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**Effects of aging in Musculoskeletal
- Alterations in bone density
- Muscle wasting and slow decline in strength >50 yrs of age
- Hormonal changesHeight decreases
**Goal and strategies for arthritis and connective tissue disease
- Suppress inflammation, inflammation causes pain so we must Control pain
- Maintain or improve joint mobility maintain or improve functional status
- Increase patient’s knowledge of disease process
- Promote self-management compatible with therapeutic regimen to lead a functional lifestyle
Administer medication : Anti-inflammatory, Disease modifying agents
Protect the joints: Ease pain with splints, minimize any activity to exacerbate chronic pain, Thermal modalities (heat/ice)
Implement exercise programs for joint motion and muscle strengthening
Make use of adaptive devices and techniques: adl's, management, driving modalities
Provide and reinforce patient teaching, emphasis compliance
Emphasize compatibility of therapeutic regimen and lifestyle
** GOUTY ARTHRITIS**
Primary vs. Secondary
Metabolic bone disorders considered a form of acute arthritis marked by joint inflammation
Characterized by recurrent attacks of acute arthritis in conjunction with increased uric acid levels (hyperuricemia)
Primary ir Secondary modality with routine or repeat attacks that deposit uric acid crystal levels in the joint so joints become nodulus. "tophi"
- =>Primary Gout reason: Hereditary
- Hereditary error of purine metabolism: how are we exposed? by what we ingest. Crabs, spinach, lentils, shellfish, veggies, asparagus, alcohol (red wines)
- Accounts for 90% of all cases of gout
- Initial attack occurs in middle aged men
- 30-40 yrs oldExcessive intake of alcohol
- => Secondary Gout ( or Acquired)
- Related to another acquired condition
- Alcoholism: as one is ingesting, it seems to have inability to break down uric acids due to excess of ketoacid bodies.
- Hypertension-relative nature to those have developed gouts.Blood disorders (leukemia, anemia)
- -Secondary gout is a clinical feature secondary to another acquired condition (psoriasis, leukemia and some types of anemias)
- May also result from:
- Prolonged use of diuretics (thiazides):Low dose salicicylates (aspirins)
- Alcohol and starvation
- Radiation therapy
- Clinical Manifestations
- **Acute attack of gouty arthritis
- First attack develops quickly , often overnight and pain peaks within several hours usually at big toe. Precipitated by trigger event
- Redness, swelling and pain Low grade fever
- Chronic gout-moves into another joints usually adjacent joint.; Multiple joint involvement
- Deposits of sodium urate crystals (tophi) in synovial lining and fluid
- -Acute gouty arthritis is usually precipitated by some event ie trauma, surgery, or alcohol injestion or systemic infection. Onset of symptoms are rapid with pain and swelling and peak within several hours and frequently awakens the patient at night. May have low grade fever but is not always present; Attacks can last 2 to 10 days and most people with gout are asymptomatic between attacks and can have symptom free periods that can last for months or years
- **Chronic gout is characterized by multiple joint involvement and deposits of sodium urate crystals called tophi. Tophi develop over time and collect in the along tendons, and in skin and cartiledge resulting in deformed joints. Fig 63-7 pg 1738
- Excessive uric acid levels my lead to kidney or urinary tract stones.
** Gout Diagnostic studies &
**Gout Drug therapy and teaching for client with gout
Patient history and physical
Serum uric acid level >6mg/dl
24-hour urine uric acid (acid determines if the disease is cased by decreased renal excretion or overproduction of uric acid); first void is discarded and the time starts. Collect ENtIRE urine for that 24 hour period and place it in ICE. Any discarded urine... you MUST start all over again.
Aspiration of the involved joint
- **Gout Drug therapy and teaching for client with gout
- Two goals:Management of the acute attack by antiinflammatory: Colchicine (works really well) and normal NSAID
- Long term management of hyperuricemia production by using maintenance dose of allopurinol (Zyloprim)
- Avoidance of alcohol and high purine foods
- Drugs to reduce uric concentration (increases uric acide removal through urine excretion) and prevent kidney stone because if urine acide levels high stones are a risk.
antihypertensive meds-angiotensin 2.
**Nursing Management and Client Teaching For GOUT.
- Pain management
- Affected joints immobilized until pain subsides (acute attack)
- Need for crutches or walker, wheelchair for lower extremities
- Teaching: managing Chronic problem- controlled with adherence to treatment program
- Demonstrate knowledge of precipitating factors that could lead to an attack
- Drink at least 2.5-3 liters of fluid a day when taking medications; INCREASE FLUIDS to wash out crystals
**Systemic Lupus Erythematosus (SLE)
Chronic multi-system inflammatory disease of connective tissue
Unpredictable course of exacerbation and remission; some triggers MAY be trigged but not always the same triggers--frustration and anger. Debilitating. Sudden onset.
Autoimmune disease: involves organ, musculo tissue pretty much anywhere.
