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Nursing of Adult Patients with Medical & Surgical Conditions Musculoskeletal Disorders.

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Presentation on theme: "Nursing of Adult Patients with Medical & Surgical Conditions Musculoskeletal Disorders."— Presentation transcript:

1 Nursing of Adult Patients with Medical & Surgical Conditions Musculoskeletal Disorders

2 Assessment w Scoliosis Lateral curvature of the spine

3 Assessment w Kyphosis A rounding of the thoracic spine Hump-backed appearance

4 Assessment w Loradosis An increase in the curve at the lumbar region

5 Assessment w Blanching Test Capillary nail refill Signals circulation status Compress each fingernail or toenail, release the pressure, and note how quickly the pink color returns to the nail bed. Should return to normal color within 2 seconds

6 Diagnostic Tests w Myelogram Injection of a radiopaque dye into the subarachnoid space at the lumbar spine to determine the presence of herniated disk or tumors. Assess for allergies to iodine and seafood Oil-based dye Removed to prevent meningeal irritation Flat for 12 hours (keeps air space in lower spine) Water-soluble dye Not removed; absorbed by body Semi-fowler’s position for 8 hours (keeps dye in lower spine) Encourage fluids to assist with absorption of dye

7 Diagnostic Tests w Nuclear Scanning Given a low dosage of radioactive isotopes Scanner or camera detector is used to record images Nursing Measures Written consent Informing the patient about radioacive isotopes; will not affect others Follow instrucitions by nuclear medicine dept.

8 Diagnostic Tests w Magnetic Resonance Imaging Involves the use of magnetism and radio waves to make images of cross sections of the body Gives detailed picture of fluid filled soft tissue and blood vessels Patient must remove any metal objects patients with metal prosthesis (heart valves, othopedic screws) cannot undergo and MRI Sedatives may be given for anxiety due to claustrophobia

9 Diagnostic Tests w Computer Axial Tomography (CAT scan) 3-D picture of the structure (Soft tissue & bones) More sensitive than standard x-rays Iodine contrast may be used Nursing Measures Written consent Ask about allergies to iodine and seafood NPO 3-4 hours before test Baseline vital signs Remove jewelry, etc. Teach pt. about procedure

10 Computer Axial Tomography (CAT scan)

11 Diagnostic Tests w Bone Scan Detects metastatic and inflammatory bone disease Radioisotopes administered IV 2-3 hours before test Encourage fluids A scanning camera is used to reveal the degree of uptake Areas of uptake may indicate a tumor or other abnormality

12 Diagnostic Tests w Arthroscopy Direct visualization of a joint exploration of joint drainage of fluid from the joint removal of damaged tissue or foreign bodies Involves insertion of a large-bore needle into the suprapatellar pouch. Patient may be given a general or local anesthetic Activities may be limited for several days

13 Diagnostic Tests w Synovial Fluid Aspiration The puncture of a joint with a needle and the withdrawal of synovial fluid Used for diagnosis of trauma, systemic lupus, gout, osteoarthritis, and rheumatoid arthritis Normally straw colored, clear, or slightly cloudy After procedure support extremity joint rest for 12 hours ice to joint for 24 - 48 hours assess for s/s of infection

14 Diagnostic Tests w Electromyogram (EMG) Insertion of needle electrodes into the skeletal muscles to record the electrical activity Muscles do not produce electrical charge at rest Unusual patterns may be observed for neuropathy and myopathy

15 Rheumatoid Arthritis w Etiology/Pathophysiology Most serious form of arthritis Chronic, systemic disease Most common in women of childbearing age Autoimmune disorder, but may also be genetic Agents that should protect the body attack joint tissues Can affect lungs, heart, blood vessels, muscles, eyes and skin Chronic inflammation of the synovial membrane of the diarthrodial joints (movable)

16 Rheumatoid Arthritis w Signs & Symptoms Characterized by periods of remission and exacerbation Malaise Muscle weakness Loss of appetite Generalized aching Edema & tenderness of joints Limited range of motion (morning stiffness)

17 Rheumatoid Arthritis

18 w Diagnostic Tests Radiography studies show loss of articular cartilage and change in bone structure Laboratory Tests Erythrocyte Sedimentation Rate (ESR) –increase indicates inflammation Rheumatoid Factor (RF) –elevation indicates abnormal serum protein concentration Latex agglutination test –detects presence of IgM version of rheumatoid factor (anti-IgG antibodies) Synovial fluid aspiration –fluid is cloudy, yellow, less viscous and increased protein

