Transcript Nursing Management RESPIRATORY FAILURE

MUSCULOSKELETAL
Professor Alecia Nye
Rheumatoid Arthritis (RA)
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Affects all ethnic
groups
Incidence ↑ with age,
peaks 30–50 years old
1.3 million Americans
Women > men
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Chronic, systemic
autoimmune disease
Inflammation of
connective tissue in
diarthrodial (synovial)
joints
Periods of remission
and exacerbation
Extraarticular
manifestations
Clinical Presentation
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40-year-old woman who presents to the clinic
with fatigue, morning stiffness, and painful
swelling of her fingers.
Pathophysiology
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Autoimmune etiology
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Antigen triggers formation of abnormal
immunoglobulin G (IgG)
Autoantibodies develop against the abnormal IgG
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Combination of genetics and environmental triggers
Rheumatoid factor (RF)
Rheumatoid factor combines with IgG immune
complexes → deposit on synovial membranes or
cartilage in joints → activates complement →
inflammatory response
Neutrophils → proteolytic enzymes → damage
cartilage and thicken synovial lining
Pathophysilogy
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T helper cells (CD4) activated → stimulate
monocytes, macrophages, and synovial
fibroblasts → secrete proinflammatory cytokines
 Interleukin-1 (IL-1)
 Interleukin-6 (IL-6)
 Tumor necrosis factor (TNF)
Pathologic Changes in RA
Pathophysiology
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Genetic link
 Higher incidence in identical twins
 HLA-DR4 and HLA-DR1 antigens
 Smoking increases risk in patients genetically
predisposed
Stages of Disease Progression
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Stage I through IV (1-4)
Stage I - Early in the disease
Stage II - Moderate effects with no joint deformities
Stage III - Severe with joint deformities
Stage IV – Terminal
Clinical Manifestations
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Joints
Onset typically insidious
 Fatigue, anorexia, weight loss, generalized stiffness
 May report history of precipitating event
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Specific articular involvement
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Infection, stress, exertion, childbirth, surgery
Pain, stiffness, limitation of motion, and signs of
inflammation
Symptoms occur symmetrically
Most often affects small joints
Larger joints and cervical spine may be involved
Clinical Manifestations
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Joint stiffness after inactivity
Morning stiffness 60 minutes to several hours or
longer
MCP and PIP joints typically swollen
Fingers spindle shaped
Joints tender, painful, warm to touch
Pain ↑ with motion, intensity varies
Clinical Manifestations
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Tenosynovitis
Deformity and disability
Subluxation
Walking disability
Typical Deformities of RA
Labs & Diagnostics
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Laboratory studies
 Rheumatoid factor (RF)
 Erythrocyte sedimentation rate (ESR)
 C-reactive protein (CRP)
 Antinuclear antibody (ANA)
 Anti-citrullinated protein antibody (ACPA)
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Synovial fluid analysis
X-rays of involved joints
Bone scan
Plan of Care
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Patient teaching
 Drug therapy
 Disease process
 Home management strategies
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NSAIDs
Physical therapy
Occupational therapy
Individualized treatment plan
Medications
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↓ Permanent effects of RA
 Methotrexate (Rheumatrex)
 Sulfasalazine (Azulfidine)
 Hydroxychloroquine (Plaquenil)
 Leflunomide (Arava)
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Monitor for bone marrow suppression and
hepatotoxicity
Teratogenic
Biologics/Targeted Therapy
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Tumor necrosis factor (TNF) inhibitors
 Etanercept (Enbrel), infliximab (Remicade),
adalimumab (Humira), certolizumab (Cimzia), and
golimumab (Simponi)
 Bind with TNF, inhibiting inflammation
Biologics/Targeted Therapy
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IL-1 receptor antagonist (IL-1Ra)
 Anakinra (Kineret)
 Given SQ; reduces pain and swelling
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Tocilizumab (Actemra)
 Blocks IL-6, a proinflammatory cytokine
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Abatacept (Orencia)
 Blocks T-cell activation
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Rituximab (Rituxan)
Other Medications
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Corticosteroid therapy
 Intraarticular injections
 Low-dose oral for limited time
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NSAID and salicylates
 Antiinflammatory, analgesic, and antipyretic
