Chapter 4 Care of the Patient with a Musculoskeletal Disorder

Chapter 4 Care of the Patient with a Musculoskeletal Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Overview of Anatomy and Physiology
Functions of the skeletal system Support Protection Movement Mineral storage Hemopoiesis Structure of bones Four classifications based on form and shape Long, short, flat, and irregular The skeletal system performs five vital functions in the body. These functions include support, protection, movement, mineral storage, and hemopoiesis. Review the minerals that play a role in the functioning of the skeletal system. How does the body compensate for alterations in dietary intake of these minerals?

Skeleton, anterior view.
Figure 4-2 Review the types of bones discussed in the previous slide. What are specific examples of each of the different types of bones in the skeleton? (From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.) Skeleton, anterior view.

Articulations (joints) Allow movement and flexibility Hold bones together Three types according to degree of movement Synarthrosis—no movement (skull) Amphiarthrosis—slight movement (pelvis) Diarthrosis—free movement (shoulder) Divisions of the skeleton Axial skeleton Appendicular skeleton What are examples of each of the joint types? Provide examples of bones in the axial skeleton. What are some of the bones in the appendicular skeleton?

Structure of a freely movable (diarthrotic) joint.
Figure 4-1 (From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.) Structure of a freely movable (diarthrotic) joint.

Under voluntary or involuntary control Functions of the muscular system Motion Maintenance of posture Production of heat (85% of body heat) Skeletal muscle structure Epimysium (connective tissue covering skeletal muscle) Perimysium Endomysium Both join with epimysium to create tendon Tendons anchor muscle to bone Tendon sheaths contain synovial fluid for easy movement Contraction and relaxation provides the motion needed for muscular movement. Review how tendons and ligaments differ. How do muscles provide posture for the body? Approximately 85% of the body’s heat is produced by the muscles. What processes are responsible for this vital function?

Anterior view of the body.
Figure 4-5 The body contains more than 600 muscles. (From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.) Anterior view of the body.

Nerve and blood supply Blood vessels provide a constant supply of oxygen and nutrition, and nerve cells/fibers supply a constant source of information Muscle contraction Muscle stimulus—when a muscle cell is adequately stimulated, it will contract Muscle tone—skeletal muscles are in a constant state of readiness for action Types of body movements—flexion, extension, abduction, adduction, rotation, supination, pronation, dorsiflexion, and plantar flexion Nutrition and oxygenation are chief requirements for muscle health. Optimal muscle health is needed to maintain the constant state of readiness of the body for action and reaction. How will disease processes of the muscles impact the body’s ability to move?

Laboratory and Diagnostic Examinations
Radiographic studies X-ray Myelogram Nuclear scanning Magnetic resonance imaging (MRI) Computed axial tomography (CT or CAT scan) Bone scan Aspiration/Synovial fluid aspiration Endoscopic examination Arthroscopy Endoscopic spinal microsurgery Radiographic studies are the most common type of diagnostic testing done for the musculoskeletal system. What special precautions and nursing implications are needed for patients undergoing radiographic studies? How is arthroscopy both diagnostic and therapeutic in nature?

Laboratory and Diagnostic Examinations
Electrographic procedure Electromyogram (EMG) Laboratory tests Calcium Erythrocyte sedimentation rate (ESR) Lupus erythematosus (LE) preparation Rheumatoid factor (RF) Uric acid (blood) Needle aspiration is used to obtain body fluids from joint cavities. Review the nursing interventions when caring for a patient having this type of examination. When caring for a patient undergoing diagnostic musculoskeletal testing, what education should be provided to the patient?

Inflammatory Disorders of the Musculoskeletal System
Arthritis Several types; most common RA, rheumatoid spondylitis, OA, DJD, gout Rheumatoid arthritis Etiology/pathophysiology Most serious form of arthritis; Chronic, systemic disease Most common in women of childbearing age Autoimmune disorder, but may also be genetic; smoking greatly increases risk May affect lungs, heart, blood vessels, muscles, eyes, and skin Chronic inflammation of the synovial membrane of the diarthrodial joints (movable) An estimated 50 million Americans are victims of arthritis. Arthritis is a costly disease resulting in lost wages and health care expenses. Review the autoimmune reaction that is suspected when rheumatoid arthritis strikes.

Rheumatoid arthritis (continued) Clinical manifestations/assessment Characterized by periods of remission and exacerbation Malaise Muscle weakness Loss of appetite Generalized aching Edema and tenderness of joints Limited range of motion (morning stiffness) Can lead to gross deformity and loss of function

Rheumatoid arthritis of hands.
Figure 4-7 Notice how the patient’s fingers are affected by rheumatoid arthritis. (From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.) Rheumatoid arthritis of hands.

Rheumatoid arthritis (continued) Diagnostic tests Radiography studies show loss of articular cartilage and change in bone structure Laboratory tests Erythrocyte sedimentation rate (ESR) (0-15mm/hr) Rheumatoid factor (RF) (0-30 IU/ mL) Latex agglutination test (neg) Synovial fluid aspiration (clear, viscous) A single definitive diagnostic tool for rheumatoid arthritis is not available. A diagnosis involves a complete physical examination and patient history. Review the anticipated findings in the erythrocyte sedimentation rate, Rheumatoid factor, latex agglutination test, and synovial fluid aspiration when a diagnosis of rheumatoid arthritis is confirmed. What other disorders could have similar diagnostic test results?