19 Rheumatoid Arthritis w Treatment Medications Salicylates (Aspirin) Nonsteroidal Anitinflammatory Drugs (NSAID’s) –indomethacin (Indocin) –ibuprofen (Motrin) –naproxen (Naprosyn) –piroxicam (Feldene) –nabumetone (Relafen) Potent Antiinflammatory Agents –adrenocorticosteroids (prdnisone) –phenylbutazone (Butazolidin) Slow-Acting Antiinflammatory Agents (6-12 mo.) –hydroxychloroquine (Plaquenil)

20 Rheumatoid Arthritis Rest 8-10 hours of sleep a night; 2 hour nap during day Exercise Range of motion 2-3 times per day prevents joints from “freezing” and muscles from weakening Heat Hot packs, heat lamp, and/or hot paraffin Relaxes and soothes muscles Rehabilitation Help pt. to adapt to physical limitaions and promoting normal daily activities

21 Rheumatoid Arthritis w Prognosis Remissions and exacerbations are common Disease normally progresses to include joint deformity, extensive muscle atrophy, soft tissue lesions, bone and cartilage destruction, and fibrous or bony ankylosis (fixed joints)

22 Ankylosing Spondylitis w Etiology/Pathophysiology Chronic, progressive disorder of the sacroiliac and hip joints, the synovial joints of the spine, and the adjacent soft tissues. Most common in young men Strong hereditary tendency

23 Ankylosing Spondylitis w Signs & Symptoms Low back pain and stiffness “sciatica pain” lasts for a few days then subsides worse when standing May also affect joints in the neck, jaw, shoulders, knees, and hips Decreased ROM Elevated temperature Tachycardia Hyperpnea

24 Ankylosing Spondylitis

25 w Diagnostic Tests Hemoglobin and Hematocrit Low due to anemia ESR elevated due to inflammation Serum alkaline phosphatase elevated due to immobilization Radiographic reveals sacroiliac joint and intervertebral disk inflammation with bony erosion and joint space fusion

26 Ankylosing Spondylitis w Treatment Analgesics NSAID’s Exercise program swimming and walking Surgery replace fused joints Maintain spine alignment firm mattress bed board back brace Breathing exercises Turn and position every 2 hours

27 Ankylosing Spondylitis w Prognosis Chronic disease Lasts about 20 years leaving permanent damage

28 Degenerative Joint Disease (Osteoarthritis) w Etiology/Pathophysiology Nonsystemic, noninflammatory disorder that progressively causes bones and joints to degenerate Primary Cause is unknown Secondary Caused by trauma, infections, previous fractures, rheumatoid arthritis, stress on weight-bearing joints.

29 Degenerative Joint Disease (Osteoarthritis)

30 w Signs & Symptoms Joint edema, tenderness, instability, and deformity Heberden’s Nodes nodules on the sides of the distal joints of fingers Bouchard’s Nodes nodules on the proximal joints of fingers

31 Degenerative Joint Disease (Osteoarthritis)

32 w Diagnostic Tests Radiographic studies Arthroscopy Synovial fluid examination Bone scans

33 Degenerative Joint Disease (Osteoarthritis) w Treatment Exercise balanced with rest Heat applications Gait enhancers (canes, walkers, etc.) Medications Salicylates (aspirin) NSAID’s (Motrin) Steriods (cortisone) Surgery Osteotomy Joint replacement

34 Degenerative Joint Disease (Osteoarthritis) w Prognosis Chronic disease that ultimately causes permanent destruction of affected cartilage and underlying bone.

35 Gout (Gouty Arthritis) w Etiology/Pathophysiology Metabolic disease resulting from an accumulation of uric acid in the blood Caused by an ineffective metabolism of purines Primary hereditary factors Secondary use of certain drugs, complication of other diseases, or idiopathic Affects men more frequently than women Does not occur before puberty in the male or before menopause in the female

36 Gout (Gouty Arthritis) w Signs & Symptoms Excruciating pain Edema Inflammation Most common in the great toe Tophi calculi deposits

37 Gout (Gouty Arthritis)

38 w Diagnostic Tests Serum and uric acid levels Complete blood count ESR Radiography studies reveal cysts Synovial fluid aspiration contain urate crystals

39 Gout (Gouty Arthritis) w Treatment Medications colchicine –decreases uric acid phenylbutazone (Butazolidin) indomethacin (Indocin) –antiinflammatory corticosteroids allopurinol (Zyloprim) –decreased the production of uric acid sulfinpyrazone (Anturane) –increases secretion of uric acid by the kidneys

