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Nursing Care of Clients with Musculoskeletal Disorders Chapter 43 1 Gout Inflammatory response to high levels of uric acid in body Primary gout – characterized by elevated uric acid levels from error of purine metabolism Secondary gout – results from a treatment or disease leukemia, CRF, meds. 2 Gout Manifestations – 1. hyperuricemia – – – – – levels 9-10mg/dL recurrent attacks of inflammation of single joint tophi in and around the joint renal disease and stones 2. Acute gouty arthritis – – – – single joint - red, swollen, hot, painful triggered by trauma elevated WBCs, ESR last hours to weeks 3 Gout 3. Chronic gout – – – – occurs when hyperuricemia not treated tophi develop in cartilage, synovial membranes tendons and soft tissue urate crystals may lead to kidney disease Treatment – end acute attacks and prevent recurrence 4 Urate Crystals in a tophi 5 Gout Affects many Joints 6 7 Gout Diagnostic tests – – uric acid above 7.5mg/dL elevated WBC and ESR Medications – – – – NSAIDs - indocin cochicine - interrupts the uric crystal cycle corticosteroids Zyloprim - lowers serum uric acid levels 8 TABLE 43-6 (continued) Giving Medications Safely: Gout Gout Dietary – – – low-purine diet – avoid liver, meats, seafood, beans lose wt avoid ETOH or foods known to precipitate gout Other Treatments – acute attack B/R, elevate joint with hot/cold compress, increase fluid intake 11 Gout Definition Clinical manifestations Hyperuricemia Acute gouty arthritis Chronic gout Treatment? 12 Osteoarthritis - Joints affected 13 Healthy Joint 14 15 16 17 18 Degenerative Joint Disease Osteoarthritis OA Most common form of all arthritis loss of articular cartilage in joints and hypertrophy of bones at articular margins causes are idiopathic or secondary Risk Factors – – age inactivity excessive wt repetitive exercise 19 Osteoarthritis Patho – – degeneration of cartilage lining, bone thickens and that reducing the ability to absorb energy in joint load osteophytes form, change the joint, these spurs enlarge, break off and lead to synovitis 20 Inflamed Joint Changes 21 Joint Narrowing 22 23 Osteoarthritis OA Manifestations – – – – – – – gradual, insidious pain, stiffness in one or more joints pain aggravated by use and relieved by rest immobility are followed by stiffness decrease ROM, joint crepitus during movement joint enlargement flexion contractures 24 Changes in the hip 25 Patho of Osteoarthritis 26 Changes in the Knee What might your client be feeling? 27 Osteoarthritis Diagnostic tests – changes are seen on X-ray Medications – – – – pain management ASA, tyl., NSAIDs, topical creams celebrex - fewer GI side effects vioxx - recalled - heart arrhythmia, death corticosteriod injection of joints 28 Osteoarthritis Conservative treatment – – – – – P.T rest of involved joints using ambulation devices wt loss analgesic and anti-inflammatory meds 29 Late Stage Osteoarthritis 30 Osteoarthritis OA Surgery – arthroscopy debridement – and lavage involved joints osteotomy incision into bone to realign affected joint shift joint load toward areas of less cartilage damage – Joint arthroplasty reconstruction or replacement of joint 31 32 Osteoarthritis Joint Arthroplasty – – usually TJR - replaces both articulating surfaces Cemented vs uncemented most uncemented, porous, new bone growth 6 weeks, requires longer time of non-wt bearing, lasts longer cemented - inflammation eventually loosen joint 33 Osteoarthritis OA Complications – – – – – infections dislocation loosening of prosthesis impaired circulation thromboembolism 34 Osteoarthritis OA Total Hip Replacement THR – Total knee replacement – articular surfaces of acetabulum and femoral head are replaced success rate >90% vigorous rehab, success rate > 80% Total shoulder and elbow – indicated for unremitting pain and limited ROM 35 Total hip replacement 36 Total Joint Replacement Knee 37 Nursing Care Promote comfort Maintain mobility Assist with adaptation of life-style Health Promotion – – maintenance of normal wt. Regular moderate exercise 38 Gout vs. arthritis? Which is it? 39 Autoimmune and Inflammatory Disorders - Rheumatoid arthritis Chronic systemic disease causing inflammation to connective tissue in joints – – – – 3x more likely in females onset 20-40 years course and severity variable cause unknown - genetic, environmental, hormonal, infectious agents - Epstein barr 40 41 Rheumatoid Arthritis 42 Rheumatoid arthritis Patho – synovial membrane damaged from inflammatory and immune processes, leads to erosion of articular cartilage and inflammation of ligament and tendons 43 Rheumatoid arthritis Joint Manifestations – Onset insidious or after a stressor Systemic – fatigue, anorexia, wt