15Musculoskeletal Disorders ObjectivesSee the Study Guide for Complete List of ObjectivesCompare and contrast different types of fracturesDiscuss the usual healing processes for boneIdentify complications of fracturesDescribe the nursing care of the client with casts or traction, including client educationPrioritize nursing care for patients who are at risk for osteopeniaDescribe the role of drug therapy, diet, and exercise in management of osteoporosis.
16Musculoskeletal Disorders Objectives—See the Study Guide for Complete List of ObjectivesDescribe the pain management of client with bone disordersPrioritize nursing care for a patient who has had a hip ORIF or knee replacementIdentify common types of amputationsIdentify appropriate nursing care for patients with degenerative joint disease (DJD)Prioritize nursing care for patients who are at risk for osteomylitis (bone infection)Describe the role of drug therapy in prevention and management of degenerative joint diseaseDescribe the causes of gout and appropriate treatments.
17Musculoskeletal Disorders Review of Bone physiology – this is a picture of normal bone, with osteoblasts rebuilding injured or old bone, faster than osteoclasts can break it downHealthy bone
18Musculoskeletal Disorders This is one osteoclast dissolving boneAs part of the normal healing process
19MusculoSkeletal Disorders Healthy bone provides structure and support for the human body. The marrow makes stem cells which produce our red and white cells when they mature.
21Musculoskeletal Disorders ----Osteoporosis Osteoporosis– number one cause of fractures in the elderly, >1.5 million per yearPrimary Osteoporosis is caused by osteopenia or thinning of the bone. This occurs when osteoclastic bone loss is faster than osteoblastic (bone building) activity.This is measured by BMD (bone mineral density)Osteopenia = T-score of less than- 1.0Treatment starts here, new guidelines 2008Osteoporosis = T-score of > -2.5
22Musculoskeletal Disorders- -----Osteoporosis Secondary OsteoporosisCaused by other disease mechanisms, or treatments, i.e. long term corticosteroids, methamphetamine or alcohol abuse, or prolonged immobility – can occur within 12 weeksTreatments are the same for both types and osteoclastic activity is the same
23Low-power scanning electron microscope image of normal bone architecture in the 3rd lumbar vertebra of a 30 year old woman marrow and other cells have been removed to reveal thick, interconnected plates of bone Slides courtesy of the Bone Research Society BRS, UK
24Low-power scanning electron microscope image of osteoporotic bone architecture in the 3rd lumbar vertebra of a 71 year old woman marrow and other cells have been removed to reveal eroded, fragile rods of bone
25Detail of a trabicular bone element perforated by osteoclast action-- note pitting of the bone ‘stalagmite’
26Musculoskeletal diseases Osteoporosis Risk FactorsAgePost-menopause (lack of estrogen stimulation)Thin lean body buildAsian or thin Caucasian raceCalcium and Vitamin D deficiencyLack of weight bearing exerciseAlcohol abuseTobacco useExcessive caffeine use (> 3 cups per day)Eating disordersMalabsorption disorders
27Musculoskeletal diseases OsteoporosisDiagnostics:DEXA Scan Screening annually of post-menopausal womenDEXA Screening for hypothyroid and hyperthyroid patientsQualitative US – not used muchBone Scan is used for differential diagnostics, i.e. to rule out bone cancerLabs for Calcium, Magnesium, Phosphorus levelsUrine for pyridinium levels
28DXA ScanThis is a typical bone densitometry study. A low dose x-ray is performed of the lumbar spine, hip (shown here) or wrist.From the resulting image /measurement, calculations can be made to determine the density of the patient's bone (T-score) and compare it to the reference standard of a healthy thirty-year-old of the same sex and ethnicity to determine future risk of fracture.