**Systemic Manifestation of SLE:
There is multisystem involvement in systemic lupus erythematosus
There are three different dematologic manifestations of lupus.
In chronic cutaneous lupus (discoid lupus) the most common dermatological manifestation is skin lesions that resemble coins in shape without systemic complaints.
With acute systemic lupus the classic and most familiar skin manifestation is a cutaneous lesion consisting of a butterfly shaped rash across the bridge of the nose and over the cheek. This is seen in about 50% of the patients.
Sunlight or artificial ultraviolet light can cause a severe flare up of disease and people with lupus must use sunscreen every day of there life regardless of there skin type or where they live.
Alopecia is common and the scalp becomes dry and scaly
problems include polyarthralgia, diffuse swelling by joints, Arthritis in 90% of patients
problems include tachypnea and cough suggesting restrictive lung disease, pleurisy, dysrhythmias resulting from fibrosis of the SA and AV nodes (advanced stages of Lupus),
include lupus nephritis in 40-85% of pts. Aggressive tx of this disease includes corticosteroids, cytotoxic agents, and immunosuppressive agents
problems include seizures, peripheral neuropathies, cognitive and psychiatric disorders (depression and psychosis)
abdom pain, diarrhea, Dysphagia, N/V
includes the formation of antibodies against blood cells. Anemia, leukopenia and thrombocytopenia are often present in SLE. Antiphosholipid syndrome is common (hypercoagulability associated with high blood levels of IgG antibodies against phospholipids, which are major component of cell membranes)
- Infection: SLE patients are at a high risk for developing infections because of defects in the ability to phagocytize invading bacteria, deficiencies in production of antibodies and the immunosuppressive effect of many ant-iinflammatory drugs they routinely take. Body is attacking itself causing ALL these problems.
- Malar rash-butterlfly
**Systemic Lupus Erythematosus
- => Hormones
- Occurs most frequently in young women of childbearing age
- Three times higher in African-American, Latino and Asian women
- Onset of menarche
- Use of oral contraceptives during and after childbirth
- => Other factors
- Environmental: Sun exposure and burns most significant;The end result is the photosensitive rash and feeling ill with migraine, nausea and joint pain.
- Stress and infectious agents
- Medications (Drug induced lupus can be found as a response to sulfonamides, BCP (affects a clients estrogen level) and a number of anti-seizure agents ie Dilantin and also INH.) and foods (such as celery, alfalpha sprouts, and shitake mushrooms should be avoided.)
**Assessment findings with Lupus
- Fever and chronic fatigue
- Anorexia and weight loss
- Joint pain and morning stiffness (arthralgia)
- Excessive fatigue and arthritis
- Skin lesions
- Positive LE prep: blood sample
- Elevated ESR and CRP-usual for ppl with autoimmune system disorders (not difinitive)
- Positive ANA titre-usual for ppl with autoimmune system disorders (not difinitive)
- Most common cause of death; Proteinuria, hematuria and renal failure (lupus nephritis)CNS and cardiopulmonary involvement (seizures)
**Management of SLE
- Immunosuppressive drugs-halts autoimmune process depending on exacerbations and the extent.
- Avoid direct exposure to sunlight-big trigger, very photophobic to sun
- Regular medical follow-up
- Avoid physical and emotional stress: shouldn't be excessively exercising
- Avoid ultraviolet light
- Martial counseling (pregnancy)-genetic purposes-refer to counseling for reproduction because pregnancies is a stress and body is attacking that "foreign" substances. /: No exact hereditary gene.
- Referral to community agencies
- Pharmacological management
- Corticosteroids-long term use has a bad effect on body, "steroid sparing" products levotrexate, and ASA or NSAIDS-folic acide to reduce anemia caused by drug-drug
Plaquenil-common drug; helps with inflammation of joints and very retinal toxic -follow up with opthamologist; may be used to treat polyarthritis condition.
Cytoxan and Imuran;
Immunosuppressive agents (Cytoxin and Imuran) are prescribed to reduce the need for long term cortisone therapy. Both drugs require close monitoring because of toxic effects.
Cytoxan interferes with the replicaton of susceptible cells, stops the autoantibody effect of ANA.
**Nursing considerations SLE
- Physical assessment during an exacerbation is important to gage drug effects
- Severity of symptoms in response to therapyPain, fever pattern, joint inflammation gooing on?, ROM, fatigue
- Monitor weight and I/O 24 hr urine for protein/creatinine Signs of bleeding
- CNS changes
- Peripheral neuropathies
- Emotional support for patient and family
**RHEUMATOID ARTHRITIS (RA)**
- Occurs generally in women of childbearing age
- 2-3 times higher in women until age 60
- Periods of exacerbation and remission
- Significant national health problem
- Cause unknown-may be autoimmune or genetic
- **Another systemic autoimmune disease is Rheumatoid arthritis or RA
- Rheumatoid arthritis is a chronic disorder of the connective tissue characterized by exacerbations and remissions with inflammation of the synovial lining of the joints. It can lead to long-term joint damage, resulting in chronic pain, loss of function and disability. Rheumatoid arthritis progresses in three stages. The first stage is the swelling of the synovial lining, causing pain, warmth, stiffness, redness and swelling around the joint.