loss, non-specific aching and stiffness precede joint involvement Joint – – swelling, stiffness, warmth, tenderness and pain, multiple joints and symmetric involvement fingers, wrists knees, ankles and toes 44 Rheumatoid arthritis Extra-articular – – low grade fever, anemia, rheumatoid nodules in subcutaneous tissue pleural effusion, pericarditis, splenomegaly Collaborative Care – – – relief of pain and inflammation slow or stop joint damage improve well-being and ability to function 45 47 Arthritic hands 48 Early and Late Stages Swan neck deformity Ulnar deviation 49 50 Knee 51 Arthritic Hip 52 Rheumatoid arthritis Diagnostic tests – – – – – Rheumatoid factors (RF) autoantibodies to IgG ESR - indicator of inflammation - often used to evaluate effectiveness of treatment plan synovial fluid X-rays CBC 53 Rheumatoid arthritis Medications – ASA, NSAIDs tx symptoms, no effect on disease progression, many GI side effects – corticosteroids reduce pain, inflammation, slows progression long-term side effects 54 Rheumatoid arthritis Disease-modifying - antirheumatic drugs – gold compounds weekly, IM injections watch for toxic reactions – – antimalarial agents, sulfasalzine Immunosuppressive and cytoxic drugs methotrexate – intra-articular corticsteroids 55 Rheumatoid arthritis Treatments – balanced program of rest and exercise rest with exacerbation - utilize splints exercise to maintain ROM, muscle strength low impact exercises – – – P.T. and O.T heat and cold assistive devices and splints 56 Rheumatoid arthritis – Diet well-balanced, – omega-3 fatty acids Surgeries synovectomy, arthodesis, joint fusion, arthoplasty, TJR Nursing Diagnosis – Chronic pain, Fatigue, Ineffective Role Performance, Disturbed Body Image 57 Normal - Rheumatoid - Osteo - Joint 58 Rheumatoid Arthritis What is it? How is it different from osteoathritis? How would you assess for it? What’s the treatment? Nursing care? 59 60 Aids to promote usual ADL’s 61 Septic Arthritis Occurs when joint space invaded by pathogens - staph, strep, E. coli, pseudomonas Risk factors – – – persistent bactermia previous joint damage arthroscopic surgery and TJR 62 Septic arthritis 63 64 Septic Arthritis – Onset abrupt with pain and stiffness, joint is red, swollen, hot and tender to touch systemic - chills and fever Collaborative Care – – requires prompt treatment to preserve joint function joint aspiration and X-ray 65 Septic Arthritis Treatment – rest, immobilization and elevation antibiotics recurrent joint aspiration P.T. – Nursing Care - education, prevent disease – – – 66 Osteoporosis - loss of bone mass, increased bone fragility, increased risk for fx Risk Factors – – depends on amount of bone mass achieved between 25-35 yrs old Unmodifiable aging gender 67 – – Ethnicity Endocrine disorders affecting metabolism Modifiable risk factors – – – – – calcium menopause, decreasing estrogen cigarette smoking excessive ETOH intake sedentary life style 68 Osteoporosis 69 Osteoporosis 70 Osteoporosis Patho – – – diameter of bone increases, thinning outer supportive cortex spongy tissue lost and outer cortex thins minimal stress leads to fx 71 Cross Section of Bone 72 Bone X-ray 73 Osteoporosis of the Spine 74 Osteoporosis Manifestations – – – – – “silent disease” loss of height progressive curvature of spine low back pain fx of forearm, spine or hip 75 Osteoporosis Complications – fx may be spontaneous or resulting from every day activities – persistent pain and posture changes Diagnostic Tests – – X-ray DEXA - measure bone density mass 76 How Injuries can occur 77 Osteoporosis Medications – estrogen replacement therapy reduces bone loss increases bone density in spine and hip controversial - increase risk of endometrial and breast cancer, cardiovascular disease – – Biphosphonates - fosamax Calcitonin - can be nasal spray 78 Osteoporosis Health Promotion – – Calcium intake Exercise activity – that is wt. Bearing Health related behaviors no smoking limit ETOH, caffeine, soda 79 Ospeoporosis 80 Osteoporosis 81 82 Paget’s Disease - bone enlarging and softening 83 Paget’s Disease Progressive skeletal disorder where bones become larger and softer – femur, pelvis, vertebrae, sternum, skull Manifestations – – bone pain, aggravated by pressure and wt. Bearing and noticed at night warmth over bones 84 Paget’s Disease Complications – – osteoarthritis pathological fx Treatment – – hip or knee replacement braces 85 Osteomalacia Is a metabolic bone disease Affects the structure and integrity of bone Known as adult rickets 86 Osteomalacia Caused by inadequate mineralization of bone – – – – Insufficient amounts of calcium or phosphate Bone does not harden Bone is deformed and unable to bear weight Pathologic fractures occur 87 