Rheumatoid arthritis (continued) Medical management/nursing interventions Pharmacological management Salicylates, NSAIDs, anti-inflammatory agents, disease-modifying antirheumatoid drugs Rest: 8 to 10 hours of sleep a night Exercise: Range of motion two to three times per day Heat: Hot packs, heat lamp, and/or hot paraffin Rehabilitation Joint replacement if needed Rheumatoid arthritis is a chronic disease with no known cure. “Quiet” exercise is recommended. What are examples of quiet exercise? What are the goals of disease management? Given the age of the most commonly stricken population and the absence of a complete cure, what are potential psychosocial implications for a family after a member is diagnosed with rheumatoid arthritis?

Salicylates Action Uses
Analgesic, antipyretic, and antiinflammatory effects Stop the production of prostaglandins; antiplatelet aggregate Uses Treatment of mild to moderate pain; reduces the risk of myocardial infarctions and stroke, as well as transient ischemic attacks (TIAs) in men First-line therapy for various forms of arthritis, fever, myalgia, neuralgia, arthralgia, headache, and dysmenorrhea Systemic lupus erythematosus, acute rheumatic fever What physiologic actions occur in the body when salicylates stop prostaglandin production? What is the action of the salicylates when they are used to prevent conditions of ischemia? When is low-dose therapy indicated? Adverse Reactions Tinnitus, visual disturbances, edema, urticaria, anorexia, epigastric discomfort, and nausea Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Salicylates (cont.) Drug Interactions Nursing Implications
Alcohol use increases the chance for GI bleeding; NSAIDs; sulfonamides, sulfonylureas; phenytoin Nursing Implications Assessment, diagnosis, planning, implementation, and evaluation Patient Teaching Administration time, adverse effects; time for drug effectiveness; implications for drug interactions and when to contact the healthcare provider; storage and safety; other routes of administration if PO is not tolerated What is the most common test for occult blood in stool? What are the contraindications for use of salicylates? What patient warning has been implemented for the COX-2 inhibitors? What signs and symptoms would the patient report if he or she were experiencing excessive bleeding due to salicylate use? Which conditions and concurrent use of salicylates increase the risk for Reye syndrome? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Acetaminophen Over-the-counter drug; antipyretic analgesic; no antiinflammatory effect Action: antipyretic – direct action of the hypothalamic heat-regulating center; blocks pyogenic cytokines through vasodilation and sweating Use: chronic, nonmalignant pain; osteoarthritis Adverse reactions: rare blood response; liver toxicity; overdosage can be fatal Drug interactions and hepatotoxicity How does acetaminophen differ from aspirin? Why was phenacetin taken off the market? Which drugs increase the risk for liver damage when combined with acetaminophen? Overdosage of acetaminophen may be fatal. What information should be included in the patient’s teaching plan? What information should the patient who is prescribed combination therapy (narcotic and acetaminophen) receive? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Nonsteroidal Antiinflammatory Drugs
Action: unknown; may block prostaglandins; analgesic, antiinflammatory, and antipyretic effects Ex: ibuprofen, indocin, tolectin, naproxen Uses: rheumatic disease, degenerative joint disease, osteoarthritis, and acute musculoskeletal problems Adverse reactions: GI most common Drug interactions Nursing implications and patient teaching What are common adverse reactions associated with the use of NSAIDs? Each NSAID must be checked for possible drug interactions; the structure of each drug varies. What important assessments should the nurse review for the patient prescribed NSAIDs? Why would lower doses be prescribed for the elderly patient? Why is it important to assess the patient for aspirin sensitivities? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Slow-Acting Antirheumatic Drugs - Gold Compounds
Chrysotherapy Action: unknown; interference with biochemical reactions at the cellular level; inhibit lysosomal enzyme activity; effect on antigen response in rheumatoid arthritis; stops synovitis Adverse reactions and toxicities –stomatitis; renal and hepatic damage Dosage and administration -3 months for effect Forms of medication -IM and oral What are the physiologic responses of the lysosomes in the body? What are the risks and benefits associated with gold compounds? What symptoms will the patient exhibit when experiencing a “nitritoid-like response?” Which IM site will be used to administer gold injections? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Slow-Acting Antirheumatic Drugs - Hydroxychloroquine Sulfate
Action: unknown; antimalarial drug; acts to stop antigen formation in the body Uses Adverse reactions – retinal edema Drug effectiveness – needs 6-12 months before effects are seen Drug interactions What is the most serious side effect of this drug? For which type of arthritis would this drug be prescribed? For what other conditions would this drug be prescribed? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Slow-Acting Antirheumatic Drugs - Methotrexate
Action: unknown, may affect immune function to reduce inflammation; alters the way the cells use folic acid Uses: treatment of cancer and rheumatoid arthritis Toxicities – do not get pregnant or have immunizations while on this drug What outcomes are associated with the use of this drug for rheumatoid arthritis? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Disease Modifying Antirheumatoid Drugs (DMARDs): - Penicillamine
Action: chelating agent Use: rheumatoid arthritis Nursing implications: take 1 hour before or 2 hours after food or drugs Patient and family teaching: treatment length/drug effectiveness; toxic effects; when to contact healthcare provider; monitoring; brief pain increase following injection; adverse reactions What is the action of a chelating agent? What laboratory tests are used to monitor patients while taking this drug? In what amount of time will the patient observe effects from this drug? For which adverse reactions will the LPN/LVN monitor the patient who has been prescribed this drug? When should the patient be advised to contact the healthcare provider? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Disease Modifying Antirheumatoid Drugs (DMARDs): Infliximab
Action/Use: in combination with methotrexate to reduce signs and symptoms of rheumatoid arthritis, Crohn disease, other orthopedic inflammatory or destructive processes Antibody that binds to proinflammatory enzymes Adverse reactions: FDA warning; symptoms Use of this drug in patients with preexisting congestive heart failure places them at increased mortality risk. What adverse reactions will this drug produce in the patient with a depressed immune system? For what adverse reactions should the patient be monitored during administration of this drug? What is the route of administration for this drug? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Disease Modifying Antirheumatoid Drugs (DMARDs): etanercept
Binds to Tumor Necrosis factor to block normal and immune inflammatory responses Prevents body’s ability to fight infections Given subq twice weekly Make cause or aggravate systemic lupus erythematosus Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Disease Modifying Antirheumatoid Drugs (DMARDs): Humira
Reduces infiltration of inflammatory cells Adverse: neutropenia Nursing: monitor for infections; hold drug if infection present Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Disease Modifying Antirheumatoid Drugs (DMARDs): azulfidine
Blocks prostaglandin synthesis Adverse: many GI side effects; hepatotoxic Nursing: space doses evenly around the clock; monitor for bruising, bleeding, itching and jaundice; may discolor urine and skin an orange-yellow color; monitor CBC Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Immunosuppresant: Imuran & Cytoxan
Inhibits DNA/RNA protein synthesis May take 12 weeks to see effect Causes GI irritation Monitor for liver impact: bleeding and bruising Avoid pregnancy while taking these drugs Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Corticosteroids Leader of antiinflammatory medications
Give with food or milk to prevent GI irritation Causes sodium retention = water retention; I COME TAPE; fat deposits, hirsutism and diabetes mellitus Taper off dose per MD instructions Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