- Second is the rapid division and growth of cells, or pannus, which causes the synovium to thicken. In the third stage, the inflamed cells release enzymes that may digest bone and cartilage, often causing the involved joint to lose its shape and alignment, more pain, and loss of movement.
- Approximately 2.1 million people in the United States, or 1 percent of the population, have rheumatoid arthritis. It can affect anyone, including children, but 70% of people with RA are women. Onset usually occurs between 30 and 50 years of age
What exactly causes RA is unknown, whether it is a single causation factor or multifactoral. Some researchers theorize that it’s the body’s reaction to a virus or a bacterium but what triggers might be involved is still unknown?
Whatever the cause the immune system (protective white blood cells) goes into an attack mode and release enzymes that break down collagen - producing swelling and pain.
** RA Clinical Manifestations
**Extraarticular manifestations of RA-
- Joints inflammation: have deformities with fingers or feet/toes in opposite directions
- Bilateral symmetric involvement
- Inflammation of the joints with subsequent joint deformity
- Frequently affect small joints of the hands, wrist, knee and joints of fingers: starts a small joins and moves its way up.
- Stiffness After period of inactivity, they are told to be put through CONSTANT ROM or else stiffness will ge worse. Induced by stress.
- Extraarticular manifestations
- Long term-Subcutaneous rheumatoid nodules , Hand, leg and foot deformity
And Felty syndrome
- **Extraarticular manifestations of RA-Similar to SLE there is multisystem involvement.
- The 3 most common extraarticular manifestions are:Rheumatoid nodules
- Sjogren’s syndrome is an autoimmune disease that targets moisture-producing glands (lacrimal and salivary) leading to the symptoms of xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes). The risk of developing Lymphoma is high due to the the inclusion of lymphocytes in the disease process. Treatment includes artifical tears, drinking fluids with meals, good dental care and corticosteriods and immunosuppressive drugs for more advanced disease.
which is seen in patients with severe, nodule-forming RA. It is characterized by inflammatory eye disorders, plenomegaly, lymphadenopathy, pulmonary disease and blood dyscrasias like leukopenia.
**Diagnostic studies for RA
Erythrocyte sedimentation rate-ESR : Elevated in inflammationGood indicator in 85% of patients
Serum Rheumatoid factors-RF; Elevated titers>1:60 in 80% of patients C-reactive Protein
-CRP: C-reacting protein (CRP) which is elevated in inflammation may be positive. CRP and ESR are general indicators of active inflammation; ) is found in the body and is elevated when inflammation is found in the body. The higher the level of CRP the more disease activity is involved. Although ESR and CRP reflect similar degrees of inflammation, sometimes one will be raised when the other isn’t. This test may be repeated regularly to monitor your inflammation and your response to medication.
Antinuclear Antibodies- ANA (This test detects a group of autoantibodies (antibodies against self), which is seen in about 30 to 40 percent of people with RA. Although it commonly is used as a screening tool, ANA testing isn't used as a diagnostic tool because many people without RA or with other diseases can have ANAs.)
X-ray: not diagnostic but may show some demineralization with bony erosion and narrowed joint spaces. Only show swelling of soft tissue and bone density loss.
Synovial fluid analysis: Straw colored with fibrin flecks with elevated WBC count: caught during surgery.
**Therapeutic Management of RA
Goal: To arrest inflammatory process BEFORE bone erosion and joint destruction can occur, Provide pain relief
-Balanced program: Pharmacological therapy, Education, Physical and psychosocial therapy
**Pharmacologic Management RA
Disease-modifying antirheumatic drugs (DMARD’s) are used with NSAIDS and/or corticosteriods to slow joint destruction caused by RA over time.
- =>Mild RA
- Hydroxychloroquine (plaquenil) (like SLE)
- Sulfasalazide (Azulfidine)-antiinflammatory properties
=>Biologic response modifiers
- =>Moderate to severe disease
- Gold therapy-injectable in IV.
- Azathioprine (Imuran) or D-penicillamine (Cuprimine)-), immunospressive drugs like imuran and cuprimine which suppress cell-mediated hypersensitivities and alters antibody production.
- Combination of methotrexate and sulfasalazine
- -Cox2 inhibitors-antiflammatory for longterm b/c don't upset GI system like nsaids do.. (COX (cyclo-oxygenase) is an enzyme involved in joint inflammatory process. COX-2 inhibitors block the enzyme involved while leaving the enzyme that protects the stomach lining. Celebrex and Vioxx are 2 of the COX2 inhibitors showing good results.)