40 Gout (Gouty Arthritis) Encourage fluid intake at least 2000 cc/day Monitor intake and output Bed rest and joint immobilization Diet Avoid high purine foods –organ meats –anchovies –yeast –herring –mackerel –scallops

41 Gout (Gouty Arthritis) w Prognosis Signs and symptoms are usually recurrent Can progress to destructive joint changes

42 Osteoporosis w Etiology/Pathophysiology Reduction of bone mass Most common in women ages 55-65 possibly related to lack of estrogen Contributing Factors Immobilization Use of steroids High intake of caffeine Diet low in calcium Smoking Excessive protein in diet Sedentary lifestyle

43 Osteoporosis w Magnification of: Healthy Bone Bone with Osteoporosis

44 Osteoporosis w Signs & Symptoms Backache especially in the thoracic and lumbar regions worse with sitting, standing, coughing, sneezing, and straining Bones porous and brittle pathological or spontaneous fractures Dowager’s hump spinal deformity and height loss that develop from repeated spinal vertebral fractures

45 Osteoporosis w Diagnostic Tests CBC Serum calcium Phosphorus Alkaline phosphatase Blood urea nitrogen Creatinine level Urinalysis Liver and thyroid function tests Radiography studies

46 Osteoporosis w Treatment Calcium supplements 1000 mg for men 1500 mg for women Vitamin D Weight-bearing exercises Estrogen alendronate (Fosamax) absorbs calcium phosphate crystal in bone Diet Milk and dairy products provide the most calcium Limit caffeine

47 Osteoporosis w Prognosis Chronic disorder Prevention should begin before bone loss occurs

48 Osteomyelitis w Etiology/Pathophysiology Local or generalized infection of the bone and bone marrow Staphylococci most common cause Introduced through trauma (injury or surgery) or by the bloodstream from another site in the body to the bone Bacteria invade the bone and degeneration of bone occurs

49 Osteomyelitis w Signs & Symptoms Persistent, severe, and increasing bone pain Wound draining purulent fluid S/S of infection temperature, tachycardia, and tachypnea Edema of affected area

50 Osteomyelitis w Diagnostic Tests Radiography studies Bone scan CBC (esp WBC) ESR Cultures of blood and drainage

51 Osteomyelitis w Treatment Antibiotic therapy broad-spectrum antibiotic –Keflin (cephalothin) IV for several weeks Surgery removal of necrotic bone Absolute rest of affected extremity Wound Care irrigate with hydrogen peroxide or antibiotic solution cover with sterile dressing Drainage and secretion precautions Diet high in calories, protein, and vitamins

52 Osteomyelitis w Prognosis Acute usually responds to treatment after several weeks Chronic may persist for years with exacerbations and remissions

53 Herniation of Intervertebral Disk (Herniated Nucleus Pulposus) w Etiology/Pathophysiology Rupture of the fibrocatrilage surrounding an intervertebral disk, releasing the nucleus pulposus that cushions the vertebrae above and below Lumbar and cervical herniations are most common May occur from lifting, twisting, trauma, or degenerative changes.

54 Herniation of Intervertebral Disk (Herniated Nucleus Pulposus)

55 w Signs & Symptoms Lumbar low back pain that radiates over the buttock and down the leg numbness and tingling in affected leg Cervical neck pain, headache, and neck rigidity

56 Herniation of Intervertebral Disk (Herniated Nucleus Pulposus) w Diagnostic Tests Radiography studies CT Myelogram Electromyelography (EMG)

57 Herniation of Intervertebral Disk (Herniated Nucleus Pulposus) w Treatment Bed rest Pain medication Muscle relaxants Physical therapy muscle strengthening ultasound heat - cold application Traction pelvic or cervical

58 Herniation of Intervertebral Disk (Herniated Nucleus Pulposus) Surgery Laminectomy –Removal of the bony arches or vertebrae –Removal of displaced vertebral disk Spinal Fusion –Immobilization of joint –Remove disk and fuse vertebrae; may use bone from iliac crest Diskectomy –Removal of extruded disk material Chemonucleolysis –Injection of chymopapain to dissolve the nucleus pulposus

59 Tumors of the Bone w Etiology/Pathophysiology May be primary or secondary Benign or Malignant Osteogenic sarcoma primary malignant bone tumor seen most often in male ages 10-25 can metastasize via bloodstream fast-growing and aggressive Osteochondroma benign tumor seen most often in males ages 10-30 may be a single tumor or muliple tumors