COX 2 INHIBITOR - CELEBREX
Analgesic and antiinflammatory Risk of GI bleeding; increased risk of MI or CVA Give with or without food Do not give to patients with sulfa allergy or asthma Give carefully with Lasix, ACE inhibitors, warfarin, and lithium Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Ankylosing spondylitis 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 Clinical manifestations/assessment Pain and stiffness in back; decreased ROM Elevated temperature; tachycardia; hyperpnea Ankylosing spondylitis is a progressive inflammatory disorder. Although both men and women are affected, it is typically milder in women. How does ankylosing spondylitis differ from rheumatoid arthritis?

Ankylosing spondylitis (continued) Diagnostic tests Hemoglobin, hematocrit, ESR, alkaline phosphatase Radiographic Medical management/nursing interventions Pharmacological management Analgesics, NSAIDs Exercise program: swimming and walking Surgery: replace fused joints Maintain spine alignment Turn, position, and breathing exercises every 2 hours Review the diagnostic tests used to confirm the presence of anklyosing spondylitis. What findings for each test are used in the confirmation process?

Osteoarthritis (degenerative joint disease) 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 Osteoarthritis is the most common type of arthritis. It is a chief cause of disability. What risk factors are associated with the development of osteoarthritis? Differentiate between the modifiable and nonmodifiable risk factors. What impact does aging have on the development of osteoarthritis?

Osteoarthritis (degenerative joint disease) (continued) Clinical manifestations/assessment Joint edema, tenderness, instability, and deformity Heberden’s nodes – sides of distal joints of fingers Bouchard’s nodes – proximal joints of fingers Diagnostic tests Radiographic studies Arthroscopy Synovial fluid examination Bone scans There are no definitive tests available for osteoarthritis. What findings can be anticipated when a diagnosis of osteoarthritis is confirmed? Compare and contrast osteoarthritis and rheumatoid arthritis.

Figure 4-9 Heberden’s nodes.
Heberden’s nodes are nodules on the distal sides of the fingers’ joints. Explain how Heberden’s nodes differ from Bouchard’s nodes. (From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.) Heberden’s nodes.

Osteoarthritis (degenerative joint disease) (continued) Medical management/nursing interventions Pharmacological management Salicylates, NSAIDs, corticosteroids, glucosamine supplements Exercise balanced with rest Heat applications Gait enhancers (canes, walkers, etc.) Surgery Osteotomy Joint replacement What are the goals of disease management for osteoarthritis? What is the role of the nurse in the care of a patient diagnosed with osteoarthritis?