Osteomalacia Pathophysiology – Lack of vitamin D Obtained by certain foods and radiation from the sun Vitamin D is necessary to maintain calcium and phosphate levels Risk factors Inadequate intake and/or impaired absorption Chronic kidney or liver disease 88 Osteomalacia Manifestations – – – – – – Bone pain Difficulty changing positions Muscle weakness Waddling gait Dorsal kyphosis Pathologic fractures 89 Osteomalacia Diagnostic tests – – Bone x-rays Lab tests – calcium and alkaline phosphatase Treatment Adequate vitamin D, calcium, and phosphate intake or supplements Bisphosphonates and calcitonin Teach exercise and how to prevent falls 90 Paget’s - bone enlarging and softening 91 Lets Review Osteoporosis definition risk factors clinical manifestations #1 complication 92 Oops, did I pump it too high? 94 Ankylosing Spondylitis Chronic inflammatory arthritis affecting axial skeleton leading to pain and progressive stiffening and fusion of the spine Patho – inflammation - scar tissue - gradual calcification - joint consolidations and immobility 95 96 Ankylosing Spondylitis 97 Ankylosing Spondylitis Manifestations – – – – gradual and insidious bouts of low back pain worse at night, followed by morning stiffness relieved by activity back motion become limited intermittently wit mild to moderate acute episodes 98 Ankylosing Spondylitis Collaborative Care – – P.T. and daily exercise NSAIDs, topical or intra-articular corticosteroids 99 Changes in the axial spine 100 Ankylosing Spondylitis Which part of the skeletal system is affected? What are the clinical manifestations? Nursing care? 101 More Ortho Here’s the BIG question What will be be discussing next? 102 Systemic Lupus Erythematosus Affects Connective Tissue Chronic inflammatory immune complex connective tissue disease affecting multiple body systems affects females of child bearing years cause unknown mild chronic cases with remissions and exacerbation. 103 Systemic Lupus Erythematosus Manifestations – Early fever, anorexia, malaise, wt. Loss, multiple arthalgias and symmetric non-deforming polyarthritis – Skin red butter fly rash across cheeks and bridge of nose photosensitivity alopecia 104 Butterfly Rash 105 106 Figure 43-10 The multisystem effects of systemic lupus erythematosus. Systemic Lupus Erythematosus – – – – – – – renal hematologic cardiovascular pulmonary neurological ocular GI 108 Multi-system effects of Lupus 109 Systemic Lupus Erythematosus Diagnostic – – – difficult due to diversity of symptoms anti-DNA of various antibodies elevated ESR, CBC, UA, Kidney bx Treatment – – ASA, NSAIDs, anti-malarial, corticosteriods avoid sun, ESRD - dialysis and kidney transplant 110 Polymyositis Systemic connective tissue disorder with inflammation of connective tissue and muscles leading to muscle weakness and atrophy – – – auto-immune affects >females between ages 40-60 111 Polymyositis Manifestations – Initial muscle pain, tenderness weakness rash arthralgias fatigue, fever, wt. Loss – Later increase weakness, dysphagia, cough 112 Erythematous rash 113 114 Polymyositis No specific dx test Treatment – rest, corticosteroids, immunosuppressive therapy Nursing Care - supportive – comfort, nutrition, skin care, medications, maintain mobility 115 116 Lyme Disease 117 Geographic locations 118 Lyme Disease Inflammatory disorder caused by spirochete Borrelia burgdorferi and transmitted by ticks carried by deer and mice – prevalent in mid-Atlantic and north central U.S. Manifestations – Initial flu-like and skin rash “bull’s eye” lesion at site of tick bite 119 Bull’s eye rash in lyme disease 120 Lyme Disease Followed by fatigue, malaise, fever, chills, myalgias later, more skin lesions and muscle and joint pain Weeks to months later – – Bell’s palsy and meningitis H/A and neck stiffness Months to years later – arthritis 121 Lyme Disease Treatment – antibiotics for up to a month Nursing Care – – – avoid tick infested areas appropriate dress, insect repellant inspect skin - remove ticks 122 Let’s review Lupus Definition? Early Manifestations? Systemic Manifestations? Treatment? Nursing Diagnosis? 