29Musculoskeletal diseases Osteoporosis Treatments and Nursing InterventionsEducate – Side effects of medsCalcium supplementation – new evidence is 1700 mg of calcium per day, or more for post-menopausal women not on hormone therapy. May use TUMS if stomach is upset with supplementsExercisesFall prevention and safetyBiphosphonates i.e. Fosamax, Actonel, Boniva– have to be taken 1 hour before any other foods or vitamins, with only water to be absorbed.Vitamin D therapy – not usually needed in the sunny desert, found in dairy and green leefy vegetables
31Musculoskeletal Disorders Fracture treatmentNursing primary concern is to assess and prevent neuro-vascular dysfunction.Neuro / circulation checks should be done of the affected limb every 15 minutes x 4, then every 30 minutes x2, then every hour. ( The book says every hour, but that is really too long, and your patient could go into shock)Immobilize the limbControl the painAssess for shock
32Risk for Peripheral Neurovascular deficit Other fracture interventions (with casting or immobilization/traction).Monitor for numbness, tingling, hyperesthesia, hypoesthesiaMonitor for DVT’s – check pulses and colorInstruct the client to examine the skin daily for any breakdown or alterations, call MD if oozing or redness occurInstruct client to avoid crossing their legsInstruct patient to completely abstain from tobaccoRemove home safety hazards in the homeInstruct patient not to scratch underneath the cast or around the pins/tractionGive patient anticoagulants and analgesics if orderedInstruct patient to take vitamins, adequate amoaunts of magnesium, vitamin C, etc…for healing.
33“The 6 P’s” Pain Paresthesia Pallor Polar Paralysis Pulses NeurovascularComponents:“The 6 P’s”Early orLate SignsAssessment ParametersClient Teaching /Symptoms to ReportPainEarlyAssess area involved using 0 to 10 rating scale:0 = no pain10 = worst pain imaginableIncreasing pain not relieved with elevation or pain medicationParesthesiaAssess for numbness/tingling, pins or needlessensation:Should be absent.Numbness or tingling, pins or needles sensationPallorAssess capillary refill.Brisk is < 3 secondsIncreased capillary refill time > 3 seconds, blue fingers or toesPolarLateAssess skin temperature bytouch:Warm <or> CoolCool/cold fingers or toesParalysisAssess mobility:Moves fingers or toesAble to plantar dorsiflex the ankle area not involved or restricted by castUnable to move fingers or toesPulsesAssess pulse(s) distal toinjury:Pulse is palpable and strongWeak palpable pulses, unable to palpate pulses, pulse detected only with Doppler
34Musculoskeletal Disorders Fractures- Pathological fracturesoccur when abnormal force is applied, or the bone is already weakened (osteoporosis, cancers, sarcomas, benign bone cysts, etc.).The type of fracture depends on the type of loading force and stress applied to the bone. See below.Closed - Greenstick -Spiral - Open (compound)
35This is a photograph of 70 year old woman who first presented like this with a massive chondrosarcoma of her right upper humerus of 8 months duration. She refused all treatment, and she died of a massive haemorrhage when the tumour burst the following week.
37Musculoskeletal Disorders Fractures-Complications of fractures include:Fat emboli syndrome/CVA/StrokeHematoma (leakage from the bone marrow usually), which can also be a hemmorhageCallus formationDVT - thromboembolismInfection – to OsteomyelitisIschemic necrosisFracture blistersDelayed union, nonunion, and malunionOsteoblastic proliferation…..
38i.e. Osgood’s Schlatter’s Osteoblastic proliferation:Osgood Schlatter’s is a commondisorder among athletes and runnersstemming from small fractures of thetibial plateau from impact which healsbuilds up bone callous.
39Immobilizing Interventions: Casts, Splints, & Traction Perform/assist with relevant laboratory, diagnostic, and therapeutic procedures within the nursing role, including:Preparation of the client for the procedure.Client teaching (before and following the procedure).Accurate collection of specimens.Accurate interpretation of procedure results (compare to norms) and appropriate notification of the primary care provider.Assessment and evaluation of the client’s response (expected, unexpected adverse response, comparison to baseline) to the procedure.Planning and implementing body system specific interventions as appropriate.Monitoring and taking actions, including client education, to prevent or minimize the risk of complications.Recognizing signs of potential complications and reporting to the primary care provider.Recommending changes in the test/procedure as needed based on client findings.Protect the client from injury.Monitor therapeutic devices (drainage/irrigating devices, chest tubes), if inserted, for proper functioning.Identify the client’s prognosis based on knowledge of pathophysiology and understanding of the client’s pathology report.