- -ASA and NSAIDS
- -Corticosteriods-are used to aid in symptom relieve and are injected right into the affected joint. Short term usage is advisable until DMARD’s take effect. High does must be short termed
-chemotherapy drugs/must be given by chemotherapy certified nurses!(drugs that directly modify the immune system by inhibiting proteins called cytokines, which contribute to inflammation slowing the progress of RA. Examples of these are etanercept (Enbrel), infliximab (Remicade), adulimumab (Humira), anakinra (Kineret), and abatacept (Orencia).) If all the other agents haven't worked in the past. May be used for crohns, diverticulitis, irritable bowel.
- Protein-A immuoabsorption therapy (Another therapy useful in the treatment of RA for patients who either fail to respond to pharmacologic agents or who are intolerant to DMARD’s is apheresis or
- Protein-A Immuoadsorption Therapy – This is not a drug, but a therapy that filters your blood to remove antibodies and immune complexes that promote inflammation. Apheresis removes RF as the blood is filtered. Patients have apheresis once a week for 12 weeks)
- -Last resort is Apheresis: like blood dialysis where it strips all the antibodies out of your blood (dialysis takes away toxins) and here the toxins are considered the antibodies!
- -Tell them to wear masks..
**Surgical approach Rheumatoid Arthritis. w
Synovectomy: removing all synovial fluid from that joint space
Arthroplasties: removing entire joint.. but RA can travel to another joint. usually Total Knees, Total Hips, etc. Knee, Hip, Wrist, Elbo
**Ambulatory home care for patients with RA
Rest Joint protection: not a lot of ROM is wanted
Daily heat/ice and exercise
- Evaluate support
- No specific diet
- -Regular scheduled activity and rest periods during the day help relieve fatigue and pain and minimize excessive weight bearing on joints
Total bed rest should be avoided to prevent stiffness and immobility. Lying prone for 1/2 hour daily is recommended with small pillow under head. No pillows should be used under the knees.
With education on home care the patient learn how to accomplish activities that place less stress on joints. Pg 1710 Table 65-10 teaching for Protection of Small joints
Teach patient to schedule morning care and procedures later in the day after morning stiffness subsides. May need assistive devices that help simplify tasks
Warn moist heat help relieve stiffness, pain and muscle spasm (not to exceed 20 min) and Ice (for 10 to 15 min) may help in acute inflammation (frozen peas or corn)
ROM exercises (active and passive), Warm water (78 to 86F) aerobics are excellent. Teach importance of exercising THE JOINTS TO THE POINT OF PAIN BUT NOT PAST THE POINT OF PAIN.
**Osteoarthritis (OA) Degenerative joint disease
OA is a chronic non-systemic, non-inflammatory disorder of the joints characterized by degeneration of the articular joint cartilage
No longer considered normal part of aging
Most common joint disorder in North American; Affects more than 85% of people over age 75Most frequently seen in weight bearing joints; seen a lot in younger athletes due to overues. In knees and hips. Accounts for more disability in the population than any other disease: that we're having to not have individuals be productive.-losing cartilage-boneonbone! So you'd need joint replacement.
- **OA Physio: Articular cartilage (joints) can experience wear. Wear is the removal of material from solid surfaces by biomechanical action.
- Due to the changes in the nature of gylcoproteins with aging, cartilage becomes less able to retain water. The “drying out” effect can change the biomechanics of cartilage and lead to increased stress fractures or cracks in the collagen network.
Over time and with joint wear, microcracks can accumulate and fragments of cartilage can detach into the joint space creating “loose bodies”. Inflammation of the synovium occurs when phagocytic celss try to rid the joint of these small pieces. This causes the early pain and stiffness of OA. The resulting cartilage surface is rough and irregular and subject to further mechanical wear and degenerations. This process forms the basis of osteoarthritis. Affected cartilage gradually becomes softer, less elastic, and less able to resist wear with heavy use.
Two basic types of OA
- No know cause
- Women due to estrogen reduction at menopause
- Genetic factors
- Most common type
- Weight bearing joints are most commonly affected
- =>Secondary (more prevalant)
- Influenced by many factors: Injury, heredity, obesity or something else?
- Identifiable precipitating event: like a slip or a fall
**Assessment findings- OA
- Pain aggravated by use and relieved by rest
- Early morning stiffness is common
- Usually main weight-bearing joint such as knees, hips and spine (walkers, wheelchairs)
- May effect distal (DIP) and proximal interphalangeal (PIP) joints of the fingers and first carpometacarpal joint of thumb-joint replacement therapies.
Joints are usually affected asymmetrically
common manifestation (DIP); Bony growth spurs at the end of the finger
Bouchards nodes (PIP);
Bony growth spurs at the middle joint
-is the grating sensation caused by loose particles of cartilage in the joint cavity that also contribues to stiffness.
**Collaborative Care for OA
=> 2nd line drug therapy
- =>1st line drug therapy
- (Mild to moderate)Acetaminophen 1g up to 4x/day
- Capsaicin (kap-say-sin) cream
NSAIDS or Cox-2 inhibitors (inhibitors like Celebrex that inhibit the COX-2 (cyclooxygenase-2 enzyme that causes inflammation) but spare the COX-1 enzyme that protect the stomach lining.Injectable corticosteriods –
that inhibit the release of inflammatory mediators. They are injected into the joint for fast, targeted pain relief. This therapy can only be done for a limited time.)
