oops, did I pump it too high?
94
Ankylosing Spondylitis
Chronic inflammatory arthritis affecting
axial skeleton leading to pain and
progressive stiffening and fusion of the
spine
 Patho

–
inflammation - scar tissue - gradual
calcification - joint consolidations and
immobility
95
96
Ankylosing Spondylitis
97
Ankylosing Spondylitis

Manifestations
–
–
–
–
gradual and insidious
bouts of low back pain worse at night, followed
by morning stiffness relieved by activity
back motion become limited
intermittently wit mild to moderate acute
episodes
98
Ankylosing Spondylitis

Collaborative Care
–
–
P.T. and daily exercise
NSAIDs, topical or intra-articular
corticosteroids
99
Changes in the axial spine
100
Ankylosing Spondylitis
Which part of the skeletal system is affected?
What are the clinical manifestations?
Nursing care?
101
More Ortho
Here’s the BIG question
What will be be discussing next?
102
Systemic Lupus Erythematosus
Affects Connective Tissue
 Chronic inflammatory immune complex
connective tissue disease affecting multiple
body systems
 affects females of child bearing years
 cause unknown
 mild chronic cases with remissions and
exacerbation.

103
Systemic Lupus Erythematosus

Manifestations
–
Early
 fever,
anorexia, malaise, wt. Loss, multiple
arthalgias and symmetric non-deforming
polyarthritis
–
Skin
 red
butter fly rash across cheeks and bridge of nose
 photosensitivity
 alopecia
104
Butterfly Rash
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Figure 43-10 The multisystem effects of systemic lupus erythematosus.
Systemic Lupus Erythematosus
–
–
–
–
–
–
–
renal
hematologic
cardiovascular
pulmonary
neurological
ocular
GI
108
Multi-system effects of Lupus
109
Systemic Lupus Erythematosus

Diagnostic
–
–
–

difficult due to diversity of symptoms
anti-DNA of various antibodies elevated
ESR, CBC, UA, Kidney bx
Treatment
–
–
ASA, NSAIDs, anti-malarial, corticosteriods
avoid sun, ESRD - dialysis and kidney
transplant
110
Polymyositis

Systemic connective tissue disorder with
inflammation of connective tissue and
muscles leading to muscle weakness and
atrophy
–
–
–
auto-immune
affects >females
between ages 40-60
111
Polymyositis

Manifestations
–
Initial
 muscle
pain, tenderness
 weakness
 rash
 arthralgias
 fatigue, fever, wt. Loss
–
Later
 increase
weakness, dysphagia, cough
112
Erythematous rash
113
114
Polymyositis
No specific dx test
 Treatment

–

rest, corticosteroids, immunosuppressive
therapy
Nursing Care - supportive
–
comfort, nutrition, skin care, medications,
maintain mobility
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Lyme Disease
117
Geographic locations
118
Lyme Disease

Inflammatory disorder caused by spirochete
Borrelia burgdorferi and transmitted by
ticks carried by deer and mice
–

prevalent in mid-Atlantic and north central U.S.
Manifestations
–
Initial
 flu-like

and skin rash
“bull’s eye” lesion at site of tick bite
119
Bull’s eye rash in lyme disease
120
Lyme Disease
 Followed
by fatigue, malaise, fever, chills, myalgias
 later, more skin lesions and muscle and joint pain

Weeks to months later
–
–

Bell’s palsy and meningitis
H/A and neck stiffness
Months to years later
–
arthritis
121
Lyme Disease

Treatment
–

antibiotics for up to a month
Nursing Care
–
–
–
avoid tick infested areas
appropriate dress, insect repellant
inspect skin - remove ticks
122
Let’s review Lupus
Definition?
 Early Manifestations?
 Systemic Manifestations?
 Treatment?


Nursing Diagnosis?
123
Let’s Review Polymyositis

How is it different from Lupus?

Clinical Manifestations?

Nursing Care?
124
Lyme Disease
Definition?
 Clinical Manifestations?

–
–
–
Initial
Weeks to months later
Months to years later
Treatment
 Nursing Care

125
Infectious Disorders
Osteomyelitis
Infection of the bone - interferes with
vascular supply, necrosis occurs
 Patho

–
usually bacterial - staphylococcus aureus
 direct
contamination
 complication of surgery
 extension of chronic ulcers
127
128
Osteomyolitis - leg wound
129
Figure 43-2 Osteomyelitis. (A) Bacteria enter and multiply in the bone.
132
133
Osteomyelitis

Hematogenous osteomyelitis
–
–

Osteomyelitis from contiguous infection
–

carried by the blood
older adult, sickle cell anemia, IV drug users
deep penetrating wounds, TJR, decubitis ulcers
Osteomyelitis associated with vascular
insufficiency
–
PVD
134
135
Osteomyelitis

Collaborative Care
–
–
–
–

pain relief
infection elimination or prevention
early dx to prevent bone necrosis
bone debridement and long term antibiotic
therapy
Diagnostic Tests
–
MRI, CT Scan, Bone Scan, cultures
136
Osteomyelitis