Gout (gouty arthritis) 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 males or before menopause in females

Gout (gouty arthritis) (continued) Clinical manifestations/assessment Excruciating pain, often occurring at night Edema Inflammation (most common in the great toe) Tophi (calculi containing Na urate deposits occurring in periarticular fibrous tissue) Diagnostic tests Serum and uric acid level, CBC, ESR Radiography studies Synovial fluid aspiration Discuss the characteristics of the pain experienced by the patient having gout. What subjective data should be collected by the nurse from the patient suspected of having gout?

Gout (gouty arthritis) (continued) Medical management/nursing interventions Pharmacological management Colchicine, phenylbutazone (Butazolidin), indomethacin (Indocin), corticosteroids, allopurinol (Zyloprim), sulfinpyrazone (Anturane) Encourage fluid intake Monitor intake and output Bed rest and joint immobilization Dietary restrictions Develop a list of foods that should be avoided by the patient diagnosed with gout. What is the importance of monitoring kidney function in the patient with gout? Purines are restricted in the patient with gout. What foods should be avoided?

Antigout Medications Uric acid levels increase; crystal formation
Gouty arthritis Relief of pain/ inflammation – acute period Uricosuric agents Probenecid – inhibits renal tubular reabsorption of uric acid allowing increased excretion – also slows PCN secretion Allopurinol – decrease production of uric acid Anturane – prevents tophi build up *** ASA inactivates these drugs***** Uric acid is a metabolite of protein metabolism. What are the causes of high serum uric acid levels? Crystals form in the kidneys and joint spaces. What type of damage occurs when uric acid crystals come in contact with tissues? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Uricosuric Agents (cont.)
Adverse reactions: drug-specific symptoms Drug interactions Salicylates Increased drug effects Acidifying and alkalinizing agents Anticoagulants Hypersensitivity reactions On what topics would the nurse counsel the obese patient concerning lifestyle changes? What other lifestyle factors may affect the patient’s gout? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Uricosuric Agents (cont.)
Nursing implications: assessment, diagnosis, planning, implementation, evaluation Patient and family teaching: preventing attacks; drug administration; diet and fluid intake; self-monitoring of urine and stools; when to contact the health care provider; colchicine administration; drug interactions How much fluid should the nurse advise the patient to drink daily? Why is it essential that the patient take gout medication regularly as ordered? How is the dosage of allopurinol adjusted? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Other Disorders of the Musculoskeletal System
Osteoporosis Etiology/pathophysiology Reduction of bone mass Most common in women ages 55 to 65 Contributing factors: immobilization; steroids; high intake of caffeine; diet low in calcium, high in protein; smoking; sedentary lifestyle Clinical manifestations/assessment Backache Porous and brittle bones Dowager’s hump Osteoporosis is a disorder in which the skeleton’s function is impaired because of the loss of bone mass. Explore reasons that support the development of osteoporosis in high-risk populations. Why are women affected more often than men? How does immobility or a sedentary lifestyle influence the onset of osteoporosis?

Osteoporosis (continued) Diagnostic tests CBC, serum calcium, phosphorus, alkaline phosphatase, blood urea nitrogen, creatinine level, urinalysis, liver and thyroid function tests Radiography studies Medical management/nursing interventions Pharmacological management Calcium supplements, vitamin D Estrogen, alendronate (Fosamax) Weight-bearing exercises Dietary recommendations What laboratory findings support a diagnosis of osteoporosis? Develop a list of calcium-rich foods. Review the nursing implications for the administration of Fosamax.

Medications for Osteoporosis
Biphosponates – absorb calcium phosphate crystal into bone; take in am 30 minutes before other meds, sit up for 30 minutes to prevent stomach irritation EX Fosamax, Actonel, Aredia, Skelid, Boniva Calcitonin – salmon –increases bone mass EX: Miacalcin, Fortical Estrogen receptor modulator – prevents bone loss and spinal fractures EX Evista Parathyroid hormone – prevents sloughing of osteoblasts in spongy bones; increases bone mass EX: Forteo

Osteomyelitis Etiology/pathophysiology Local or generalized infection of the bone and bone marrow Staphylococci are the most common cause Introduced through trauma (injury or surgery) or via the bloodstream from another site in the body to the bone Bacteria invade the bone and degeneration of bone occurs What other organisms are associated with osteomyelitis? Identify patient populations at increased risk for the development of osteomyelitis. What behaviors or pathophysiology increase their risk of developing the infection?

Osteomyelitis (continued) Clinical manifestations/assessment Persistent, severe, and increasing bone pain Wound draining purulent fluid Signs and symptoms of infection: temperature, tachycardia, and tachypnea Edema of affected area Diagnostic tests Radiography studies; bone scan CBC; ESR; cultures of blood and drainage What subjective data will be collected by the nurse? What objective data will be collected by the nurse? Review diagnostic findings supportive of a diagnosis of osteomyelitis.