60 Tumors of the Bone w Signs & Symptoms Spontaneous fractures Anemia Pain esp. with weight bearing Edema and discoloration of skin at site

61 Tumors of the Bone w Diagnostic Tests Radiography studies Bone Scan Bone biopsy CBC Platelet count Serum protein levels serum alkaline phosphatase level

62 Tumors of the Bone w Treatment Surgery Depends on tumor size, location and extent of tissue involvement Wide excision or resection Bone curettage Leg or arm amputation Chemotherapy and Radiation Decrease size or tissue involvement before surgery Limb-salvage procedure

63 Tumors of the Bone w Prognosis Survival rates with aggressive treatment are approximately 50% at 5 years

64 Traumatic Injuries w Contusions An injury from a blow or blunt force which causes local bleeding under the skin Treatment Cold compresses for 15-20 minutes intermittently for 12 to 36 hours Elevate involved extremity

65 Traumatic Injuries w Sprains Results from a wrenching or hyperextension of a joint, tearing the capsule and ligaments May involve bleeding into the joint (hemarthrosis) Treatment Cold compresses for 15-20 minutes intermittently for 12 to 36 hours Elevate involved extremity

66 Traumatic Injuries w Whiplash Injury at cervical spine caused by hyperextension Usually caused by violent back-and-forth movements of the head and neck Symptoms Pain in the cervical area; may radiate down the arm Headache, blurred vision, weakened hand grip Treatment Analgesics Muscle relaxants Cervical traction (neck brace)

67 Traumatic Injuries w Ankle Sprains Caused by a wrenching or twisting of the foot and ankle Signs & Symptoms Edema of the ankle Pain with movement of ankle Treatment Elevate injured area Cold compresses for 15-20 minutes intermittently for 12-36 hours Warm compresses for 15-30 minutes four times a day after 24 hours Compressive dressings and splint Surgery –may be necessary for torn ligaments

68 Traumatic Injuries w Strains Microscopic muscle tears as a result of overstretching muscles and tendons Signs & Symptoms Sudden & severe pain in affected muscle Ecchymosis and edema over area Treatment Analgesics Exercise legs Cold compresses 15-20 minutes for 12-36 hours then warm compresses 15-30 minutes after 24 hours Surgery –may be required if muscle is completely ruptured

69 Traumatic Injuries w Dislocations Etiology/Pathophysiology Temporary displacement of bones from their normal position May be caused by: –congenital –disease process –trauma

70 Traumatic Injuries Signs & Symptoms Erythema Discoloration Edema Pain Limitation of movement Deformity or shortening of the extremity

71 Traumatic Injuries Treatment Closed reduction Open reduction Cold compresses first 24 hours and warm compresses after 24 hours Elevate injured extremity Elastic bandage Immobilze –splint –sling Analgesics –Demerol, Morphine –Motrin, Tylenol

72 Carpal Tunnel Syndrome w Etiology/Pathophysiology Compression of the median nerve between the carpal ligament and other structures in the carpal tunnel

73 Carpal Tunnel Syndrome Predisposing Factors Obese, middle aged women Employment in occupations involving repetitious motions of the fingers and hands –computer usage –basket weaving –meat carving –typing

74 Carpal Tunnel Syndrome w Signs & Symptoms Paresthesia sensation of pricks of pins and needles Hypoesthisia decrease in sensation in response to stimulation Burning pain or tingling in the hands may be intermittent or constant Inability to grasp or hold small objects Edema of the hand, wrist, or fingers Muscle atrophy Depressed appearance at the base of the thumb on the palmer side

75 Carpal Tunnel Syndrome w Diagnostic Tests Physical exam Tinel’s sign –increased tingling with gentle tap over tendon sheath on ventral surface of central wrist Electromyogram MRI

76 Carpal Tunnel Syndrome w Treatment Immobilizer cock-up splint Elevate extremity ROM exercises Surgery Release carpal ligament Post-op Interventions –Elevate the hand and arm for 24 hours Needs to be elevated as high as possible –ROM to thumb and fingers –Analgesics –Monitor vital signs –Assess fingers for circulation, sensation, and movement every 1- 2 hours for 24 hours

77 Carpal Tunnel Syndrome w Prognosis Mild symptoms may be relieved by nonsurgical treatment Severe symptoms may be relieved by surgical treatment Pregnancy induced usually subside after delivery


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