Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Few4y efewfwfny - Wilkes-Barre Area Career & Technical
Document related concepts
no text concepts found
Transcript
Chapter 33 Care of Patients with Musculoskeletal and Connective Tissue Disorders Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Theory Objectives State the factors to be assessed for the patient who has a connective tissue injury. Compare the assessment findings of a connective tissue injury with those of a fracture. State the care that is needed for the patient who has an external fixator in place. Identify the “do’s and don’ts” of cast care. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 1 Theory Objectives (cont.) Discuss the potential complications related to fractures. Identify the special problems of patients with arthritis and specific nursing interventions that can be helpful. Compare the preoperative and postoperative care of a patient with a total knee replacement with that of a patient with a total hip replacement. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 2 Theory Objectives (cont.) Explain the process by which osteoporosis occurs, ways to slow the process, and how the disorder is treated. Describe the care of the patient with a metastatic bone tumor. Identify important postoperative observations and nursing interventions in the care of the patient who has undergone an amputation. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 3 Sprain A sprain is a partial or complete tearing of the ligaments that hold various bones together to form a joint A sprain occurs when a joint may be forced, during trauma, past its normal range of motion, or there may be twisting The ankle, knee, and wrist are most commonly sprained Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 4 Signs and Symptoms Grade I (mild): Tenderness at site; minimal swelling and loss of function; no abnormal motion Grade II (moderate): More severe pain, especially with weight-bearing; swelling and bleeding into joint; some loss of function Grade III (severe, complete tearing of fibers): Pain may be less severe, but swelling, loss of function, and bleeding into joint are more marked Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 5 Diagnosis Physical examination X-ray to rule out a fracture or other pathology Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 6 Treatment and Management RICE Rest Ice after injury and for 24-72 hours Compression—snug elastic bandage, careful to not to cut off circulation Elevation Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 7 Sprains The Goal is to protect the ligament until it heals by scarring. Ligaments do not grow back together. If a joint is immobile too long, and muscles are not exercised muscle atrophy can begin within a matter of days- can cause permanent disability. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 8 Treatment and Management (cont.) Grade II or III Rest the joint Crutches for lower extremity sprain NSAIDs around the clock for first couple of days Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 9 Etiology and Pathophysiology A strain is a pulling or tearing of a muscle, a tendon, or both A strain occurs by trauma, overuse, or overextension of a joint Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 10 Etiology and Pathophysiology (cont.) The most common muscle strain occurs in the back muscles (back problems are discussed in Chapter 23, because they often have a neurologic component) Muscle strains do occur in other skeletal muscles—the most common sites are the hamstrings, quadriceps, and calf muscles Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 11 Strain Signs, symptoms, and diagnosis History of overexertion Soft tissue swelling Pain Bleeding if muscle is torn Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 12 Complementary and Alternative Therapies Soothing sore muscles Arnica purchased and applied topically as an essential oil is supposed to soothe sore, tired muscles after a long day’s work Valerian or kava brewed as a tea is also said to relax muscles Honey or apple juice will make the teas more palatable Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 13 Treatment and Nursing Management Ice and compression should be immediately applied and the part should be rested The patient is taught to use ice for 20 minutes out of the hour only When compression is used, the distal parts of the extremity must be checked for sensation and adequate circulation. Pallor (color) Pain Parasthesia (numbness or tingling) Pulse (Capillary Refill) Pressure (Swelling) Edema Paralysis (Movement) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 14 Treatment and Nursing Management (cont.) Heat can be applied after 48 hours Anti-inflammatory medications are used for discomfort and, when spasm is present, a muscle relaxant may be prescribed Time is the greatest healer The patient is cautioned against reinjury and is taught proper ways to lift and move Surgical repair may be necessary Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 15 Dislocation and Subluxation Dislocation is the stretching and tearing of ligaments around a joint with complete displacement of a bone. Subluxation is a partial dislocation. Most common sites are the shoulder, knee, ankle, and temporomandibular joint. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 16 Dislocation cont. Dislocation often includes: History of an outside force pushing from a certain direction Severe pain, aggravated by motion of the joint, muscle spasm, or abnormal appearance of the joint. Diagnosis Physical Exam X-ray Example dislocated shoulder. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 17 Dislocation and Subluxation (cont.) Treatment Reduction of displacement under anesthesia Nursing management Rest the joint Pain control Heat or cold applications (Ice first 48 hours then heat.) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 18 Rotator Cuff Tear Usually results from repetitive activity. Example: Throwing or making overhead motions with the arm. Basketball, baseball players Signs and Symptoms Pain The patient will not be able to externally rotate the shoulder, or perform abduction Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 19 Rotator Cuff Injury Treatment Rest Sling will be applied to the affected shoulder Anti-inflammatory medications When acute episode is over: Gentle progressive exercise is ordered. PT Prior to exercise Heat is recommended before the joint is exercised. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 20 Rotator Cuff Tear If the tear does not heal: Surgical repair usually by arthroscopy is indicated. Shoulder is immobilized Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 21 Bursitis Etiology and pathophysiology Injury or overuse Usually repetitive motion Signs, symptoms, and diagnosis Mild to moderate aching pain Swelling History of injury Physical examination Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 22 Bursitis (cont.) Treatment Rest, ice, and massage Anti-inflammatory agents Compression wrap Bursa cortisone injection Nursing management Assess pain and perfusion Assist with mobilization Activity limitations Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 23 ACL Tear ACL (Anterior Cruciate Ligament Most commonly occurs from athletic injuries Falls and motor vehicle accidents may also cause injury Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 24 ACL Tear cont The ligament may be torn from the femur or tibia. Often the patient will tell you that they heard a loud “pop” the time of injury. Swelling will occur within hours The knee may feel unstable and feel like it can “give way”. Full extension of the leg is difficult Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 25 ACL Tear cont. Diagnosis Physical Exam and data collection how injury occurred MRI Arthroscopy is performed at which time the repair may be done. Grafting may be done if there is complete tearing. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 26 ACL Tear According to the text some physicians order (CPM) continuous passive range of motion to promote full range of motion. Not so common today. Isometric exercises are prescribed in the recovery period including quadriceps bent knee exercises and foot exercises. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 27 Meniscal Injury The meniscus is the shock absorber of the knee and lies on top of the tibia, between tibia and the femur. A meniscus injury may accompany an ACL injury. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 28 Mensical Injury Often occurs from a fixed foot rotation in weight bearing with the knees flexed, during sports activities such as basketball or skiing. Hear either a “Popping”, described like they feel like the knee is catching or buckling on them Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 29 Meniscal Injury cont Diagnosis Physical exam patient history. May hear a click with localized pain with movement of the joint. How did it happen, what activity was the patient doing? MRI is order to confirm Surgical repair is done arthroscopically Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 30 ACL Tear After injury the knee is: immobilized usually with a long brace with fixed flexion Measures are instituted to decrease pain and reduce swelling. Ice dependent upon doctor Pain Management initial opiods, anti inflammatory medications Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 31 Achilles Tendon Rupture The Achilles attaches to the calcaneus (heel bone) If overstretched it can rupture. Sports injuries or a fall from a height are the usual ways that this injury occurs. Injury most often occurs with bursts of jumping, pivoting, and running such as tennis, and basketball. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 32 Achilles Tendon Rupture Some predisposing factors that can increase risk include Diabetes Arthritis Some antibiotic use ( Cipro) Side effect can cause tendonitis. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 33 Achilles Tendon Rupture Symptoms Sudden pain in the back of the ankle May hear a “ popping” sound or a snapping sound Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 34 Achilles Tendon Rupture Physical Exam May see a depression 2 inches above the back of the heel Pain Swelling Stiffness Inability to point toes, or stand on tiptoe Bruising Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 35 Achilles Tendon Rupture Treatment Achilles Tendon Rupture Splinting Surgery followed by casting Recovery 6-8 weeks followed by PT Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 36 Meniscal Injury Pain Management is a priority PT is prescribed for muscle strengthening Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 37 Carpal Tunnel Syndrome Etiology and pathophysiology Compression of the median nerve Signs and symptoms Pain Numbness Tingling of the hand, particularly at night Repetitive movements of hands and wrists Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 38 Carpal Tunnel Syndrome (cont.) Diagnosis Treatment Physical examination Compression test Electromyography Rest and splinting Changing the angle of the wrist during repetitive movements Steroid injections Surgery Nursing management Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 39 Bunion A bunion is the most common foot problem. It is a painful swelling of the bursa that occurs when the great toe, at the metatarsal joint. It may hereditary, or from ill fitting shoes More common in females than males Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 40 Bunion Wearing open toed shoes made of soft leather or athletic shoes that are wider in the toes area helps to reduce the pain. Shoes that have give. Properly fitting shoes. Metatarsal pads may provide some relief or pressure. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 41 Bunion Corticosteroid injections are given into the joint if there is active bursitis and pain. Analgesics and anti-inflammatory medications may be prescribed. Surgical Intervention Bone realignment or bunionectomy may be done if becomes too painful. The key is too painful. Hammertoes often accompany bunions and they may be repaired at the same time. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 42 Fractures Etiology and pathophysiology Definition Trauma Osteoporosis and metabolic problems Mechanism of injury Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 43 Fractures (cont.) Signs and symptoms Minimal to severe pain depending on the type of fracture, the bone(s) involved, and the amount of displacement Swelling and/or bleeding Tenderness, deformity of the bone, ecchymoses, crepitation with any movement, and loss of function Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 44 Fractures (cont.) Diagnosis Physical examination X-ray Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 45 Types of Fractures Complete Incomplete Comminuted Closed (simple) Open (compound) Greenstick Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 46 Types of Fractures (cont.) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 47 Types of Fractures (cont.) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 48 Types of Fractures (cont.) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 49 Elder Care Points The elderly are more at risk for fractures because of decreased reaction time, failing vision, lessened agility, alterations in balance, and decreased muscle tone Proton pump inhibitors (PPIs) increase the risk for fracture of the hip, wrist, and spine In epidemiologic studies, the risk was highest for people over age 50, who had used PPIs for more than a year Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 50 Treatment of Fracture Emergency care Prevent shock and hemorrhage “Splint as it lies” Tetanus immunization Prophylactic antibiotics Primary aim of treatment Establish union between broken ends to restore bone continuity Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 51 Five Stages of Bone Healing and Repair 1. Blood oozes from the torn blood vessels in the area of the fracture; the blood clots and begins to form a hematoma between the two broken ends of bone (1 to 3 days) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 52 Five Stages of Bone Healing and Repair (cont.) 2. Other tissue cells enter the clot, and granulation tissue is formed. This tissue is interlaced with capillaries, and it gradually becomes firm and forms a bridge between the two ends of broken bone (3 days to 2 weeks) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 53 Five Stages of Bone Healing and Repair (cont.) 3. Young bone cells enter the area and form a tissue called “callus.” At this stage, the ends of the broken bone are beginning to “knit” together (2 to 6 weeks) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 54 Five Stages of Bone Healing and Repair (cont.) 4. The immature bone cells are gradually replaced by mature bone cells (ossification), and the tissue takes on the characteristics of typical bone structure (3 weeks to 6 months) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 55 Five Stages of Bone Healing and Repair (cont.) 5. Bone is resorbed and deposited, depending on the lines of stress. The medullary canal is reconstructed during consolidation and remodeling (6 weeks to 1 year) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 56 Reduction of Fractures Closed reduction Open reduction Stabilization Internal fixation External fixation Casts, splints, and braces Traction Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 57 Internal Fixation Pins, nails, or metal plates Open reduction and internal fixation Prosthesis and autotransfusion IV antibiotics and risk for infection Nursing care Maintain good alignment of the affected leg Prevent complications of immobility Control pain Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 58 Examples of Internal Fixation Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 59 External Fixation Indications Massive open fractures with extensive soft-tissue damage Infected fractures that do not heal properly Multiple trauma such as burns, chest injury, or head injury Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 60 External Fixation (cont.) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 61 Nursing Management Pin site care and premedicate for pain Showering Physical therapy and ADLs Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 62 Casts and Fractures Materials including plaster and synthetic casts Long-leg and short-leg casts, slings, and spicas Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 63 Synthetic Limb Cast Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 64 Braces and Splints Fracture boot, hinged brace, and slab Patient teaching Explain the procedure—feel warmth as cast sets and dries Never put a fresh cast on plastic Never cover a fresh plaster cast with a blanket Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 65 Walking Boot Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 66 Skeletal Traction Pins, wires, or tongs directly through the bone at a point distal to the fracture so that the force of pull from the weights is exerted directly on the bone Skeletal traction uses 10 or more pounds of weight and the body acts as the countertraction Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 67 Skin Traction Bandage (moleskin or foam traction boot) is applied to the limb below the site of fracture and then pull is exerted on the limb No more than 7 to 10 lb of weight are used Continuous or intermittent Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 68 Common Types of Traction Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 69 Common Types of Traction (cont.) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 70 Points of Care for the Patient in Traction Traction devices must be assessed to see that they are in correct position and that the weights are hanging free The patient’s body position should be assessed for proper alignment Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 71 Complications of Fractures The sooner a fracture is fixed, the less likely the chance for complications. Healing can be impeded by improper alignment and inadequate immobilization Continued twisting, shearing, and abnormal stresses prohibit a strong, bony union. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 72 Fractures and Infection Open comminuted fractures and surgery Antibiotics Inadequate calcium and phosphorus, vitamin deficiency, and atherosclerosis Temperature, white blood cells, and wound appearance (redness, swelling, heat, and purulent drainage) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 73 Osteomyelitis Osteomyelitis is a bacterial infection of the bone Staphylococcus aureus Sudden onset with severe pain and marked tenderness at the site, high fever with chills, swelling of adjacent soft parts, headache, and malaise Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 74 Diagnosis The earlier osteomyelitis is diagnosed and treated, the better the prognosis History of injury to the part, open fracture, boils, furuncles, or other infections Sedimentation rate and WBC count X-rays Biopsy, in which the bone sample exhibits signs of necrosis Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 75 Treatment Antibiotics are prescribed for 4 to 6 weeks, and the abscess is incised and drained Dead bone and debris are débrided from the site The affected limb is immobilized for complete rest Sometimes amputation is the only cure Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 76 Nonunion of Fractures Electrical bone growth–stimulating device Surgery and bone grafting Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 77 Fat Embolism Signs and symptoms Change in mental status Respiratory distress, tachypnea, crackles and wheezes Rapid pulse, fever, and petechiae (a measles-like rash over the chest, neck, upper arms, or abdomen) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 78 Nursing Management Stay with the patient High Fowler’s position Use a non-rebreather mask Establish a peripheral IV Summon the physician immediately Anticipate hydration with IV fluids and correction of acidosis Intubation and mechanical ventilation Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 79 Venous Thrombosis The veins of the pelvis and lower extremities are very vulnerable to thrombus formation after fracture, especially hip fracture Immobility, traction, and casts may contribute to venous stasis Compression stockings, sequential compression devices, range-of-motion (ROM) exercises on the unaffected lower extremities are used to help prevent the problem Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 80 Compartment Syndrome External or internal pressure that restricts circulation in one or more muscle compartments of the extremities Severe, unrelenting pain unrelieved by narcotics Assess for 6 “Ps”: pain, pallor, paresthesia, pulselessness, paralysis, and poikilothermia (cold to the touch) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 81 Treatment and Nursing Management Recognition and immediate notification of the physician can prevent permanent loss of function If a cast is in place, the cast can be bivalved (split through all layers of the material) Dressings will be cut or replaced Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 82 Treatment and Nursing Management (cont.) Surgical fasciotomy (linear incisions in the fascia down the extremity) may be necessary to relieve the pressure on the nerves and blood vessels if other measures do not relieve the problem Elevation is the key to preventing compartment syndrome; toes and fingers should be higher than the trunk Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 83 Fascial Compartments of the Calf Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 84 Fasciotomy Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 85 Nursing Management of Fractures Assessment (data collection) Initial assessment (pretreatment) • Mechanism of injury • Physical assessment • Special consideration of open fractures Daily assessment (posttreatment) Physical assessment of neurovascular status Thorough assessment of a patient in a cast Nutrition for immobile musculoskeletal patients Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 86 Nursing Management of Fractures (cont.) Implementation Cast care—fiberglass and polyester cotton knit casts and plaster casts Comfort measures Positioning and repositioning Itching and skin care Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 87 Nursing Management of Fractures (cont.) Evaluation Pain should be under control Progress toward independent ADLs No problems with immobility (skin breakdown, constipation, atelectasis, or DVT) No complications (infection, compartment syndrome) If the goals are not being met, the plan should be revised Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 88 Inflammatory Disorders of the Musculoskeletal System Lyme disease Osteoarthritis Rheumatoid arthritis Gout Osteoporosis Paget’s disease Bone tumors Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 89 Lyme Disease Cause Transmitted by the bite of a deer tick. A systemic infection occurs from a bacteria called Spirochete, Borrelia burgdorferi. Signs and symptoms 1-2 weeks Flu-like symptoms Bull’s-eye rash Pain and stiffness in joints and muscles Progresses to Stage II if untreated 2-12 weeks Carditis Meningitis, peripheral neuritis, or facial paralysis similar to Bells Palsy Fatigue, cognition problems, and arthralgias Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 90 Lyme Disease Rash Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 91 Deer Tick Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 92 Lyme Disease cont. Treatment Oral antibiotics such as doxicycline, amoxicillin by mouth for 10-21 days. Later stages are treated with IV antibiotics Steps to prevent Lyme disease include using insect repellent, wearing long sleeve clothing when in woods. Removing ticks promptly from clothing. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 93 Osteoarthritis Etiology and pathophysiology A non inflammatory degenerative joint disease that can affect any weight-bearing joint The exact cause is not known Risk factors: Heredity, aging, female gender, obesity, previous joint injury, and recreational/occupational usage People with osteoarthritis seem to produce less collagen to strengthen and protect the joints With time joints become thickened and withstand weight poorly causing more damage to cartilage. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 94 Osteoarthritis Signs, symptoms, and diagnosis Usually occurs Asymmetrically Typically affects only one or two joints Chief symptoms Aching pain with joint movement and stiffness and limitation of mobility Joints may be deformed and nodules may be present Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 95 Treatment of Osteoarthritis Pain management—including salicylates, acetaminophen, or NSAIDs Strengthening and aerobic exercise, Weight reduction if the patient is overweight Maintenance of joint function Complementary and alternative therapies Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 96 Nursing Management of Osteoarthritis Balance exercise and rest, Walking, knitting, and swimming improve mobility Moist heat application Encourage to maintain weight within normal limits decreases stress on the joints. Imagery, relaxation, and diversion Quadriceps strengthening exercises may relieve pain and disability of the knee Yoga and massage may help to manage the pain Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 97 Rheumatoid Arthritis Etiology and pathophysiology Is an Inflammatory Disease of the joints Rheumatoid factor will appear in the blood and in the synovial fluid of the joints. Remissions and exacerbations As the disease progresses Pannus is formed which is granulated tissue this can lead to ankylosis, and damage/atrophy of muscles Subcutaneous nodules may form in the pleura, heart valves, or eyes Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 98 Rheumatoid cont. Cause is unknown Can occur at any age. More common in older women Maybe hormonal, genetic, environmental An infectious agent may trigger an autoimmune response Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 99 Rheumatoid Arthritis (cont.) Signs and symptoms Joint pain, warmth, edema, limitation of motion, and multiple joint stiffness lasting more than 1 hour, worse in the morning. Symmetrical—affects joints of the hands, wrists, and feet. Nodules may form on the joints. Limitations of ADLs due to joint deformity, and pain. Systemic symptoms Low grade fever, anorexia, weight loss, anemia resistant to iron. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 100 Comparison of Rheumatoid Arthritis and Osteoarthritis Definition Pathology Etiology Rheumatoid factors (autoantibodies) Age at onset Weight General state of health Appearance of joints Muscles Other Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 101 Rheumatoid Arthritis Diagnosis History of morning stiffness that lasts more than one hour or arthritis pain in 3 or more joints that lasts more than 6 weeks for greater than 1 hour Blood tests for RF, C-reactive protein, and erythrocyte sedimentation rate, synovial fluid will be positive for RA X-rays confirm the cartilage destruction and bone deformities Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 102 Treatment of Rheumatoid Arthritis Aimed at Relieving pain Minimizing joint destruction Promote joint function Rest exercise, and medication. Preserve ability to perform self-care Immobilization and use of splints and other supportive devices during periods of severe inflammation Hot and Cold Treatments Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 103 Medications for Rheumatoid Arthritis NSAIDs (i.e., ibuprofen) are the first-line agents used for arthritis pain Other medications include salicylates, corticosteroids, antimalarial drugs, methotrexate, gold compounds, sulfasalazine, d-penicillamine, and disease-modifying antirheumatic drugs (DMARDs) Tumor necrosis factor drugs (TNF inhibitors) Humeria, Prolia Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 104 Rheumatoid Treatment cont. Systemic corticosteroids (Once thought to be miracle drugs) Long term affects diminish over time requiring and increase in the dose to obtain the same results. Long term steroids increase the risk for diabetes mellitus, osteoporosis, hypertension, acne, cataracts, and weight gain. Reserved for patient who do not get relief with the other drugs. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 105 Medications for Rheumatoid Arthritis (cont.) The injection of steroids directly into a joint (intra-articular administration) has been used successfully in treating painful flare-ups, shortening the period of inflammation, and relieving pain and other symptoms When intra-articular steroid therapy is used, it is recommended that not more than two or three doses be injected into any joint within 1 year’s time Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 106 Clinical Cues Monitor patients taking NSAIDs for GI intolerance Assess liver, kidney, and central nervous system function frequently Watch for signs of blood dyscrasias and check for tinnitus and hearing loss regularly The side effects of NSAIDs can be serious and sometimes permanent If early signs of toxicity appear, they should be reported promptly to the physician Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 107 Elder Care Points Elderly arthritic patients must be taught to watch for side effects and promptly report to the physician or nurse Dizziness, which predisposes to falls, can occur with analgesics for arthritis pain, particularly if the medication contains codeine Advise patients to arise slowly, hold on to furniture until steady, and to wait until dizziness passes before trying to walk Assistive devices for ambulation can also prevent falls Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 108 Surgical Intervention and Orthopedic Devices Casts/braces and splints may be used to immobilize an affected part so that it can rest during an active phase of the arthritic disease Surgery Synovectomy -Excision of synovial membrane. Osteotomy - Excision of a wedge of bone to allow realignment Tendon reconstruction Joint replacement Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 109 Nursing Management of Rheumatoid Arthritis Expected outcomes Patient’s pain will be controlled with medications, heat, and exercise within 2 weeks Patient’s mobility will improve with the use of assistive devices and physical therapy within 3 weeks Patient will demonstrate less disturbance of body image by partaking in more social activities within 1 month Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 110 Implementation and Evaluation of Rheumatoid Arthritis Rest and exercise Instructions for joint protection Applications of heat and cold Safety considerations Patient teaching Diet Psychosocial care Resources for patient and family education Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 111 Total Joint Replacement May be done for a knee, shoulder, hip, elbow or finger Hip and Knee the most common Non cemented press fit prosthesis usually used for a younger, heavier, or active patient. Cement used in the prosthetic