40Splints and Immobilizers CastsCasts are more effective than splints or immobilizers because they cannot be removed by the client.Types of casts include:Short and long arm casts.Short and long leg casts.Spica cast, which refers to a portion of the trunk and one or two extremities.Body cast, which encircles the trunk of the body.Splints and ImmobilizersSplints are removable and allow for monitoring of skin swelling or integrity.Splints can be used to support fractured/injured areas or used for postparalysis injuries to avoid joint contracture.Immobilizers are prefabricated and are fastened with Velcro straps.
41Traction Goals of traction include: Types of Traction Manual Skin Traction uses a pulling force to promote and maintain alignment to the injured area. In straight or running traction, the countertraction is provided by the client’s body. In balance suspension traction, the countertraction is produced by devices such as slings or splints.Goals of traction include:Realignment of bone fragments.Decreasing muscle spasms and pain.Correcting or preventing further deformitiesTypes of TractionManualSkinSkeletalHalo Traction
42Pin Site Care* Pin care is done frequently throughout immobilization (skeletal traction andexternal fixation methods) to prevent and to monitor for signs of infectionincluding:--Drainage (color, amount, odor).--Loosening of pins.--Tenting of skin at pin site(skin rising up pin).Pin care protocols (use of hydrogen peroxide, povidone iodine) are basedon provider preference and institution policy.A primary concept of pin care is that one cotton-tip swab is used per pin to avoid cross-contamination.Every 8 hr is a common parameter for pin care schedule.
51External FixationExternal fixation involves fracture immobilization using percutaneous pins and wires that are attached to a rigid external frame.Used to treat:Comminuted fracture with extensive soft tissue.Leg length discrepancies from congenital defects.Bone loss related to tumors or osteomyelitis.Advantages include:Immediate fracture stabilization.Allows three plane correction of the injury.Minimal blood loss occurs in comparison with internal fixation.Allows for early mobilization and ambulation.Disadvantages include:Risk of pin tract infection.Potential overwhelming appearance to client.
58Musculoskeletal Disorders Fractures- complicationsAcute Compartment Syndrome (ACS)A serious condition which can lead to a loss of life and limb, usually an arm or a leg. The swelling of an injury or trauma causes lack of innervation and compromised circulation to the affected part of the body, causing tissue death and necrosis. Edema causes this.Treatment is mandated by alleviating the pressure.The most common type of acute compartment syndrome in the hospital is infiltration of IV fluids, and in trauma victims.Notify Healthcare Provider
60Musculoskeletal Disorders Signs and Symptoms of ACS:Greater pain with passive movement than with active movementSwellingPain not relieved with analgesicsThese are early signs and the physician needs to notified at once.ACS can lead to renal failure, shock, and loss of the limb or life.
62Musculoskeletal Disorders Acute Compartment Syndrome (ACS)TreatmentDetermine the cause of swelling,If the cast is too tight then it needs to be cut off.If the dressing is too tight, loosening the bandage will release the pressureSurgical release of tissue pressure is often required. (Fasciotomy)
63Musculoskeletal Disorders Assessing fractures and trauma:Color or pallor of patientColor of the limb distal to the injuryMovementSensationDistal pulsesPainSkin temperatureCapillary refil
64Musculoskeletal Nursing End of Musculoskeletal,Part 1
67Pharmacology Associated with Musculoskeletal Patients--General Information Assess/monitor the client’s need for pain medication, and plan and provide care to meet the client’s needs for pain intervention.Assess/monitor the effectiveness of pain intervention, and advocate for the client’s needs as indicated.Provide appropriate client education, and reinforce client teaching regarding the purposes and possible effects of pain medications.Assess/monitor the client for expected effects of medications.Assess/monitor the client for side/adverse effects of medications.Assess/monitor the client for actual/potential specific food and medication interactions.Identify contraindications, actual/potential incompatibilities, and interactions between medications, and intervene appropriately.Identify symptoms/evidence of an allergic reaction, and respond appropriately.Evaluate/monitor and document the therapeutic and adverse/side effects of medications.Assess/collect data regarding the client’s medication use over time.
