13Assessing Articular Joints DeformitiesNodesPulses in extremitiesROMEdemaFever
14Range of Motion Ability to change position Muscular strength CoordinationSize of musclesActivePassive
15Neurovascular Assessment Following trauma, surgery, casting, splinting, bandaging: Assess the 7 P’sPulselessnessParesthesiasParalysis or paresthesiasPolar temperaturePallorPuffiness (edema)Pain
16Skeletal Changes in Aging Loss of calcium saltsLoss of protein in boneDecreased collagen in bone, tendons and ligamentsLoss of height (0.5 in/20y)Chest diameter decreases about 1 in and less flexible
19Skeletal Muscle Relaxants Used to prevent/relieve muscle spasms, treat spasticity associated with spinal cord lesions, painful musculoskeletal disordersContraindicated in severe liver, renal, heart diseaseShould not be taken with CNS depressants
20Skeletal Muscle Relaxants Act directly on neuromuscular junctionAct directly on muscleORAct indirectly on the CNSDepress neuron activity in the brain or spinal cord
21Skeletal Muscle Relaxants Side effects:Dizziness/hypotensionDrowsinessDry mouthGI upsetPhotosensitivity
22Skeletal Muscle Relaxants Baclofen (Lioresal)Causes CNS effectsFrequently causes nausea, constipation, retentionCan be given by physician through intrathecal pump
23Skeletal Muscle Relaxants Dantrolene (Dantrium)Acts directly on skeletal muscles to relieve spasticityLiver damage most serious adverse effectMonitor LFT’sCan cause GI bleeding, impotence, photosensitivity, rash
24Skeletal Muscle Relaxants Cyclobenzaprine (Flexeril)Contraindicated in clients who have taken MAOI s within 14 days of initiation (can lead to ↑BP, HTN crisis)Caution in clients with hx urinary retention, glaucoma, or increased intraocular pressureShort term (2-3 weeks) use
25Skeletal Muscle Relaxants Methocarbamol (Robaxin)May cause urine to turn brown, black or greenNotify MD if blurred vision, nasal congestion, urticaria occurParenteral form can cause hypotension, bradycardia, anaphylaxis, seizures
26Skeletal Muscle Relaxants Chlorzoxazone (Paraflex, Parafon Forte)Monitor for hypersensitivity reactionsMay cause malaise and urine discolorationCarisoprodol (Soma)Take with food to prevent GI upsetReport hypersensitivity to MD
27Antigout Medications Decrease inflammation Reduce uric acid production, increase uric acid secretionUse cautiously in clients with GI, renal, cardiac or hepatic diseaseAllopurinol can increase effect of warfarin and oral hypoglycemic agents
28Antigout Medications Side effects HA N/V Blood dyscrasias Flushed skin, rashUric acid kidney stonesSore gumsMetallic taste
29Nursing Considerations Monitor serum uric acid levelsMonitor I&OMonitor CBC and LFT’sDo not give large doses of Vitamin C with AllopurinolAvoid foods high in purines; ie wine, alcohol, organ meats, sardines, salmon, gravyConcurrent ASA; increased uric acid level, gout attack
31Osteoporosis Prevention Calcium and Vitamin D supplementationEstrogen replacement therapy after menopauseCalcitonin (Calcimar)
32Antiarthritic Medications (Source: ATI Testing Tutorial)Types of DrugsNSAIDSTx. Pain and inflammationGlucocorticoidsDisease-Modifying Antirheumatic DrugsTarget: Musculoskeletal system
33Antiarthritic Medications Disease-Modifying Antirheumatic Drugs“DMARD”↓ joint inflammation↓ joint damageInitially given with NSAIDS slow onset of therapeutic effects. NSAIDS may be discontinued when DMARDs begin exerting therapeutic effect
34Antiarthritic Medications DMARD ICategory: Major Non-biologicAntimetabolite Drug: interferes with normal metabolic processProtogype Drug: Methotrexate (RheumatrexOther: Leflunomide (Arava)NOTE: DMARDs suppress the immune system (a primary effect)
35Antiarthritic Medications DMARD I (cont.)Can slow or stop progression of RACan tx. Cancer in larger dosesAdverse effect/side effects:Liver damageBone marrow suppression (↓platelets, RBCs, WBCs)↑ risk for infectionGI ulcerationPulmonary Fibrosis
36Antiarthritic Medications DMARD I (cont.)Methotrexate = Cat. D Pregn. (can damage developing fetus & can pass through breast mild)Leflunomide = Cat. X pregn.