Osteomyelitis (continued) Medical management/nursing interventions Pharmacological management Antibiotic therapy based upon culture results 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 Dietary recommendations: high in calories, protein, and vitamins The treatment regimen prescribed for osteomyelitis is lengthy. Parenteral antibiotics are needed for several weeks. What broad-spectrum antibiotics could be used to treat osteomyelitis? When planning patient education, what elements concerning safety should be included for the patient diagnosed with osteomyelitis?

Fibromyalgia syndrome (FMS) Etiology/pathophysiology Musculoskeletal chronic pain syndrome Unknown etiology Clinical manifestations/assessment Generalized aching/stiffness Irritable bowel syndrome Tension headache Paresthesia of upper extremities Sensation of edematous hands Fibromyalgia syndrome is a disorder associated with chronic pain. The vague complaints often make diagnosis challenging. In what population is fibromyalgia syndrome most commonly seen?

Fibromyalgia syndrome (FMS) (continued) Diagnostic tests No specific laboratory or radiographic tests diagnose FMS Medical management/nursing interventions Pharmacological management Tricyclic antidepressants Patient education and reassurance Exercise Relaxation techniques Given the often lengthy period of illness that precedes a diagnosis, what are some psychological concerns that could be experienced by a patient suspected of having fibromyalgia syndrome? What is the impact of tricyclic antidepressants on the patient with fibromyalgia?

Surgical Interventions for Total Knee or Total Hip Replacement
Knee arthroplasty (total knee replacement) Replacement of the knee joint Restore motion of the joint, relieve pain, or correct deformity Hip arthroplasty (total hip replacement) Replacement of the hip joint What patients can be helped/treated by undergoing a hip or knee replacement?

Figure 4-11 (from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.) A, Tibial and femoral components of total knee prosthesis. B, Total knee prosthesis in place.

Hip arthroplasty (total hip replacement).
Figure 4-14 Hip arthroplasty (total hip replacement).

Arthroplasty Nursing interventions Intake and output Drainage from operative drains Oral and intravenous intake Urinary output Promote respiratory function Give oxygen 2 to 3 L/min Incentive spirometer; cough and deep-breathe Bed rest for 24 to 48 hours Change dressing as ordered Diet as ordered Neurovascular checks and vital signs every 4 hours What are the patient goals for the patient undergoing a total joint replacement? Outline the priorities for nursing care during the postoperative period following a total joint replacement.

Arthroplasty (continued) Nursing interventions (continued) Physical therapy will initiate ambulation and prescribe routine Antiembolisim stockings or pneumatic boots/ stockings Educate on prophylactic antibiotics before invasive procedures Avoid dislocation of prosthesis Avoid adduction and hyperflexion of hip Use toilet riser to prevent hyperflexion of hip

Fractures Fracture of the hip Etiology/pathophysiology
Most common type of fracture Women at higher risk due to osteoporosis when postmenopausal Types: intracapsular and extracapsular Clinical manifestations/assessment Severe pain at site Inability to move the leg voluntarily Shortening or external rotation of the leg The elderly are at risk for hip fractures. What factors associated with aging promote this population’s increased risk? How can hip fractures in the elderly be prevented? Review the 7-Ps that must be reviewed when completing a neurological assessment in a patient suspected of having a fractured hip. How should abnormal findings in the “7-P” assessment be handled?

Figure 4-16 Fractures of the hip.
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby. Fractures of the hip.

Fractures Fracture of the hip (continued) Diagnostic tests
Radiographic examination Hemoglobin Medical management/nursing interventions Buck’s or Russell’s traction until surgery Surgical repair Internal fixation Neufeld nail and screws, Kuntscher nail Prosthetic implants Austin Moore prosthesis, bipolar hip replacement In an effort to prevent further damage, the leg and hip must be kept as still as possible. Review the role of traction in the care of a patient who has suffered a fracture to the hip. How is this traction applied? What laboratory test results can be seen when evaluating the hemoglobin and blood glucose of a patient whose hip is fractured?

Fractures Fracture of the hip (continued)
Medical management/nursing interventions (continued) Postoperative interventions Wound and drain assessment Vital signs Incentive spirometer and turning every 2 hours Antiembolic stockings; anticoagulation therapy Maintain leg abduction Limit weight-bearing on affected side Chairs and commode seats should be raised to prevent flexion of hip beyond 60 degrees What are the goals of nursing care for the patient who has undergone a total hip or knee replacement? Review the parameters for abnormal and normal findings in the postoperative period.

Medical management/nursing interventions (continued) Patient teaching for open reduction internal fixation (ORIF) Assess ability to understand Assist to dangle at bedside No weight on operative side Turn every 2 hours, maintain abduction Physical therapy will instruct as to ambulation and weight-bearing As patient progresses, encourage continuing ambulation only with assistance List the potential complications associated with total hip and knee replacement surgeries.

Medical management/nursing interventions (continued) Patient teaching for hip prosthetic implant Avoid hip flexion beyond 60 degrees for approximately 10 days; beyond 90 degrees for 2 to 3 months Avoid adduction of the affected leg beyond midline for 2 to 3 months (maintain abduction) Maintain partial weight-bearing for approximately 2 to 3 months Avoid positioning on the operative side Demonstrate positioning options for the patient who has had a total hip replacement surgery. Define abduction and adduction. What positions are contraindicated? Why? Review alternative positions that can be used by the patient.