Medications
–

antibiotics, 4-6 weeks
Surgery
–
debridement, wound is opened, irrigated,
drainage tubes inserted for irrigation, suction
and antibiotic instillation
137
Osteomyelitis

Nursing Care
–
–
–

frequent and lengthy treatment
awareness of recurrent infections
prognosis is uncertain
Home Care
–
home care agency - wound treatment, antibiotic
adm. Supplies and nutritional teaching
138
139
Bone tumors
140
Bone tumors
141
Neoplastic Disorder - Bone
Tumors

Tumor may be malignant or benign
–
–
–

benign grow slow and do not invade
malignant grow rapidly and metastasize
most often are mets from breast, prostate,
kidney, thyroid and lung
Manifestations
–
often hx of a fall or blow to extremity brings
mass to attention
142
Bone Tumors
–

Pain, mass, impaired function
Diagnostic tests
–
X-ray
 benign
- sharp margins
 malignant “moth eaten” pattern
–
–
C-T Scan, MRI
needle bx
143
Bone Tumors

Treatments
–
Chemotherapy
 shrink
tumor before surgery
 control reoccurrence
 tx metastasis
–
Radiation
 pain
control
 combo with chemo to eliminate tumor after surgery
144
Treatment Bone Graft
145
Nursing Diagnosis
Risk for injury
Acute Pain
Chronic Pain
Impair Physical Mobility
Knowledge Deficit
146
Many Faces of Scleroderma
147
Connective Tissue Disorders
Scleroderma

Chronic disease, formation of excess
fibrous connective tissue and diffuse
fibrosis of skin and internal organs
–
–

cause unknown - person exposed to chemicals?
more common in females
Prognosis
–
localized -good
systemic - poor
148
Scleroderma

Manifestations
–
–
–
–
thickening of skin, diffuse non-pitting swelling
eventually skin atrophies, becomes taut and
hyperpigmented
arthralgias and Raynaud’s phenomenon
Visceral organ involvement
 dysphagia,
pulmonary hypertension, pericarditis,
G.I. Renal failure
149
Multi-system effects
150
Hand Changes
151
Scleroderma

Diagnostic tests
–

confirmed by skin bx
Treatment
–
meds
 immunosuppressive,
–
–
corticosteroids, tx symptoms
P.T
Nursing care - supportive
152
153
Inspection leads your assessment
154
Fibromyalgia
Common rheumatic syndrome,
musculoskeletal pain, stiffness, tenderness
 No inflammatory structural or muscle
changes
 Cause

–
unknown
155
Fibromyalgia

Manifestations
–
–
–
–

gradual onset of chronic, achy muscle pain
tightness or muscle spasm
pain when palpating localized tender points
fatigue, sleep disruption H/A, IBS
Diagnosis
–
–
based on H & P
check thyroid
156
157
Fibromyalgia

Treatment
–
–
–
–
–
–
heat applications
massage
stretching exercises
sleep improvement
stress-reduction
anti-depressant therapy
158
Low Back Pain Difficult to Treat!
159
160
Low Back Pain
Most often due to strain of muscle/tendons
caused by abnormal stress/overuse
 Collaborative Care

–
–
pain relief
correct underlying condition prevent
complication client education
161
Low Back Pain

Diagnostic tests
–
–

conservative tx for 4 weeks
X-rays, CT Scans MRI
Medications
–
–
NSAIDs, analgesic, muscle relaxants
epidural steroid injection for intractable pain
162
Low Back Pain

Nursing Care
–
health promotion
 exercise
 lose
wt.
 Body mechanics
 ergonomically appropriate work places
163
Treatment
164
Foot Disorders

Types
–
–
–

Hallux valgus - bunion
Hammer toe
Morton’s neuroma
Collaborative Care
–
–
–
pain relief
correct structural deformity
prevent recurrence
165
Foot Disorders
Hallux Valgus
Hammer toe
Morton’s Neuroma
166
Foot Disorders

Treatment
–
–
conservative - corrective shoes, orthotic devices
analgesics
Surgery
 bunionectomy
 shortening
or lengthening of ligaments
 pins to correct toe positioning
 casting
167
Muscular Dystrophy progressive muscle wasting
Muscular Dystrophy MD
Inherited muscle disease, progressive
degeneration and wasting
 Duchenne’s muscular dystrophy

–
–
–
most common
mother to male child
dx in early childhood , 15 year life span
Muscular Dystrophy

Manifestations
–
–

progressive muscle weakness with cardiac and
endocrine abnormalities
possible mental retardation
Collaborative Care
–
–
preserve and promote mobility
support child and family
Now
ambulating
Gait Assessment?
Posture Changes
Muscular Dystrophy

Diagnostic tests
–
–
–

creatine kinases (CK-MM) elevated
muscle bx
electromyelogram (EMG)
Nursing Care
–
–
–
promote independence, mobility
psychological support
assist with self care deficits
Yes, we are done!
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