 May take 2 to 3 weeks for full effectiveness
Nutrition
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Balanced nutrition important
Loss of appetite or inability to shop for and
prepare food → weight loss
Corticosteroid therapy → weight gain
Self Care
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Relieve pain, stiffness, and muscle spasm
Ice
Especially beneficial during periods of disease
exacerbation
 Application should not exceed 10–15 minutes at one time
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Moist heat
Heating pads, moist hot packs, paraffin baths, warm baths
or showers
 Relieve stiffness
 Should not exceed 20 minutes at a time
 Be alert for burn potential
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Functionalitiy
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Gentle ROM exercises done daily to keep joints
functional
Aquatic exercises in warm water beneficial
Limit to one or two reps during acute
inflammation
Challenges
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Patient is constantly challenged by problems of
 Limited function and fatigue
 Loss of self-esteem
 Altered body image
 Fear of disability or deformity
Osteoporosis
Osteoporosis
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Porous bone
Chronic, progressive metabolic bone disease
characterized by
Low bone mass
 Structural deterioration
 Increased bone fragility
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Over 44 million people in the United States
One in 2 women and 1 in 4 men over 50 will sustain an
osteoporosis-related fracture.
Known as the “silent thief
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Why more common in women?
 Lower
calcium intake
 Less bone mass
 Bone resorption begins earlier and accelerates after
menopause.
 Pregnancy and breastfeeding
 Longevity
Risk Factors
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Risk factors
 Advancing
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age (>65
yr)
 Female gender
 Low body weight
 White or Asian
ethnicity
 Current cigarette
smoking
 Nontraumatic fracture
 Sedentary lifestyle
Risk factors
 Postmenopausal
 Family
history
 Diet low in calcium.
Vitamin D deficiency
 Excessive use of
alcohol (>2
drinks/day)
 Low testosterone in
men
 Specific diseases
 Certain drugs
Etiology
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Peak bone mass (by age 20) determined by
heredity, nutrition, exercise, and hormone function
Bone loss after age 35-40 inevitable, rate of loss
variable
Rapid bone loss for women at menopause
Pathophysiology
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Remodeling
 Osteoblasts
– deposit bone
 Osteoclasts – resorb bone
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In osteoporosis, bone resorption exceeds bone
deposition
Prevention
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Preventive factors
 Regular
weight-bearing exercise
 Fluoride
 Calcium
 Vitamin
D
Clinical manifestations
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Occurs most commonly in spine, hips, and wrists
Back pain
Spontaneous fractures
Gradual loss of height
Dowager’s hump (kyphosis)
Screening
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Screening guidelines
 Initial
bone scan in women before age 65
 Repeat
in 15 years if normal
 Earlier and more frequent if high risk
 Men
 By
screened before age 70
age 50 if high risk
Assessment
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History and physical exam
X-ray and lab studies not diagnostic
Bone mineral density (BMD)
 Quantitative
ultrasound
 Dual-energy x-ray absorptiometry (DXA)
Plan of Care
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Focus on
 Proper
nutrition
 Calcium supplements
 Exercise
 Prevention of fractures
 Drug therapy
Plan of Care
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Adequate calcium intake
1000 mg/day
premenopausal and
postmenopausal taking
estrogen
 1500 mg/day
postmenopausal without
estrogen
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Supplemental calcium
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Must be taken in divided
doses with food to
enhance absorption
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Good sources of calcium
Milk
 Yogurt
 Turnip greens
 Cottage cheese
 Ice cream
 Sardines
 Spinach
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Plan of Care
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Vitamin D necessary for calcium
absorption/function; bone
formation
Sunlight for 20 minutes adequate
Supplemental (800-1000
IU/day)
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Postmenopausal
Older adults
Homebound
Minimal sun exposur
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Vitamin D is important in calcium
absorption and function and may
also have a role in bone
formation.
Most people get enough vitamin D
from their diet or naturally through
synthesis in the skin from exposure
to sunlight.
Being in the sun for 20 minutes a
day is generally enough.