Fractures Other fractures Etiology/pathophysiology
A traumatic injury to a bone in which the continuity of the tissue of the bone is broken Pathological or spontaneous fractures Types of fractures: open, closed, greenstick, displaced, complete, comminuted, impacted, transverse, oblique, spiral, Colle’s, and Pott’s Fractures occurring as a result of an injury or trauma are termed “spontaneous.” Pathological fractures happen due to a disease process. Give examples of both spontaneous and pathological fractures.

Fractures Other fractures (continued)
Clinical manifestations/assessment Pain Loss of normal function Obvious deformity Change in the curvature or length of bone Crepitus (grating sound with movement) Soft tissue edema Warmth over injured area Ecchymosis of skin surrounding injured area Loss of sensation distal to injury

Fractures Other fractures (continued) Diagnostic tests
Radiographic examination Medical management/nursing interventions Splinting to prevent edema Body alignment Elevation of body part Application of cold packs, first 24 hours Administration of analgesics Assess for change in color, sensation, or temperature Observe for signs of shock Review the rationale for the interventions to manage a fracture.

Fractures Other fractures (continued)
Medical management/nursing interventions (continued) Closed (simple) Closed reduction; immobilization; traction Open reduction with internal fixation device Open (compound) Surgical debridement and culture of wound Administration of tetanus toxoid Observation for signs of infection Closure of wound Reduction and immobilization of fracture An open fracture is one in which the bone has broken through the skin. A closed fracture has not protruded through the skin. When caring for a closed fracture, a cast can be employed to immobilize the fracture. Review the nursing responsibilities when caring for a newly casted extremity. An open fracture has a unique set of potential risk factors. What medical concerns are raised when an open fracture occurs?

Fractures Fracture of the vertebrae Etiology/pathophysiology
Diving accidents Blows to the head or body Osteoporosis Metastatic cancer Motorcycle and car accidents Displaced fracture may place pressure on or sever the spinal cord nerves Vertebral fractures happen due to a variety of causes. Injuries can involve the vertebral body, articulating processes, and lamina. What factors will determine if permanent paralysis will occur as a result of the injury?

Fractures Fracture of the vertebrae (continued)
Clinical manifestations/assessment Pain at site of injury Partial or complete loss of mobility or sensation Evidence of fracture/fracture dislocation on x-ray Medical management/nursing interventions Stable injuries Pain medication, muscle relaxants Back support, brace, or cast Unstable fractures Traction (Halo), open reduction The patient might or might not experience pain after a vertebral fracture. How can a lack of discomfort be explained? Assessment of neurological function is vital when caring for the patient who has suffered a vertebral fracture. What should be included in the neurological assessment? Review the medication therapy that will accompany the postinjury care of a patient who has experienced a vertebral fracture.

Fractures Fracture of the pelvis Etiology/pathophysiology
Falls, automobile accidents, crushing accidents Clinical manifestations/assessment Unable to bear weight without discomfort Pelvic tenderness and edema Signs of shock Medical management/nursing interventions Bed rest—More severe fractures may require surgery and/or spica or body cast A fracture of the pelvis may be accompanied with injuries to other parts of the body. What other body systems can be involved? Review signs and symptoms that indicate additional trauma to the area.

Complications of Fractures
Compartment syndrome Cause Progressive development of arterial vessel compression and reduced blood supply to an extremity Clinical manifestations/assessment Sharp pain with movement, numbness or tingling in the affected extremity, cool and pale or cyanotic, slow capillary refill Medical management/nursing interventions Fasciotomy (incision into the fascia) Can lose the limb if pressure is not relieved Review the presence of compartments in the body’s extremities. What prognosis accompanies the development of compartment syndrome? Identify factors that affect this prognosis.

Figure 4-26 Compartment syndrome.
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.) Compartment syndrome.

Shock Cause Blood loss, pain, fear Clinical manifestations/assessment Altered level of consciousness, restlessness Hypotension, tachycardia, and tachypnea Pale, cool, moist skin Medical management/nursing interventions Restore blood volume; shock trousers IV (blood and/or isotonic solutions) Oxygen Shock related to a bone fracture can occur for one of two reasons. Bone is vascular and can experience blood loss. Severed blood vessels from the injury can also cause significant blood loss followed by shock. Review the early and late clinical manifestations of shock. Prioritize the interventions associated with treatment and management of shock. What precautions should be taken during management of the patient experiencing shock?

Fat embolism Cause Embolization of fat tissue with platelets Clinical manifestations/assessment Irritability, restlessness, disorientation, stupor, coma, chest pain, and dyspnea Medical management/nursing interventions IV fluids Steroids, digoxin Oxygen Will TPA work? Development of a fat embolism is rare. Identify at-risk populations for the occurrence of a fat embolism. In what time frame is the typical fat embolism seen in the patient? Prioritize care and treatment interventions for the management of a patient who has experienced a fat embolism.