37Antiarthritic Medications DMARD I (cont.)Nursing considerations:Monitor for: ↓ platelets, wbc’s, rbc’sS/sx. InfectionLFT, Observe for jaundiceGI bleed (Methotrexate)Respiratory distress, ↓ oxygenation
38Antiarthritic Medications DMARD I (cont.)Nursing considerations (cont.)Dosing and Administration:Methotrexate – 1x / week (po, sq, im)Weekly folic acid supplement (↓ risk toxicity)Drink oz. Glasses water/dayReport: jaundice skin/eyes; s/sx infection; ulcerations of mouth, tongue; abdominal bldg, bruising, petechaeie; blood in vomit or stool; dyspnea, SOB
39Antiarthritic Medications DMARD I (cont.)Nursing considerations (cont.)Avoid: 1. giving DMARD I drugs during pregnancy and for 6 months after completion of treatment2. ingestion of alcoholPrecautions: (while on DMARD I tx.)↑ risk for active bacterial or viral infectionPeptic Ulcer DiseaseUlcerative CollitisContraindications: (to DMARD tx.)Liver InsufficiencyHepatitisRenal InsufficiencyWomen who are pregnant
40Osteoarthritis Prevention and Treatment BiphosphonatesInhibit osteoclast mediated bone resorption, increases total bone massExamplesEtidronate (Didronel)Alendronate (Fosamax)Pamidronate (Aredia)Risedronate (Actonel)
41Osteoporosis Prevention BiphosphonatesFosamax-taken after rising in AM with full glass waterNo eating/drinking for 30 min after taking med, do not lie down for 30 min after taking med
42Osteoporosis Prevention Estrogen receptor modulators (Evista)Mimic effect of estrogen in bone by reducing bone resorptionTeriparitide (Forteo)Stimulates new bone formationUsed to treat osteoporosis in men and post menopausal women at high risk for fractures
45Laboratory and Diagnostic Examinations Radiographic studiesMyelogramElectromyographyBone scanBone mineral densityX-rayEndoscopic examinationArthroscopy
46Radiographic StudiesReveals presence of fluid in joint, irregularity of joint, spur formation, and changes in size or contour of the jointVisualizes fractures, length, tumors, and cavities of bonePregnant women should not have an x-ray, unless it is absolutely necessary, to prevent potential damage to the fetus
47Laminography/planography or body section roentgenography Radiographic StudiesLaminography/planography or body section roentgenographyLocates small cavities, foreign bodies andlesions that are overshadowed by opaquestructures
48Scanography Radiographic Studies Uses a series of parallel beams that eliminate sizedistortion when producing a radiograph of internal body organsAllows accurate measurement of the lengthof the bone
49Used to determine the presence of herniated discs or tumors MyelogramUsed to determine the presence of herniated discs or tumors
50MyelogramAn x-ray study in which dye is injected into the spinal fluid. (The spinal cord is not visible on a normal x-ray.)Injection of this dye outlines the spinal cord, and makes it visible on the x-ray.
51MyelogramThe injection of dye may be done in the cervical or lumbar areaBefore the dye is injected, a sample of spinal fluid is collected from the patient and is submitted to the laboratory for analysis.