68Pharmacological Action Musculoskeletal Pharmacology : Medications for Pain & Inflammation NSAIDs—Non Steroidal Anti-Inflammatory Drugs Prototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®)Pharmacological ActionInhibition of cyclooxygenase: Inhibition of COX-2 results in ↓ inflammation, pain, and fever. Inhibition of COX-1 results in the ↓ of platelet aggregationTherapeutic UsesInflammation suppressionAnalgesia for mild to moderate painFever reductionDysmenorrheaLow level suppression of platelet aggregationAspirin contraindications include:Peptic ulcer disease.Bleeding disorders (e.g., hemophilia, vitamin K deficiency)Hypersensitivity to aspirin and other NSAIDs.Pregnancy (Pregnancy Risk Category D).Children with chickenpox or influenza.Use NSAIDs cautiously in older adults, clients who smoke cigarettes, and in clients with H. pylori infection, hypovolemia, hay fever, chronic urticaria, and/or a history of alcoholism.
69Therapeutic Nursing Interventions and Client Education Musculoskeletal Pharmacology : Medications for Pain & Inflammation NSAIDs—Non Steroidal Anti-Inflammatory Drugs Prototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®) CONTINUED…Therapeutic Nursing Interventions and Client EducationAdvise the client to stop aspirin 1 week before an elective surgery or expected date of childbirth.Advise the client to take aspirin with food, milk, or a full glass of water to reduce gastric discomfort.Instruct the client not to chew or crush enteric-coated or sustained-release aspirin tablets.Advise the client to notify the primary care provider if signs and symptoms of gastric discomfort or ulceration occur.Clients unable to tolerate aspirin due to GI ulceration, risk of bleeding, or renal impairment should be prescribed a 2nd generation NSAID, such as celecoxib (Celebrex).One 1st generation NSAID, ketorolac (Toradol), is used for short-term treatment of moderate to severe pain such as that associated with postoperative recovery.Ketorolac provides analgesia without anti- inflammatory effect.When ketorolac is used concurrently with opioids, the analgesic effect of opioids is enhanced without the occurrence of adverse effects associated with opioids (e.g., respiratory depression, constipation).When ketorolac is used with other NSAIDs serious adverse effects can occur; therefore, ketorolac should be used no more than 5 days. Usually started as parenteral administration and then progresses to oral doses.Depending on therapeutic intent, effectiveness of NSAID USE may be evidenced by:Reduction in inflammation.Reduction of fever.Relief from mild to moderate pain or dysmenorrhea.Platelet aggregation suppression.
70Nursing Interventions and Client Education Musculoskeletal Pharmacology : Medications for Pain & Inflammation Acetaminophen Prototypes: acetaminophen (Tylenol® )Nursing Interventions and Client EducationAcetaminophen is a component of multiple prescribed and over-the-counter medications. Keep a running total of daily acetaminophen intake and follow recommended dosages as prescribed by the primary care provider to prevent toxicity, not to exceed 4 g per day.In the event of an acetaminophen overdose, liver damage can be reduced by administering a weight- based dosage of the antidote acetylcysteine (Mucomyst) in a diluted form via an oroduodenal tube (has an unpleasant odor that ↑ risk of emesis).Nursing Evaluation of Medication EffectivenessDepending on therapeutic intent, effectiveness may be evidenced by:Relief of pain.Reduction of fever.Pharmacological ActionAcetaminophen slows the production of prostaglandins in the central nervous system.Therapeutic UsesAnalgesic (relief of pain) effectAntipyretic (reduction of fever) effectsSide/Adverse Effects:Nursing Interventions and Client EducationAcute toxicity that results in liver damage with early symptoms of nausea, vomiting, diarrhea, sweating, and abdominal discomfort progressing to hepatic failure, coma, and deathAdvise the client to take acetaminophen as prescribed and not to exceed 4 g per day.Administer the antidote,Acetylcysteine (Mucomyst® ).Use cautiously in clients who consume three or more alcoholic drinks/day and those taking warfarin (interferes with metabolism).