However, supplemental vitamin D
(800 to 1000 IU) is recommended
for postmenopausal women, older
adults, those who are homebound,
and those who get minimal sun
exposure.
Plan of Care
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Weight-bearing exercise
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Build up and maintain bone
mass
Increase strength,
coordination, balance
Walking, hiking, weight
training, stair climbing,
tennis, dancing
Quit smoking
Decrease alcohol intake
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Treatment of existing
disease
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Prevent further loss with
supplements and meds
Keep ambulatory
Gait aid to prevent
falls/fractures
Brace for vertebral
fracture
Vertebroplasty and
kyphoplasty to treat
osteoporotic vertebral
fracture
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Medication Therapy
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Bisphosphonates
 Inhibit
bone resorption
 Side effects: anorexia,
weight loss, gastritis
 Proper administration
 Take
with full glass of
water.
 Take 30 minutes before
food or other meds.
 Remain upright for at
least 30 minutes.
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Calcitonin
 Inhibits
bone resorption
 Give IM form at night
to minimize side effects
 Alternate nostrils when
using nasal form
 Must use calcium
supplementation
Medication Therapy
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Selective estrogen
receptor modulators
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 Monoclonal
antibody
for postmenopausal
women
 Subcutaneous injection
every 6 months
 Raloxifene
(Evista)
 Reduces bone
resorption
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Teriparatide (Forteo)
 Portion
of parathyroid
hormone
 First drug to stimulate
new bone formation
Denosumab (Prolia)
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Management of
patients receiving
corticosteroids
Bones & Healing
Assessment
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Objective Data
 Physical
examination
 Measurement
 Limb
length
 Circumferential muscle mass
 Other
 Use
of assistive devices
 Posture and gait
 Straight-leg-raising
Objective Data-Assessment
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Objective Data
 Paresthesias
 Absent, ↓
or ↑ sensation
 Restricted or lost function
 Deformities; abnormal angulation
 Shortening, rotation, or crepitation
 Muscle weakness
 Imaging findings
Labs
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Alkaline phosphatase
Serum calcium
Serum phosphorus
Rheumatoid factor (RF)
Erythrocyte sedimentation rate (ESR)
More Labs & procedures
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Antinuclear antibody (ANA)
Anti-DNA antibody
Complement, total hemolytic
(CH50)
Uric acid
C-reactive protein (CRP)
Human leukocyte antigen
(HLA)-B27
Creatine Kinase
Serum potassium
Aldolase
Arthrocentesis
Electromyogram (EMG)
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Duplex venous doppler
Clinical Manifestations of Fractures
Localized pain
 Decreased function
 Inability to bear weight or use
 Guard against movement
 May or may not have deformity
Immobilize if suspect fracture!!!!
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Fracture Reduction
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Open reduction
 Surgical incision
 Internal fixation
 Risk for infection
 Early ROM of joint to prevent adhesions
 Facilitates early ambulation
Traction
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Purpose
 Prevent or ↓ pain and muscle spasm.
 Immobilize joint or part of body.
 Reduce fracture or dislocation.
 Treat a pathologic joint condition.
Traction
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Pulling force to attain
realignment –
countertraction pulls
in opposite direction
Two most common
types of traction
 Skin traction
 Skeletal traction
External Fixation
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Metal pins and rods
Applies traction.
Compresses fracture
fragments.
Immobilizes and
holds fracture
fragments in place.
External Fixation Plan of Care
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Assess for pin loosening and infection.
Patient teaching
Pin site care
Fracture Healing
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Multistage healing
process (union)
1.
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3.
4.
5.
6.