Intraarticular injections of corticosteriods or synthetic and natural hyaluronic acid derivatives
- => Dietary supplements
- Oral glucosamine sulfate and chrondroitin
- Prevention of GI side effects (misproprostol-cytotec)
=> Patient and family education
- =>Nursing interventions
- Pain control
- Prevention of progression and disabilityRestoration of joint function
Encourage activity and ROM
- Ambulatory aids to reduce the weight on involved joints
- Promote self care and importance of rest periods
- Use of prescribed medications and side effects
- Nutritional therapy-weight reduction
**Osteoporosis & Risk Factors
- Chronic, progressive metabolic bone disease characterized by
- Porous bone
- Low bone mass
- Structural deterioration of bone tissue
- Increased bone fragility
- => Osteoporosis is a condition of decreased bone strength that leaves the bones susceptible to fracture. Both the density of the bone and the quality of the bone structure are compromised in osteoporosis. The word osteoporosis literally means bone (“osteo”) that is porous or filled with holes (“porosis”).Bone remodeling, or the removal and replacement of old bone, is a normal process that keeps the adult skeleton healthy.
- When bone reabsorption and formation are balanced, the quantity of bone replaced is essentially equal to the quantity removed. Net bone loss occurs when bone reabsorption exceeds bone formation. This happens as a normal part of aging, but when bones get too thin and weak to support your activities, you have osteoporosis.
- ** Osteoporosis: Risk Factors
- Risk factors for osteoporosis include:Female gender, increasing age, family history of osteoporosis, white (European descent) or Asian race, small stature, early menopause, history of anorexia or oophorectomy, sedentary lifestyle, and insufficient dietary calcium.
- Increases risk is associated with cigarette smoking and alcoholism.
- Decreased risk is associated with regular weight-bearing exercise and fluoride and vitamin D ingestion.CAFFEINE.
- =>Glucocorticoid-induced: Glucocorticoid use is the most common form of drug-related osteoporosis. Long-term corticosteroid use accelerates bone loss through a variety of mechanisms. It is associated with high fracture rates, particularly in patients with rheumatic disease. People treated with corticosteroids can have vertebral fractures at bone mineral densities above those considered osteoporotic.It is generally agreed that people receiving glucocorticoid therapy for two months or longer are at high risk for osteoporotic fracture.
Sedentary life style
Insufficient dietary calcium and Vitamin D
Increased risk with alcohol and cigarette smoking
**Diseases associated with Osteoporosis
**CLinical Manifestations & Diagnostcs
- Intestinal malabsorption
- Kidney disease
- Rheumatoid arthritis
- Chronic alcoholism
- Cirrhosis of the liver
- Diabetes mellitus
- **Clinical manifestations
- Silent disease: Asymptomatic
- Fractures: Forearm, hip and spine most common (fall just off a 2 inch ledge..)
- Sudden onset of lower back pain: Collapsed vertebrae, Becomes worse on movement, Relieved by rest
Bone mineral density (BMD):
- **Osteopororis Diagnostic studies
- History and physical exam
Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DEXA), which provides information about BMD at the spine and hip.
Dual-energy x-ray absorptiometry (DEXA)
** OsteoArthCollaborative Care
Focus on proper nutrition, calcium supplements, exercise, prevention of fractures, and drugs
Prevention and treatment depend on adequate calcium intake
Increased calciumD and Vit prevents future loss but will not form new bone Good sources of calcium: Milk, Yogurt, Turnip greens, Spinach, Cottage cheese, Ice cream, Sardines
Supplemental vitamin D may be recommended
Exercise should be encouraged to build up and maintain bone mass
Patients should be instructed to quit smoking or cut down on alcohol intake to ↓ losing bone mass
**Osteoporosis Drug therapy
=>Estrogen replacement after menopause: puts at risk for strokes and cancers
=>Bisphosphonates inhibit osteoclast-mediated bone resorption (e.g., etidronate (Didronel), alendronate (Fosamax); Bisphosphonates reduce spine and hip fractures associated with osteoporosis through increasing bone mass and decreasing bone loss by inhibiting osteoclast function. Fosamax and Actonel are approved for the prevention and treatment of corticosteroid-induced osteoporosis in men and women.
given weekly, has been shown to be as effective as previously used daily dosing.
is a newer agent that requires only once-monthly administration. Adequate calcium and vitamin D intake is needed for maximum effect, but these supplements should not be taken at the same time of day as bisphosphonates.
Side effects of bisphosphonates include gastrointestinal symptoms (eg, dyspepsia, nausea, flatulence, diarrhea, constipation), and some patients may develop esophageal ulcers, gastric ulcers, or osteonecrosis of the jaw related to bisphosphonate use (Ruggiero, Mehrotra, Rosenberg, et al., 2004).