Gas gangrene Cause Severe infection of skeletal muscle by Clostridium Clinical manifestations/assessment Pain at site of injury Signs of infection; gas bubbles under the skin Necrotic skin at site is moist; foul odor from wound Medical management/nursing interventions Excision of gangrenous tissue Antibiotics; strict aseptic technique How can a patient be exposed to the Clostridium toxin associated with gas gangrene?

Thromboembolus Cause Blood vessel is occluded by an embolus Clinical manifestations/assessment Area tingles and is cold, numb, and cyanotic Pulmonary embolus causes a sharp thoracic pain Medical management/nursing interventions Anticoagulants A clot carried through the bloodstream from the site of formation to another site, resulting in an occluded vessel, is known as a thromboembolism. Identify fractures that are at higher risk for developing this complication. Demonstrate an assessment for the Homan’s sign. What nursing implications accompany the administration of anticoagulation therapy? What diagnostic tests can be anticipated with the development of this complication?

Delayed fracture healing Healing is delayed but will eventually occur Nonunion The ends of the fracture fail to stabilize and heal after 6 to 9 months Identify populations at an increased risk for delayed fracture healing or nonunion. Review the prognosis for these diseases.

Skeletal Fixation Devices
External fixation devices Skeletal pin external fixation Immobilizes fractures by the use of pins inserted through the bone and attached to a rigid external metal frame Casts/cast brace Made of layers of plaster of Paris, fiberglass, or plastic roller bandages Stockinette applied, then a sheet of wadding, and casting material Numerous options are available to manage fractures. What information will be used to determine the best option for an individual patient? When a cast is used to immobilize a fracture, what postapplication assessments will the nurse perform? How should a cast be cared for? Discuss care of the extremity after the cast is removed.

Fixator Spica Cast

Nonsurgical Interventions for Musculoskeletal Disorders
Traction The process of putting an extremity, bone, or group of muscles under tension by means of weights and pulleys to: Align and stabilize a fracture site Relieve pressure on nerves Maintain correct positioning Prevent deformities Relieve muscle spasms Skeletal or skin as counter weight Compare and contrast skeletal and skin traction.

Traumatic Injuries Contusion: A blow or blunt force that causes local bleeding under the skin Sprains: Wrenching or hyperextension of a joint Whiplash: Injury at cervical spine caused by hyperextension Strains: Microscopic muscle tears as a result of overstretching muscles and tendons Injuries to the musculoskeletal system’s supportive structures result from a variety of actions including sports, exercise, and accidents. What types of activities would result in contusions, sprains, whiplash, and strains? What do sprains, whiplash, and strains have in common?

Traumatic Injuries Contusions, sprains, whiplash, strains
Medical management/nursing interventions Elevate injured area Cold compresses for 15 to 20 minutes intermittently for 12 to 36 hours Warm compresses for 15 to 30 minutes four times a day after 24 hours Compressive dressings and/or splint Surgery The care given to contusions, sprains, whiplash, and strains is initially supportive in nature. What are the primary goals of treatment? Review the rationale for the use of cold and warm compresses. Why is cold therapy used initially? When does surgery become needed?

Traumatic Injuries Dislocations Etiology/pathophysiology
Temporary displacement of bones from their normal position Clinical manifestations/assessment Erythema; discoloration Edema Pain Limitation of movement Deformity or shortening of the extremity Dislocations can result from the following: congenital causes, trauma, or disease processes. What are some of the more common locations affected by dislocations? What do these locations have in common?

Traumatic Injuries Dislocations (continued)
Medical management/nursing interventions Closed reduction Open reduction Cold compresses first 24 hours and warm compresses after 24 hours Elevate injured extremity Elastic bandage Immobilize Analgesics Treatment of dislocations can be noninvasive or surgical. What are the primary goals of the nursing care for dislocations? Identify examples of analgesics that are to be used to treat dislocations.

Traumatic Injuries Carpal tunnel syndrome Etiology/pathophysiology
Compression of the median nerve between the carpal ligament and other structures Predisposing factors Obese, middle-aged women Employment in occupations involving repetitious motions of the fingers and hands Compression of the median nerve within the wrist results in a syndrome known as carpal tunnel. It is a painful disorder. Populations at risk for development of the disorder include obese, middle-aged women, occupations using repetitive wrist and hand movements, and pregnancy. Why do the people in these categories develop this disorder?

Figure 4-38 (From Thompson, J.M., et al. [2002]. Mosby’s clinical nursing. [5th ed.]. St. Louis: Mosby.) A, Wrist structures involved in carpal tunnel syndrome. B, Decompression of median nerve.

Traumatic Injuries Carpal tunnel syndrome (continued)
Clinical manifestations/assessment Paresthesia (any subjective sensation; pricks of pins) Hypoesthesia (decrease in sensation in response to stimulation of sensory nerves) Burning pain or tingling in the hands 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 palmar side

Traumatic Injuries Carpal tunnel syndrome (continued) Diagnostic tests
Physical exam—Tinel’s sign Electromyogram MRI Medical management/nursing interventions Immobilizer for wrist Elevate extremity ROM exercises Hydrocortisone injections Surgery The diagnosis of carpal tunnel includes an electromyogram and an MRI. What findings from these tests are indicative of carpal tunnel syndrome? What is the role of the nurse in the provision of care for the patient undergoing surgical management of carpal tunnel syndrome?