53MyelogramWater based dye is used most often because the body will reabsorb it and will be excreted in the urineOil-based dye will be removed because it may cause irritation within the subarachnoid space
54MyelogramHeadache is most common after a myelogram but seizure, infection, numbness, or paralysis may occur
55Myelogram Prior to procedure: Post-procedure Informed consent Provide hydration 12h before testAssess for allergiesPremedicate as orderedPost-procedureVS/neuro checks as orderedIf water based dye used, HOB up degrees for 8 hIf oil based dye used, flat for 6-8 hIf air used, head lower than trunkForce fluids, monitor I&O
56Electromyography (EMG) Measures electrical potential associated with skeletal muscle contractionsNeedles inserted into muscle; electrical activity traced on recording paperInformed consentNeedle insertion uncomfortableNo stimulants/sedatvies 24h prior to procedureSlight bruising at insertion sites
57ElectromyographyYour doctor has ordered this test to help determine the cause of your pain.This test is specifically performed to identify if abnormal nerve function is present.The small electric pulses cause a mild tingling feeling.
58EMG are using a transcutaneous electrical nerve stimulator (TENS) unit Inform your physician if you:are using a transcutaneous electrical nerve stimulator (TENS) unitare taking blood thinnershave hemophiliahave a cardiac pacemakerDo not apply lotion to the arms or legs on the day of the test.
59Nuclear ScanningUses scanners or camera detectors that record images on radiographic filmDoses of radioactive isotopes are low; no need for precautionary measures as required for radium therapy
60Nursing Interventions Obtain written consentInforming patient that radioactive isotopes will not affect family/visitorsFollow instructions as outlined by the nuclear medicine department as to special preparation for the specific scans
61Magnetic Resonance Imaging Used to detect pathological conditions:CerebrumSpinal CordCurrently used to detect herniated nucleus pulposes (herniated disc)
62MRIInvolves use ofMagnetism and Radio Waves to make images of cross sections of the bodyVery detailed pictures of fluid-filled soft tissue and blood vessels
63Nursing Considerations Patient preparationRemove any metalNo jewelry, clothing with metal fasteners, glasses, and hair clips
64Nursing Considerations CANNOT HAVE MRI if patient has a metal prostheses:Heart valvesOrthopedic screwsCardiac pacemakers or defibrillators
65Nursing Consideration Patient must be able to lie still for 45 to 60 minutesEnters the tunnel head first anxiety and/or claustrophobiaMay need sedativeRelaxation therapy can helpHowever: No use of relaxation techniques that require flexing and relaxing of muscles – Pt. HAS TO LIE MOTIONLESS!After test:Routine vital signsPretest activities can be resumed
66Computed Axial Tomography CT Scan Views body sections from different anglesCT scanner produces a narrow x-ray beamProduces a three-dimensional picture of structures100 times more sensitive than x-rayShould not be used unnecessarily because of radiation exposureIodine contrast is sometimes usedUsed for the head and body
67CT or CAT Scan Useful in locating Injuries to ligaments or tendonsTumors of soft tissueIdentifying fractures in difficult areasPerformed with or without contrast (iodine) dye
68Patient Preparation Consent form Check Allergies to iodine and seafood (shellfish)NPO 3 to 4 hours before test if dye is used (dye can cause nausea/vomiting)Baseline vital signsVoidRemove jewelry and hairpinsLie still; may feel warm and slightly nauseated for a few minutes when dye is injected
69Nursing Consideration After the test:Observe for delayed allergic reactionEncourage fluidsPretest diet and activity can usually be resumed
70Bone ScanA bone scan is a nuclear scanning test that identifies new areas of bone growth or breakdown.It can be done to evaluate damage to the bones, detect cancer that has spread (metastasized) to the bones, and monitor conditions that can affect the bones (including infection and trauma).A bone scan can often detect a problem days to months earlier than a regular X-ray test.
72Bone ScanFor a bone scan, a radioactive tracer substance is injected into a vein in the arm.The tracer then travels through the bloodstream and into the bones.A bone scan may be done on the entire body or just a part of it.