Fracture hematoma
Granulation tissue
Callus formation
Ossification
Consolidation
Remodeling
Fracture Healing
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Factors influencing healing
 Displacement and site of fracture
 Blood supply to area
 Immobilization
 Internal fixation devices
 Infection or poor nutrition
 Age
 Smoking
Hip Replacement
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Do
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Use an elevated toilet seat
Place chair inside shower
or tub and remain seated
while washing
Use pillow between legs
for first 6 weeks after
surgery when lying on non
operative side or when
supine
Keep a neutral, straight
position when sitting,
walking or lying
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Do Not
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Force hip into greater than
90 degrees of flexion
(sitting in low chairs or
toilet seats)
Force hip into adduction
Force hip into internal
rotation
Cross legs at knees or
ankles
Put on own shoes or
stockings without adaptive
devices until 4-6 weeks
after surgery
Sit on chairs without arms
Post operative Care - Musculoskeletal
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Peripheral vascular
 Color and temperature
 Capillary refill
 Pulses
 Edema
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Peripheral neurologic
 Sensation
 Pain
and motor function
Plan of Care
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Medication Therapy
 Central and peripheral muscle relaxants
 Carisoprodol (Soma)
 Cyclobenzaprine (Flexeril)
 Methocarbamol (Robaxin)
 Tetanus and diphtheria toxoid
 Bone-penetrating antibiotics
Plan of Care
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↑ Protein (1 g/kg of body weight)
↑Vitamins (B, C, D)
↑ Calcium, phosphorus , and magnesium
↑ Fluid (2000-3000 mL/day)
↑ Fiber
Compartment Syndrome
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Swelling and increased pressure within a confined
space
Compromises neurovascular function of tissues
within that space
38 compartments in upper and lower extremities
Compartment Syndrome
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Two basic types of compartment syndrome
 ↓ Compartment size
 ↑ Compartment
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contents
Arterial flow compromised → ischemia → cell
death → loss of function
Compartment Syndrome-Clinical s/sx
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Six Ps
 Pain
 Pressure
 Paresthesia
 Pallor
 Paralysis
 Pulselessness
Compartment Syndrome (Plan of Care)
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Early recognition via regular neurovascular
assessments
 Notify of pain unrelieved by drugs and out of
proportion to injury
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Assess urine output and kidney function
Plan of Care
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NO elevation above
heart.
NO ice.
Loosen bandage and
split (bivalve) cast.
Reduce traction
weight.
Surgical
decompression
(fasciotomy)
Venous Thrombosis
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High susceptibility aggravated by inactivity of
muscles
Prophylactic anticoagulant drugs
Antiembolism stockings
Sequential compression devices
ROM exercises
Complications
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Fat embolism syndrome (FES)
 Presence of systemic fat globules from fracture that
are distributed into tissues and organs after a
traumatic skeletal injury
 Contributory factor in many deaths associated with
fracture
 Most common with fracture of long bones, ribs, tibia,
and pelvis
Fat Embolism
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Mechanical theory
 Fat released from marrow and enters circulation
where it can obstruct
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Biochemical theory
 Hormonal changes caused by trauma stimulate
release of fatty acids to form fat emboli.
Clinical Manifestations: Fat Embolism
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Early recognition crucial
Symptoms 24 to 48 hours after injury
Fat globules transported to lungs cause a
hemorrhagic interstitial pneumonitis.
Respiratory and neurologic symptoms
Petechiae – neck, chest wall, axilla, buccal
membrane, conjunctiva
Fat embolism-cont
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Clinical course of fat embolus may be rapid and
acute.
Patient frequently expresses a feeling of
impending disaster.
In a short time skin color changes from pallor to
cyanosis.
Patient may become comatose.
Fat Embolism-Cont
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Fat cells in blood, urine, or sputum
↓PaO2 < 60 mm Hg
ST segment changes
↓ platelet count and hematocrit levels
Prolonged prothrombin time
Chest x-ray → white out
Treatment
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Treatment is directed at
prevention
Careful immobilization
of a long bone fracture
is probably the most
important factor in
prevention.
Management is
essentially symptomrelated and supportive
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Cough and deep
breathing
Minimize patient
movement
Corticosteroids
controversial
Oxygen/intubate/mech
anical ventilation
Problems Associated with
Musculoskeletal injuries
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Muscle Atrophy
Contractures
Foot/drop
Pain
Muscle spasms
References
Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., &
Bucher, L. (2014). Medical-surgical nursing:
Assessment & management of client problems
(9th ed.). St. Louis, MO: Mosby
 Hogan, M., Dentlinger, N.C., & Ramdin, V.
(2014). Medical-surgical: nursing pearson
nursing reviews and rationales (3rd ed.). Boston,
MA: Pearson.
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