Patients must take these medications on an empty stomach on arising in the morning with a full glass of water and must sit upright for 30 to 60 minutes after their administration
- => Selective estrogen receptor modulators
- Raloxifene (Evista); reduce the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. They are indicated for both prevention and treatment of osteoporosis.
- =>Teriparatide (Forteo)
- -a subcutaneously administered medication that is given once daily, has recently been approved by the Food and Drug Administration for the treatment of osteoporosis. As a recombinant parathyroid hormone, it stimulates osteoblasts to build bone matrix and facilitates overall calcium absorption
- -Portion of parathyroid hormone
- -First drug to stimulate new bone formation
Infection of the bone:characterized by progressive inflammatory destruction of the bone, bone marrow, and surrounding soft tissue after formation of new bone.
- It commonly results from bacteria invading either indirectly (infection starting somewhere else in the body like a UTI or Resp tract) or directly through an open wound. Indirect invasion is very common in boys <12 yrs; mosy by staph
- -indirect: chemotherapatic and HIV and immunosupp peeps. Also have ortho surgery especially if put in hardware which is a source for pathogen to infect.
- -antibiotics take forever to get through circulatory system to actually invade the bone to eradicate that pathogen D:
- Extension of soft tissue infection
- Direct bone contamination
- Blood-borne spread from other sites of infection
- Clinical Manifestations
- Acute osteomyelitis <1 month
- Fever, night sweats, chills, restlessness, nausea and malaise
- Constant pain, swelling, warmth
**Osteomyelitis Clinical Manifestations
>1 month or failure to respond to initial course of antibiotics;-when treated, it can become very chronic where we think we get rid of it but two months later it comes back
-sometimes they can inject the joint with antibio or remove the hardware!
Systemic: Fever, night sweats, chills, restlessness, nausea and malaise, just not feeling well. When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis (eg, chills, high fever, rapid pulse, general malaise).
- Local signs of infection: Constant bone pain, swelling, and warmth some bogginess, some irritation.
- -antibiotics for 24 period after if no prior infections.
- -dirty surgeries due to trauma: then antibio for couple weeks after surgery
=> When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no symptoms of sepsis. The area is swollen, warm, painful, and tender to touch.
**Diagnostic test and assessments OSTEOMYELITIS
=>Arthroscope: Surgical procedure to examine the internal structure of a joint; flush it out with NS or antibio solution, send a sample to patho, for most part it's staph cos that's what's on our skin.
=>Arthrogram: Contrast media or air injected into joint cavity to allow visualization of joint structure; uses flouroscopy
=>CT Scan and MRI: Radioisotope bone scans, particularly the isotope-labeled white blood cell (WBC) scan, and magnetic resonance imaging (MRI) help with early definitive diagnosis to light up inspected areas
=>Arthrocentesis (joint aspiration): Fluid is removed from joint to reduce swelling and pain
=> Bone or soft tissue biopsy
=>CBC: Elevated WBC. Decreased RBC indicating anemia
=> Erythrocyte sedimentation rate (ESR)- SED rate elevated.
**Management of Osteomyelitis
- =>Pharmacologic therapy
- -Obtain culture and sensitivity before antibio.. to find out what the pathogen is.
- -Intravenous antibiotic therapy (3-6wks; After the infection appears to be controlled, the antibiotic may be administered orally for up to 3 months.) takes long to get to bonee.. PICC line for a long period.
- -Staph., Strep, E-coli sensitive drugs, Penicillin, cephalosporins (cefotetan, cefoxitin, cefazolin) aminoglycides (gentamycin, vancomycin--do lab works to see if no toxic levels in blood to see if they're metabolized well); vanco trough is the blood is drawn prior to dose iin the cycle (usually by third cycle) and we measure the amount of the drug that's left in the serum at the end of the duration. If it's too high then body isn't metabolizing it and it's toxic to the kidney.
-PO antibiotic therapy for 3-6 months (To enhance absorption of the orally administered medication, antibiotics should not be administered with food.) Long time and loooong time for COMPLIANCE.
-clean surgeries haVe no prior infections so we are preventing any infections from occurring (24 hours) to avoid any entering into circulatory system.
Surgical debridement with wound irrigation (If the infection is chronic, surgical débridement is indicated but is reserved for patients with acute osteomyelitis that does not respond to antibiotic therapy. The infected bone is surgically exposed, the purulent and necrotic material is removed, and the area is irrigated with sterile saline solution.
mpregnated beads may be placed in the wound for direct application of antibiotics for 2 to 4 weeks. IV antibiotic therapy is continued.)Antibiotic-impregnated beads
Amputation if live threatening
highly oxygen enriched cocoon/chamber that pt goes into to allow for healing of any infected sites. Post-operative care: Closed suction irrigation
- Wet to dry sterile dressing for open wounds: make sure WE are 100 percent sterile doing those dressing changes.
- -force of press
**Nursing Interventions Osteomyelitis
Relieving pain-medicate during dressing changes
- Elevation of extremity
- Monitor neurovascular status (5 P’s)
Handle with care and gentleness
- Improving physical mobility and helping with ADL's.
