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Download Chapter 46 Nursing Care of Patients with Musculoskeletal and
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N124IN Spring 2013 Pathophysiology/Etiology • Bacteria invades bone and soft tissues nearby Inflammation, ischemia occur Necrosis occurs in bone tissue • Modes of entry by bacteria Direct inoculation Contiguous spread Hematogenous spread Signs/symptoms • Acute osteomyelitis Fever Local inflammation signs (tenderness, redness, heat, pain, swelling) • Chronic osteomyelitis Ulceration Drainage Localized pain Diagnostic Tests • Increased WBC count • Increased ESR • Bone biopsy • May have positive blood culture • MRI, X-ray, CT scan Therapeutic Measures • Long-term antibiotic therapy • Drainage • Splinting • Surgery to remove necrosis of bone tissue/place healthy bone tissue • Amputations Nursing Care • Educate patient on IV antibiotic therapy Side effects, toxicity, interactions, precautions Home health care nurse may be necessary • Use sterile technique when working with wound, if present Educate patient on wound care/dressing changes if applicable Pathophysiology • Imbalance in bone remodeling process • 30-35 years old: bone density peaks After this age, bone breakdown rate is greater than bone building rate Causes bones to be porous inside and weaker Can result in fractures Types/Risk Factors • Primary: not related to another disease or health condition Aging Female Caucasian/Asian/Hispanic/Latino Fracture history/family history Small bones/petite Postmenopausal Decreased testosterone/estrogen in males Decreased calcium/vitamin D intake Increased caffeine/protein/sodium intake Sedentary lifestyle Excessive alcohol intake Smoking Types/Risk Factors, cont. • Secondary: caused by medical condition/procedure Hyperparathyroidism Renal dialysis Steroids Antiseizure meds Sleeping meds Antacids with aluminum Hormones for endometriosis Cancer meds Extended immobility Prevention • Positive health habits and nutritional intake prior to age 30 Proper calcium and vitamin D intake Weight-bearing/muscle-strengthening exercises Decreased alcohol consumption Not smoking Signs/symptoms • Fracture • Kyphosis • Height decrease • Back pain Diagnostic Tests • Computed Tomography • Ultrasound • Dual-energy x-ray absorptiometry (DEXA) • Decreased serum calcium/vitamin D • Increased serum phosphorus • Alkaline phosphatase levels may be increased Therapeutic Measures • No cure • Reduce Risk Factors • Medications Calcium supplements Vitamin D Therapeutic Measures, cont. • Medications, cont. Antiresorptive drugs Bisphosphonates Prevent, slow osteoporosis progress Ex: alendronate (Fosamax), risedronate (Actonel), Synthetic thyroid hormone Decreases bone loss Ex: Calcitonin (Fortical, Miacalcin) Selective estrogen receptor modulator (SERM) Increases bone mass Ex: Raloxifene (Evista) Estrogen therapy Prevents bone loss related to menopause Bone-forming drugs Teriparatide (Forteo) Increases osteoblast action and number: increases bone mass Therapeutic Measures, cont. • Diet Increase calcium/vitamin D intake Calcium: 18-49 years: 1000 mg/day >50 years: 1200 mg/day Vitamin D: 50-60 years: 400 IU >70 years or with low sunlight: 600 IU Therapeutic Measures, cont. • Exercise Weight-bearing exercise Stimulates building of bones Resistance exercise Fall prevention • Assess home environment • Educate patient family on creating environment that will help prevent falls No rugs No slippery floors No uneven areas Clutter free • Proper shoes • Provide walker or cane Nursing Care • Educate on prevention • Pain relief • Symptom care • Education on medication Pathophysiology • 3 phases Active Osteoclasts increase and cause bone deformity and destruction Mixed Osteoblasts create new bone, but it is disorganized Inactive Occurs when osteoblast activity surpasses osteoclast activity Bone is sclerotic with high vascularity • Common bones: spine, femur, skull, pelvis Etiology • Unknown cause • Usually runs in families • Could be related to latent viral infection from young adulthood Signs/Symptoms • Usually no symptoms, especially when only one bone is affected • Pain • Dependent on bone(s) • Other medical conditions can occur Ex: heart failure Diagnostic Tests • X-rays • Bone scans • Increased serum alkaline phosphatase (ALP) • Bone biopsy Therapeutic Measures • No cure • Controlled by meds NSAIDs Bisphosphonates Synthetic thyroid hormone • Exercise • Surgery Nursing Care • Pain relief • Symptom care • Educate Malignant tumors can be: • Primary: originating in bone • Metastatic: originating in other area of body and moving to bone Pathophysiology cancer type Unknown cause unique to bone Primary Malignant Tumors • Osteosarcoma/osteogenic sarcoma Most fatal tumor of bones Usually metastasizes to lungs in 2 years of diagnosis/treatment Typically involves people 10-25 years old and boys more than girls Site of origin: typically long bones of arms, legs Signs: pain/swelling, lump, limp Diagnostic tests: X-ray, bone biopsy, CT scan, bone scan, MRI Treatments: chemotherapy, surgical removal with bone grafting or amputation Primary cont. Malignant Tumors, • Ewing’s sarcoma Bone tumor that is most malignant Signs/symptoms: local pain/swelling, low-grade fever, leukocytosis, anemia Often affects pelvis and legs in children and younger men Primary Malignant Tumors, cont. • Chondrosarcoma Cartilaginous cell cancer Better prognosis Typically occurs in middle-aged and elderly Metastatic Bone Disease • Bone-seeking cancers: primary malignant tumors in prostate, breast, lung, thyroid gland • Once metastasized, numerous bone sites are usually found • Important concerns: pathological fractures, severe pain Signs/symptoms • Primary tumors: Local swelling Pain Tender mass • Metastatic disease Diffuse severe pain Can cause disability Diagnostic Tests • X-ray • CT scan • Bone scan • Bone biopsy • MRI • Increased ALP • Increased ESR Therapeutic Measures • Dependent on tumor type and extent • Primary bone tumors Surgery Chemotherapy/radiation • Metastatic bone disease No surgery External radiation Palliation Nursing Care • Assist patient with diagnosis • Refer patient to appropriate resources • Appropriate care with chemotherapy/radiation • Postoperative care https://www.youtube.com/watch?v=vpLZ 5Cq_dPY https://www.youtube.com/watch?v=q7b5 5yQP4g4