123 Let’s Review Polymyositis How is it different from Lupus? Clinical Manifestations? Nursing Care? 124 Lyme Disease Definition? Clinical Manifestations? – – – Initial Weeks to months later Months to years later Treatment Nursing Care 125 Infectious Disorders Osteomyelitis Infection of the bone - interferes with vascular supply, necrosis occurs Patho – usually bacterial - staphylococcus aureus direct contamination complication of surgery extension of chronic ulcers 127 128 Osteomyolitis - leg wound 129 Figure 43-2 Osteomyelitis. (A) Bacteria enter and multiply in the bone. 132 133 Osteomyelitis Hematogenous osteomyelitis – – Osteomyelitis from contiguous infection – carried by the blood older adult, sickle cell anemia, IV drug users deep penetrating wounds, TJR, decubitis ulcers Osteomyelitis associated with vascular insufficiency – PVD 134 135 Osteomyelitis Collaborative Care – – – – pain relief infection elimination or prevention early dx to prevent bone necrosis bone debridement and long term antibiotic therapy Diagnostic Tests – MRI, CT Scan, Bone Scan, cultures 136 Osteomyelitis Medications – antibiotics, 4-6 weeks Surgery – debridement, wound is opened, irrigated, drainage tubes inserted for irrigation, suction and antibiotic instillation 137 Osteomyelitis Nursing Care – – – frequent and lengthy treatment awareness of recurrent infections prognosis is uncertain Home Care – home care agency - wound treatment, antibiotic adm. Supplies and nutritional teaching 138 139 Bone tumors 140 Bone tumors 141 Neoplastic Disorder - Bone Tumors Tumor may be malignant or benign – – – benign grow slow and do not invade malignant grow rapidly and metastasize most often are mets from breast, prostate, kidney, thyroid and lung Manifestations – often hx of a fall or blow to extremity brings mass to attention 142 Bone Tumors – Pain, mass, impaired function Diagnostic tests – X-ray benign - sharp margins malignant “moth eaten” pattern – – C-T Scan, MRI needle bx 143 Bone Tumors Treatments – Chemotherapy shrink tumor before surgery control reoccurrence tx metastasis – Radiation pain control combo with chemo to eliminate tumor after surgery 144 Treatment Bone Graft 145 Nursing Diagnosis Risk for injury Acute Pain Chronic Pain Impair Physical Mobility Knowledge Deficit 146 Many Faces of Scleroderma 147 Connective Tissue Disorders Scleroderma Chronic disease, formation of excess fibrous connective tissue and diffuse fibrosis of skin and internal organs – – cause unknown - person exposed to chemicals? more common in females Prognosis – localized -good systemic - poor 148 Scleroderma Manifestations – – – – thickening of skin, diffuse non-pitting swelling eventually skin atrophies, becomes taut and hyperpigmented arthralgias and Raynaud’s phenomenon Visceral organ involvement dysphagia, pulmonary hypertension, pericarditis, G.I. Renal failure 149 Multi-system effects 150 Hand Changes 151 Scleroderma Diagnostic tests – confirmed by skin bx Treatment – meds immunosuppressive, – – corticosteroids, tx symptoms P.T Nursing care - supportive 152 153 Inspection leads your assessment 154 Fibromyalgia Common rheumatic syndrome, musculoskeletal pain, stiffness, tenderness No inflammatory structural or muscle changes Cause – unknown 155 Fibromyalgia Manifestations – – – – gradual onset of chronic, achy muscle pain tightness or muscle spasm pain when palpating localized tender points fatigue, sleep disruption H/A, IBS Diagnosis – – based on H & P check thyroid 156 157 Fibromyalgia Treatment – – – – – – heat applications massage stretching exercises sleep improvement stress-reduction anti-depressant therapy 158 Low Back Pain Difficult to Treat! 159 160 Low Back Pain Most often due to strain of muscle/tendons caused by abnormal stress/overuse Collaborative Care – – pain relief correct underlying condition prevent complication client education 161 Low Back Pain Diagnostic tests – – conservative tx for 4 weeks X-rays, CT Scans MRI Medications – – NSAIDs, analgesic, muscle relaxants epidural steroid injection for intractable pain 162 Low Back Pain Nursing Care – health promotion exercise lose wt. Body mechanics ergonomically appropriate work places 163 Treatment 164 Foot Disorders Types – – – Hallux valgus - bunion Hammer toe Morton’s neuroma Collaborative Care – – – pain relief correct structural deformity prevent recurrence 165 Foot Disorders Hallux Valgus Hammer toe Morton’s Neuroma 166 Foot Disorders Treatment – – conservative - corrective shoes, orthotic devices analgesics Surgery bunionectomy shortening or lengthening of ligaments pins to correct toe positioning casting 167 Muscular Dystrophy progressive muscle wasting Muscular Dystrophy MD Inherited muscle disease, progressive degeneration and wasting Duchenne’s muscular dystrophy – – – most common mother to male child dx in early childhood , 15 year life span Muscular Dystrophy Manifestations – – progressive muscle weakness with cardiac and endocrine abnormalities possible mental retardation Collaborative Care – – preserve and promote mobility support child and family Now ambulating Gait Assessment? Posture Changes Muscular Dystrophy Diagnostic tests – – – creatine kinases (CK-MM) elevated muscle bx electromyelogram (EMG) Nursing Care – – – promote independence, mobility psychological support assist with self care deficits Yes, we are done! 174 175