73Bone ScanAreas that absorb little or no amount of tracer appear as dark or "cold" spots, which may indicate a lack of blood supply to the bone (bone infarction) or the presence of certain types of cancer.Areas of rapid bone growth or repair absorb increased amounts of the tracer and show up as bright or "hot" spots in the pictures. Hot spots may indicate the presence of a tumor, a fracture, or an infection.
74Bone Scan Isotope excreted within 48h Hold fluids for 4 hrs. prior to Informed consent
75Bone Mineral Density Lose some bone mass as we age Bones become thinner (osteopenia)Existing bone broken down faster than new bone is made bones lose Ca⁺ and other minerals become lighter, less dense, more porous weaker bones; ↑ risk for fx.
76BMDWith further bone loss, osteopenia leads to osteoporosis . So the thicker your bones are, the longer it takes to get osteoporosis.Although osteoporosis can occur in men, it is most common in women older than age 65.
77BMD Measures bone mass of spine, other bones and total body Minimal radiation exposureUsed to diagnose metabolic bone disease, monitor changes in bone density with treatment
78Arthroscopy Provides endoscopic examination of various joints Cartilage abnormalities assessed, loose bodies removed, cartilage trimmedBiopsy may be performed
80Arthroscopy Interventions: Instruct pt. to fast 8-12h prior to procedureInformed consentPain med as prescribed post procedureElastic wrap 2-4 days post procedureWalking without weight bearing permitted after sensation returns, limit activity for 1-4 daysElevate extremity, ice to minimize swelling
81ArthrocentesisSynovial fluid aspiration, removal of pus, blood or medication instillationInformed consentCompression bandage post procedureRest joint 8-24 h afterwardsNotify physician if fever/swelling occurs
83Laboratory Tests: Serum ANA, antinuclear antibodiesDetects SLE, a collagen diseaseArthritis can result from SLENormal = negativeClient prepFor non-fasting blood drawRadioactive scan in last week may increase ANA level
84Laboratory Tests: Serum CRP, C-reactive proteininflammation and auto-immune disorders show abnormal proteinNormal = female 1-20, male 1-13mm/hCan get false negativeClient Prep, usually non-fasting blood drawMeds that increase: contraceptives & IUDMeds that decrease: NSAIDS, steroids, salicylates
85Laboratory Tests: Serum Uric Acid-BloodElevated with Gout and arthritisNormal = male , female mg/dlClient prep: usually non-fasting blood drawCause: increase: stress, ETOH, ascorbic acid, ASA, caffeine, cisplatin, diuretics, epinephrine, levdopaCause: decrease: x-ray contrast agents
86Laboratory Tests: Urine Uric Acid-Urine (24 hour collection)Normal = ml/24hrClient prep: no special diet, void and discard- note start time on specimen container, collect the rest of voids in container until same time next day, keep on ice or refrigerate,
87Laboratory Tests: Serum ESR, Erythrocyte Sedimentation RateIncreases with inflammation, infection, necrosis, or cancerNormal = male up to 15, female up to 20 mm/hrClient prep: non-fasting blood draw; hold some medsCause increase: pregnancy, menstruation, PCN, oral contraceptives, aldomet, theophylline, vitamin ACause decrease: if not processed within 3 hours, ASA, quinine, cortisone
88Laboratory Tests: Serum RF, Rheumatoid Factor (IgM)Elevated with autoimmune disease such as Rheumatoid arthritis and SLENormal = < 60 U/mlClient prep: non-fasting blood drawElderly may show false positive
89Laboratory Tests: Serum Serum Calcium (detects calcium metabolism)Normal = 9.0 – 10.5 mg/dl< 6mg/dl may lead to tetany (cramps, convulsions, twitching)> 14mg/dl may lead to comaClient prep: non-fasting blood drawIncrease may indicate: metastatic bone tumor, Paget’s disease, acromegalyDecrease may indicate: rickets, osteomalacia, vitamin D deficiency