- Controlling infectious process
Monitor response to antibiotic therapy; Monitor all mucous membranes for super infections (candidisis) in their mouths, GI system protectants for that..prone to C-Diff.
maintain Positive nitrogen balance: to avoid yeast infections
**Sprains and Strains
**Nursing care for strains and sprains
Sprain: A stretch or tear of a LIGAMENT-three diff levels, lower number=lower level of sprain.. same with strains.
Strain: A stretching or tearing of MUSCLE FIBERS
**Nursing care for strains and sprains
I = Ice (Applying ice for 24-48 hrs then moist heat (vasoconstriction and reduced perception of nerve pain impulses))
C= Compression (Compressing the involved extremity using an ace wrap (helps with swelling and can shorten the healing time). If numbness occurs wrap is too tight)
E= Elevation (Elevating the affected limb (elevate above the heart level to mobilize excess fluid from the area and prevent further swelling. Providing analgesia)
**Musculoskeletal problems Bursitis and Tendonitis
- -"itis"-inflammation and "bursa" in the joints; fluid filled area that cusions the area.
- Inflammatory condition that causes pain and swlling, w/o propper rest it'll get worse.
- Commonly occurs in shoulder
- Caused by repetitive or excessive trauma or friction
- Causes the bursa (fluid filled sacs) or tendon sheath to become inflamed
=>The bursa is what cushions the tendon and thereby helps prevent friction between the tendon and the bone. Unfortunately, constant rubbing of the tendon over the bone with high amounts of repetitive arm, shoulder, hip, knee and ankle motion can lead to enough friction of the bursa itself to cause the inflammation and irritation of the bursa called bursitis.
Bursitis and Tendonitis CLINICAL MANIFESTATIONS & Treatment
- Swelling (as a result of edema) most often occurs at sites where burse and tendons commonly found
- Shoulder and elbow
- Limited ROM
- **Treatment-Conservative treatment includes:Rest of the extremity
- Intermittent ice and heat to the joint and NSAIDS to control pain and inflammation
- Aspiration of bursal fluid and intraarticular injection of corticosteriods to decrease inflamm.
- Arthroscopy surgery may be necessary if shoulder pain and weakness persist.
- A fracture is a disruption or break in the continuity of the structure of bone
- Traumatic injuries
- Pathologic fractures from cancer of osteoporosis
- Fractures classified according to:
- Type (look at book)
- Communication or non-communication to the external environment
- Anatomic location of fracture on the involved bone
-ext fixation device: covered with vaseline gauze, change pins every two days, don't pick it up with the devices.
-didnt go through the skin
**Clinical Manifestation of fractures & Collaborative Care Goals
- Edema and swelling and bruising is typical
- Muscle spasms
- Deformity: depending on wehre it is, you can have extremities going in opp directions
- Loss of function: can they bend?
- Crepitation: they can hear the bone if they try to move it.
- **Collaborative Care-Goals include:
- Immobilization to maintain realignment
- Anatomic realignment of bone fragments (reduction) externally or do we need surgery?Restoration of function of the injured part
Application of pulling forces; Traction is the application of pulling forces to an injured or disease part of the body or an extremity while counter traction pulls in the opposite direction; usually on long bones, hip fractures, good if surgery risks are unsafe-
- skin surface gets pulled on extermity to pull the bone into alignment.
- -make sure weight stays suspended and hanging, don't bump into the weight! Don't take or add to it unless ordered.
- -usually in place short term (48-72hrs)
- =>Purpose of traction: Prevent/reduce muscle spasm
- Immobilize a joint or body part
- Reduce a fx or dislocation
- Treat a pathologic condition
- Prevent soft tissue injury
- Expand a joint space during arthroscopic procedures or major joint reconstruction
**Types of Traction
- Generally used for short term (48-72 hrs) until skeletal traction or surgery can occurTape is applied to skin to (ace wrap)
- Maintain alignment
- Assist in reduction
- Help diminish muscle spasm-supine position, offset pressure from sacral areas with pillows while keeping that leg in place.
- Used for longer periods of time
- Provides long-term pull that keeps bones in alignment
- Nail, pins, wire, or tong are put into the bone either partially or completely to align or immobilize the injured part
- Traction weights are usually >10#-use trapeze.
type of skin traction
An improvement over Buck’s traction because it allows the vector force of the traction to be changed.
- -Bryant’s traction is commonly used in child with congential hip locations
- Traction applied to the lower leg with the force pulling vertically, employed especially in fractures of the femur in infants and young children. Described by Bryant in 1873.
**Casts & care
- Common after closed reduction (meaning no surgery done)
- Temporary circumferential immobilization device
- Plaster of paris, synthetic acrylic, fiberglass nowadays, latex-free polymer or hybrid-know type so you can do pt education (waterproof? innerlinings is material so takes a long time to dry internally)Weight bearing after 48-72 hrs-know! is it FWB or NWB? or toetouch WB?Allows mobility to patient
- **Cast Care
- =>Plaster of Paris Casts
- No wt bearing until dry
- Handle with palm to prevent indentation which will cause pressure
- => Fiberglass casts
- Relatively water proof
- Support early -still need turning if in body cast..