71Pharmacological Action Musculoskeletal Pharmacology : Medications for Pain & Inflammation Opioid Agonists Prototypes: Morphine sulfatePharmacological ActionOpioid agonists, such as morphine, codeine, meperidine, and other morphine-like medications (fentanyl), act on the mu receptors, and to a lesser degree on kappa receptors. Activation of mu receptors produces analgesia, respiratory depression, euphoria, and sedation, whereas kappa receptor activation produces analgesia, sedation, and ↓ GI motility.Therapeutic UsesRelief of moderate to severe pain (e.g., postoperative pain, myocardial infarction pain, cancer pain)SedationReduction of bowel motilityCodeine: cough suppressionContraindications/PrecautionsContraindicated:after biliary tract surgery.for premature infants (during and after deliverydue to respiratory depressant effects).Used Cautiously: because of respiratory depressionasthma, emphysema, and/or head injuriesInfants and older adult clientsPregnant clientsClients in laborClients with inflammatory bowel diseaseClients with an enlarged prostate
72Demerol ® -- meperidine Repeated use of meperidine (Demerol) can result in the accumulation of normeperidine, which can result in seizures and neurotoxicity.Do not administer meperidine more than600 mg/24 hr, and limit its use to less than 48 hr.
73Side Effects / Adverse Effects Nursing Interventions / Morphine SulfateSide Effects / Adverse EffectsNursing Interventions /Client EducationRespiratory depression--Monitor the client’s vital signs.--Stop opioids if the client’s respiratory rate is less than 12/min, and then notify the primary care provider.--Avoid the use of opioids with CNS depressant medications (e.g., barbiturates,benzodiazepines, and consumption of alcohol).Constipation--↑ fluid intake and physical activity.--Administer a stimulant laxative, such as bisacodyl (Dulcolax), to counteract ↓ bowel motility, or a stool softener, such as docusate sodium (Colace), to prevent constipation.Orthostatic hypotension--Advise the client to sit or lie down if symptoms of lightheadedness or dizziness occur.--Avoid sudden changes in position by slowly moving the client from a lying to a sitting or standing position.--Provide assistance with ambulation as needed.Urinary retention--Advise the client to void every 4 hr.--Monitor I&O.--Assess the client’s bladder for distention by palpating the lower abdomen area every4 to 6 hr.Cough suppression--Advise the client to cough at regular intervalsto prevent accumulation of secretions in theairway.--Auscultate the client’s lungs for crackles, andinstruct the client to ↑ intake of fluid to liquefysecretions.Sedation--Advise the client to avoid hazardous activitiessuch as driving or operating heavy machinery.Biliary colic--Avoid giving morphine to clients who have ahistory of biliary colic. Use meperidine as analternative.Emesis--Administer an antiemetic such aspromethazine (Phenergan).Opioid overdose triadof coma, respiratory depression, and pinpoint pupils--Place the client on a ventilator.--Administer opioid antagonists, such as naloxone (Narcan) or nalmefene (Revex).
74Musculoskeletal Pharmacology Medications for Pain & Inflammation Agonist – Antagonist Opioids Prototypes: pentazocine (Talwin ®)Contraindications/PrecautionsUse cautiously in clients with a history of myocardial infarction (↑ cardiac workload) and clients who are physically dependent on opioids.Nursing Interventions and Client EducationTake the client’s baseline vital signs. If the client’s respiratory rate is less than 12/min, withhold the medication and notify the primary care provider.Warn the client not to ↑ dosage without consulting the primary care provider.Nursing Evaluation of Medication Effectiveness--Monitor for improvement of symptoms, such as relief of pain.Pharmacological ActionCompared to pure opioid agonists, agonist- antagonists have:--A low potential for abuse causing little euphoria. In fact, high doses can cause adverse effects (e.g., anxiety, restlessness, mental confusion).--Less respiratory depression. Kappa receptors will cause a certain degree ofrespiratory depression and then no more (have a “ceiling”).Therapeutic UsesAgonists-antagonists opioids relieve mild to moderate pain; not used for treatment of severe pain.