Traumatic Injuries Herniation of intervertebral disk
Etiology/pathophysiology Rupture of the fibrocartilage 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 Any portion of the spine can be affected with disk herniation. Herniation could occur suddenly or over time as a result of a disease process. Provide examples of disorders that could cause a herniation. Lumbar and cervical herniations are seen most frequently. What about their location predisposes for this condition?

Sagittal section of vertebrae showing both normal and herniated disks.
Figure 4-39 (From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.) Sagittal section of vertebrae showing both normal and herniated disks.

Traumatic Injuries Herniation of intervertebral disk (continued)
Clinical manifestations/assessment Lumbar Low back pain that radiates over the buttock and numbness and tingling in affected leg Cervical Neck pain, headache, and neck rigidity Diagnostic tests CAT scan, myelography, and electromyelography When the patient seeks treatment for the herniated disk, pain is one of the common complaints. What questions should the nurse ask when gathering the health history relating to this situation? Diagnostic tests employed to diagnose a herniated disk include a CT scan, myelography, and electromyelography. What findings are supportive of a diagnosis of disk herniation?

Traumatic Injuries Herniation of intervertebral disk (continued)
Medical management/nursing interventions Pharmacological management Analgesics Muscle relaxants Bed rest Physical therapy Traction Surgery Laminectomy, spinal fusion, diskectomy, chemonucleolysis Typically conservative management interventions are implemented in the care of the herniated disk. Rest, pharmacological therapies, and physical therapy are implemented first. What is the desired outcome of physical therapy? Discuss the medications prescribed in the management of herniated disks.

Laminectomy

Tumors Tumors of the bone Etiology/pathophysiology
May be primary or secondary Benign or malignant Osteogenic sarcoma Osteochondroma Clinical manifestations/assessment Spontaneous fractures Anemia Pain especially with weight-bearing Edema and discoloration of skin at site Osteogenic sarcoma is a rapidly growing malignant tumor. The involved bones are usually the femur, tibia, and humerus. It is most commonly seen in males 10 to 25 years old. Osteochondroma is the most common benign tumor. Like osteogenic sarcoma, it is most commonly seen in the femur, tibia, and humerus. Again, males are the most commonly involved population. Why do spontaneous fractures accompany bone tumors? Review the etiology of anemia that can occur with a bone tumor.

Tumors Tumors of the bone (continued) Diagnostic tests
Radiography studies Bone scan; bone biopsy CBC; platelet count; serum protein levels Serum alkaline phosphatase level Medical management/nursing interventions Surgery Chemotherapy and radiation When bone tumors are suspected, serum blood levels may be assessed. What findings are expected on complete blood counts, platelet counts, and serum protein levels when a diagnosis of a bone tumor is present? What factors will determine the treatment regimen employed? Discuss the prognosis that accompanies a diagnosis of bone cancer.

Amputation Amputation of a portion of or an entire extremity
Malignant tumors, injuries, impaired circulation, congenital deformities, infections Postoperative nursing interventions Raise foot of bed to elevate extremity Encourage movement Place in prone position at least two times a day Teach strengthening exercises Elastic wraps to shape residual extremity Assess for respiratory complications Phantom-limb pain is normal Amputation is the removal of all or a portion of an extremity. The amputation can be traumatic or surgical. Amputation is done for differing purposes. It might be done to promote function, to treat a disease process, or for cosmetic functions. The loss of a body part is accompanied with psychological anguish. What concerns and feelings might be voiced by a patient who has had an amputation? What is the role of the nurse during the period preceding the amputation? Identify the role of the nurse in the postoperative period.

Nursing Process Assessment Scoliosis Kyphosis Lordosis Blanching test
Lateral curvature of the spine Kyphosis A rounding of the thoracic spine Hump-backed appearance Lordosis An increase in the curve at the lumbar region Blanching test Capillary nail refill

Skeletal Muscle Relaxants
Action: reduce muscle tone and involuntary movement without loss of voluntary motor function Centrally acting or direct myotropic blocking Uses: relief of pain in musculoskeletal and neurologic disorders involving peripheral injury and inflammation; relief of spasticity in chronic conditions What physiologic response occurs in the body when these drugs are used? What other actions do these agents produce in the body? Identify a condition in which long-term use of these drugs is common. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Skeletal Muscle Relaxants (cont.)
Adverse reactions: symptoms Drug interactions: sedatives, narcotic analgesics, antianxiety agents, hypnotics, alcohol, general anesthetics, MAOIs, and tricyclics Cyclobenzaprine and orphenadrine: anticholinergic effects that interfere with antihypertensive activity of alpha-adrenergic blockers Why is long-term use of these drugs not recommended? If the patient is exhibiting adverse reactions from the drug, such as asthma, what symptoms will the patient exhibit? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Chapter 4 Care of the Patient with a Musculoskeletal Disorder

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Chapter 4 Care of the Patient with a Musculoskeletal Disorder

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