usually lasts about 10 years Primary purpose is the relieve pain Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 112 Joint Replacement cont. Most joints are elective surgery Patient will come in for PAT work Data collection will begin An appointment will be scheduled for pre op teaching usually 3 weeks ahead of time Many centers coordinating all the above on one day Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 113 Joint Replacement Expectations discussed Pain management Routine and expectations foley, IV activity Rehab and PT Pre op exercises, Isometric Blood collection post op Patient will receive instructions to complete chlorahexidine showers pre op or scrubs to the affected leg Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 114 Joint Replacement cont Patient transported to OR in bed Returned in bed Ice for pain Abductor pillows for Hip prosthesis to prevent dislocation Pillow needs to be in place when turning the patient from side to side Dislocation is the concern. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 115 Joint Replacement cont. Post Op Patient may have a blood salvage unit . It is then filtered and retuned to the patient Drain in surgical site, DVT prophalxsis important. Heparin, lovenox or counmadin Weight bearing staus PT Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 116 Total Hip Replacement Discharge Teaching It is OK to lay on operated side For 3 months, you should not cross your legs Put a pillow between legs when rolling over or lie on your side in bed It is OK to bend your hip but not beyond a right (90-degree) angle Avoid sitting in low chairs Continue daily exercise program at home Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 117 Gout Etiology and pathophysiology Arthritis of a joint caused by high Uric acid levels Possible factors • Genetic increase in purine metabolism • More common in patient populations that consume increase protein and high purine diets. Big toe most common but can occur in other joints. Diuretic therapy and secondary gout because of the loss of fluids Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 118 Gout (cont.) Signs and symptoms Tight reddened skin over an inflamed, edematous joint accompanied by elevated temperature and extreme pain in the joint Elevated serum uric acid Diagnosis History and physical examination Serum uric acid Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 119 Gout’ Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 120 Gout (cont.) Treatment NSAIDs for 2-5 days Colchicine, allopurinol, and probenecid (Benemid) given orally with drastic relief within 24-48 hours Febuxostat (Uloric) Nursing management Patient teaching and medications Diet management—weight control and restriction of high-purine foods Fluid intake Increase to 2000-3000cc per day to protect the kidney from crystal formation and stones. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 121 Gout cont. Alcohol should be restricted Patients who are placed on allopurinol require periodic liver function tests Dietary restriction high purine diets. Examples: Red meat, organ meat, sardines, anchovies, sweetbreads. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 122 Elder Care Points Elderly patients with decrease creatine clearance should not take allopurinol. If patient has elevate BP Cozar is a good choice. ARB controls BP and promotes dieresis Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 123 Audience Response Question 1 Dietary management of gout includes which measure(s)? (Select all that apply.) 1. Weight reduction 2. Salt restriction 3. High caloric intake 4. Avoiding foods high in purine 5. High-carbohydrate diet Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 124 Osteoporosis Etiology and pathophysiology Makes the patient more prone to fractures Decrease in bone mass Risk factors: Age, chronic disease (i.e., liver, lung, kidney), medications (i.e., steroids, anticonvulsants, anticoagulants, proton pump inhibitors, selective serotonin inhibitors), long-term calcium deficiency, vitamin D deficiency, smoking, excessive caffeine or alcohol intake, and sedentary lifestyle Premenopausal age of 35 women loose 1% bone mass a year. Post menopausal 2% per year Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 125 Osteoporosis (cont.) Signs and symptoms No early signs and symptoms Height loss, kyphosis, and compression of the spine Diagnosis Bone x-rays Bones appear porous Dual energy x-ray absorptiometry (DXA or DEXA); reported as a T score 1.5 to 2.0 standard deviations = osteopenia 2.5 to 3.0 standard deviations = osteoporosis Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 126 Treatment Goals Stop bone density loss Increase bone formation Prevent fractures Estrogen replacement therapy Adequate dietary and supplemental calcium and vitamin D Weight-bearing exercise Bisphosphonates (Fosamax, Actinol) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 127 Treatment of Osteoporosis and Vertebral Fracture Vertebral fractures are common in patients with osteoporosis. This are two new minimally invasive spine procedures for those who do not repond to tradtional therapy Vertebroplasty Kyphoplasty These are often treated with pain medication, activity