75Nursing Evaluation of Medication Effectiveness Musculoskeletal Pharmacology Medications for Pain & Inflammation Opioid Antagonists Prototypes: naloxone (Narcan ®)Pharmacological ActionOpioid antagonists interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no effect in the absence of opioids.Therapeutic UsesTreatment of opioid overdoseReversal of effects of opioids, such as respiratory depressionReversal of respiratory depression in an infantContraindications/PrecautionsHypersensitivityOpioid dependencyPregnancy Risk Category BTherapeutic Nursing Interventions and Client EducationNaloxone has rapid first-pass inactivation and should be administered IV, IM, or SC. Do not administer orally.Observe the client for withdrawal symptoms and/or abrupt onset of pain. Be prepared to address the client’s need for analgesia (e.g., if given for postoperative opioid-related respiratory depression).Nursing Evaluation of Medication EffectivenessReversal of respiratory depression (e.g., respirations are regular, client is without shortness of breath, respiratory rate is 16 to 20/min in adults and 40 to 60/min in newborns)
76Tricyclic antidepressants: amitriptyline (Elavil) Musculoskeletal Pharmacology Medications for Pain & Inflammation Adjuvant Pain Medications Prototypes:Tricyclic anti-depressants; anticonvulsants; CNS Stimulants; antihistamines; glucocorticoids; & biphosphonatesTricyclic antidepressants: amitriptyline (Elavil)Anticonvulsants: carbamazepine (Tegretol), gabapentin (Neurontin), phenytoin (DilantinCNS stimulants: methylphenidate (Ritalin), dextroamphetamine (Dexedrine)Antihistamines: hydroxyzine (Vistaril)Glucocorticoids: dexamethasone (Decadron), prednisone (Deltasone)Bisphosphonates: etidronate (Didronel), pamidronate (Aredia)Pharmacological ActionsAdjuvant medications for pain enhance the effects of opioids.Therapeutic UsesUsed in combination with opioids – cannot be used as a substitute for opioidsTreating pain with an adjuvant medication allows for lower dosages of opioids, and thereby ↓ the adverse effects experienced with opioids (e.g., sedation and constipation).Help alleviate other symptoms that aggravate pain (e.g., depression, seizures, dysrhythmias)Used in the treatment of neuropathic pain (e.g., cramping, aching, burning, darting and lancinating pain).Used in cancer-related conditions (e.g., ↑ intracranial pressure, spinal cord compression, bone pain).
77Contraindications/Precautions Pharmacological Action Musculoskeletal Pharmacology Medications for Pain & Inflammation Antigout Medication Prototypes: colchicineContraindications/PrecautionsAvoid use of colchicine during pregnancy (FDA Pregnancy Risk Category C, if used orally; Category D, if used intravenously).Use colchicine cautiously in older adults, debilitated clients, and clients with renal, cardiac, and gastrointestinal dysfunction.Therapeutic Nursing Interventions and Client EducationInstruct the client to concurrently take preventive measures such as avoiding alcohol and foods high in purine (e.g., red meat, scallops, cream sauces). The client should ensure an adequate intake of water, exercise regularly, and maintain an appropriate body weight.Nursing Evaluation of Medication EffectivenessDepending on the therapeutic intent, effectiveness may be evidenced by:--Improvement of pain caused by a gout attack (e.g., ↓ in joint swelling, redness, and uric acid levels).--↓ in number of gout attacks.--↓ in uric acid levels.Pharmacological ActionColchicine and indomethacin ↓ inflammation in clients with gout by possibly preventing infiltration of leukocytes. These medications do not effect uric acid production or excretion.Allopurinol inhibits uric acid production.Probenecid inhibits uric acid reabsorption by the renal tubules.Therapeutic UsesColchicine and indomethacin:--Treatment of acute gout attacks.--If given in response to precursor symptoms of an acute gout attack, can abort the attack.--↓ in the incidence of acute attacks for clients with chronic gout.Allopurinol and probenecid:--Hyperuricemia (chronic gout secondary to cancer chemotherapy).Probenecid:--Prolongs the effects of penicillins and cephalosporins by delaying their elimination.