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Musckuloskeletal Stressors Musculoskeletal Disorders arthritis

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Musckuloskeletal Stressors Musculoskeletal Disorders arthritis Powered By Docstoc

     JBorrero 10/08
   Degenerative Joint Disease
   Arthritis= joint inflammation.
   Arthralgia= joint pain
   Different types of arthritis:
       Osteoarthritis
       Rheumatoid arthritis
       Gouty arthritis

   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
   Deformity, incomplete dislocation and synovial
    effusion may eventually occur.
   Treatment: rest, heat, ice, anti inflammatory drugs,
    decrease wt. if indicated, injectable corticosteroids,
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
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
   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
Auto-Immune Disease
   Inflammatory and immune response are normally
   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
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
   Classified as autoimmune process
   Exacerbations and remissions
   Can cause severe deformities that restrict
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
    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
Nursing Interventions
   Assist with/encourage physical activity
   Provide a safe environment
   Utilize progressive muscle relaxation
   Refer to support groups
   Emotional support
   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
   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
   SLE- Chronic Inflammatory disease affecting many
   Women between 18-40, black>white, child bearing
   Autoimmune process- antibodies react with DNA,
    immune complexes form- damage organs and blood
   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
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
6. Renal- Lupus nephritis
7. Pleural effusion or PN
8. Raynaud’s phenomenon- about 15% cases
9. Neuro- psychosis, paresis, migraines, and
ANA- hallmark test, + in 98% pts.
  Antimalarial meds- hydroxychloroquine (Plaquenil)
   Immunosuppressive agents- pt teaching
   corticosteroids, methotrexate,
   Systemic Lupus- Education
Encourage 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
   Prepare for autologous blood donation.
Pre-op teaching
 Presence of drains and hemovac
 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 degrees
Importance of leg abduction post-op.
Post-op Management of THR
   Assess neurovascular status of involved
   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-
   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
   Ambulate with assistance, WB restrictions
   Turn pt. as ordered, monitor skin for
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
   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.
   Pre-op: lab work- Hgb, Hct, Pt/PTT, urine,
   History of underlying problem, meds.
   Post-op- N/V assessment, pulses distal to
   Teach: ROM to unaffected extremities,
    limitations post-op, crutch walking prn, pain
    management, reinforce explanation of
Total Knee Replacement
   Indications:Osteoarthritis, rheumatoid
    arthritis, posttraumatic arthritis, bleeding into
   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
   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.
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
   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
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
 Ability and desire to follow prescribed rehab
  plan and exercises.
 Prosthesis fitting with orthotist
   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
   Family hx, thin, lean body build
   Postmenopausal estrogen deficiency
   Hyperparathyroidism – increases bone
   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

Physical assessment:

Psychosocial assessment:
Pt. teaching- osteoporosis
   Adequate dietary calcium- 1200mg/day with
   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
 Infection of the bone
 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
 Prevention- proper tx. of infections, aseptic post op
  wound care
 Organism enters from outside the body. Eg. Open fx
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,
Contusions, Strains, Sprains
   Contusion-soft tissue injury, hematoma,
   Strain- “muscle pull” over use over stretching.
   Sprain – an injury to ligaments surrounding
    joint, caused by twisting.
   Management- RICE = rest, ice, compression,
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
   Open fracture (compound) - extends through the skin
   Comminuted- splintered into fragments
   Depressed- fragment(s) is(are) indriven
   Pathologic- through an area of diseased bone
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
   DIC
   Infection
   Avascular necrosis
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.
   Provide protection and healing of fractures
   Maintain therapeutic alignment- body parts
   Protect soft tissue injuries
   Provide support after orthopedic surgery
   Correct skeletal malformations.
   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 spasm
2. Used to reduce, align, and immobilize fractures
3. Used to correct/prevent deformity
4. Tx of dislocated, degenerated, rutured
   intravetebral discs and sc compression
Nursing 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 fractures
4.   Intermittent- for back muscle sprains
   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.
   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
              Hip fractures
   High incidence in elderly due to risk for falls,
   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          Impaired sensation
   Swelling           Loss of normal
   Bruising            function
   Muscle spasms      Abnormal mobility
   Tenderness         Crepitus
   Pain               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
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
Back Pain
Conservative Management
   Positioning
   Firm mattress and back board
   Exercise and physical therapy
   Pharmacology
   Heat and Ice
   Diet Therapy
   PT with manipulation, shoes insoles, back
   Complementary and alternative therapies
Operative Procedures
Conventional open Procedures:
 Diskectomy
 Laminectomy
 Diskectomy with fusion
Minimally 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
   Takes 6 weeks for ligaments to heal
   Schedule rest periods
   Avoid heavy labor 2-3mos postop
   Back exercises
Cervical Disc Herniation or
   Usually occurs at C5, C6, or C7 interspaces
   Surgical tx is MIS cervical diskectomy with or
    without fusion using an anterior or posterior
   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

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