limitation, physical therapy, and bracing Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 128 Osteoporosis Parathyroid hormones are alternative treatment for post menopausal women who can’t take estrogen. Miacalcin or Fortical Contains calcitonin. Diary Products are the best source of calcium; cheese, yogurt, are better choices. Sardines and anchovies are also sources of calcium Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 129 Nursing Management Promote screening for osteoporosis Teach the benefits of healthy lifestyle, need for calcium supplement, and weight-bearing exercise Medications, cautions, and side effects Upright position for 1 hour after taking bisphosphonate-type drugs to prevent esophageal irritation and erosion Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 130 Paget’s Disease Etiology More common in men Cause unknown Abnormal weak bones Problem with bone reabsorbtion followed by replacement of normal marrow with fibrous connective tissue. Prone to fracture Signs and symptoms Pain main problem Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 131 Paget’s Disease (cont.) Diagnosis X-Ray Usually diagnosed at time of fracture 24 hour urine presence of hydroxyproline presence indicates osteoclasic activity Serum alkaline phospatase is elevated in disease Nursing management Firm mattress may relieve back pain Light brace or corset Avoid lifting and twisting proper body mechanics Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 132 Bone Tumors Etiology and pathophysiology Bone is subject to both benign and malignant tumors Bone tumors are often seen in people 10-25 years of age ( Osteosarcoma) Primary and secondary tumors Arise from several types of tissues including cartilage, bone, and fibrous tissue Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 133 Bone Tumors (cont.) Signs and Symptoms Diagnosis Pain, warmth, and swelling X-ray, bone scan, and biopsy Metastatic Disease is seen more than a primary bone cancer Malignancies of the prostate, kidney, breast, thyroid, and lung spread to the bone. Vertebrae, pelvis, and femur Treatment Surgery, radiation, and chemotherapy Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 134 Amputation Lower-limb amputations are related to peripheral vascular disease, diabetes mellitus and resultant gangrene, severe trauma, malignancy, congenital defects, and military injuries from shrapnel and land mines Upper-extremity amputations are brought on by crushing blows, thermal and electric burns, severe lacerations, vasospastic disease, malignancy, and infection Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 135 Amputation: Preoperative Care Patient participation in decision-making May have preference of how to dispose of limb. Stages of loss and grieving (Denial, anger, grieving) Phantom sensations Patient remembers pain before surgery, brain still receiving signals Physical preparation Muscle strengthening exercises to prepare for post op rehabilitaion Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 136 Amputation: Postoperative Care Two most important post op concerns Hemorrhage and edema of residual limb Elevation for 24 hours after 24 hours hip contractures may develop Monitoring for excessive bleeding VS IV fluids Dressing care The initial dressing is usually removed by the surgeon 48 to 72 hours later. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 137 Amputation Post Op Care Assess the skin for inflammation or breakdown , warmth, drainage Assess pain Phantom limb sensations Miacalcin IV infusion during the week after surgery. Transcutaneous electrical nerve stimulator Stump stocking Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 138 Amputation: Postoperative Care (cont.) Alternative modes for managing stump after amputation Soft dressing with delayed prosthetic fitting Rigid plaster dressing and early prosthetic fitting Rigid plaster dressing and immediate prosthetic fitting Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 139 Amputation: Postoperative Care (cont.) Adequate healing and weight-bearing Below-the-knee amputation is better to begin walking and weight-bearing than above-the-knee amputation Abduction contractures and proper positioning Adjusting to the new center of gravity Patient teaching: stump care, activity and weight-bearing, and exercise Rehabilitation Community care Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 140 C-Leg Prosthesis in Action Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 141 Care After Accidental Amputation Rinse the detached part only enough to remove visible debris Wrap the part in a clean, damp cloth Place the part in a sealed plastic bag or in a dry water-tight container Immerse the bag or container in a mixture of water and ice (3 parts water to 1 part ice). Do not let the part get wet or freeze Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 142 Care After Accidental Amputation (cont.) Alternatively, place the container in an insulated cooler filled with ice If no ice is available, keep the part cool; do not expose it to heat Tag the bag or container with the person’s name and the name of the body part and take it to the hospital with the person Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 143