**Nursing Care Cast Care
Body cast- turn every 2 hours (until dry)
- Ice to control edema during initial phase of immobilization, put area ABOVE THE CAST to coold down the blood that is going to that area of swelling.
- No foreign objects inside cast: coat hangers-infection cause and risk of osteomyelitis. Take benadryl if itchy.I
- If immobilized push fluid intake 2000 to 2500ml per day, well balanced diet
- Don’t cover cast until it is dry (produces increased heat)
- => While cast is drying a person in a body cast must be turned every 2 hours.Assessment of GI system is vital to determine if “cast syndrome” has occurred.
- Cast syndrome is a condition that occurs if the cast is too tight. The cast compresses the superior mesenteric artery against the duodenum. Pt c/o abd pain, pressure , N/V. Abd must be assess for bowel sounds (window is left in cast at umbilicus). Tx includes gastric decompression with N/G tube, removal or splitting the cast.
- Complete neurovascular assessment: Color, temp, cap refill, pulses, and edema
Peripheral neurologic assessment: Sensation, motor function and pain, Compare both extremities -check nearest pulse point to the top of cast..
Previous hx of patient: nutrition, comorbidities, medication inhibits (steroiids and bone formataions)
**Drug therapy Casts..
Central and peripheral muscle relaxants
-if on opioids -give plenty of fiber and stool softener especailly in hip spica cast.
Tetanus and diphteria toxoid; Open fractures are tx with tetanum and diphteria toxoid if immunization has not occurred.
rophylactic antibiotics are used to treat open fracture, common meds used are the cephalosporins like cefazolin.
**Complications of fractures
Complications of fractures are either: Direct or Indirect
problems with bone infection, bone union, an davascular necrosis
complications associated with blood vessel and nerve damage resulting from conditions like compartment syndrome, venous thrombosis, fat embolism and traumatic or hypovolemic shock.
- => Infection
- High incidence in open fx and soft tissue injury
- Common pathogens include anaerobic bacilli
- Debridement is common in surgery
- Irrigated with antibiotic solution or antibiotic-impregnated beads left in wound
- Systemic IV antibiotic therapy for 3-7 days
- => Compartment syndrome
- Two basic etiologies create compartment syndrome:Decreased compartment size:
- Restrictive dressing, Splints, Casts
- Increased compartment content: Bleeding, edema-if you put cast and more swlling occurs, the tssues have no where to go..lack of blood flow and o2 causes necrosis ): Death of extermities within HOURS. Forearm (distal humerus) and lower leg (proximal tibia) are most common sites
Fractures of the upper extremities are called Volkmann’s Ishcemic contractures
Fractures of the lower extremities called anterior tibial compartment syndrome
CAST CARE: Manifestations & Therapeutic Management
- **Clinical Manifestations
- -Progressive pain distal to the injury not relieved by uxversible damage can occur within 4-12 hrs after onset
- -Progressive pain, numbness and tingling, and tenseness of compartment envelope: Loss of sensation, function, Pallor, coolness, Absent peripheral pulses (ominous sign)
- -Urinary output changes
- -Color and consistency of urine
=> Assess for the 5 P’s: pain, pulses, pallor, paresthesia, and paralysis
=> Myoglobin released from the damaged muscle cells precipitates as a gel=like substance, causing obstructin in renal tubeules because of its high molecular weight. Lg amt of myoglobinemia may result in acute tubular necrosis causing renal failure. Assess the color of urine (dark reddish-brown urine, other s/s assoicated with renal failure)
- **Complications of fractures cont
- Venous thrombosis: Venous thrombosis is a risk due to venous stasis caused by improperly applying the cast or traction, local pressure on a vein, or immobility. SCD's, lovenox, heparin, aspirin, coumadin.
is aggravated by inactivity of the muscles that normally assist in the pumping action of venous blood returning to the extremities.
- **Therapeutic Management
- Prevention and early recognition is the key
- Do not elevate the extremity above the heart level or use ice b/c we're inhibiting blood flow to that area, WE NEED BLOOD FLOW and OXYGEN for COMPARETMENT (Elevating the limb above the heart may raise venous pressure and slow arterial perfusion.
- Application of ice cause vasoconstricton further decreasing perfusion)May help to loosen bandage or cast and reduce traction weight
- May need bi-valve of cast (Bi-valve cast will help decrease pressure and increase perfusion)
(Fasciotomy or surgical decompression leaves the site open to ensure adequate soft tissue decompression. Infection is a risk.)
Fat embolism syndrome
- => Fat embolism: is characterized by the presence os sytemic fat globules from fractures that are distributed into tissues and organs after a traumatic skeletal injury. These fat globules obstruct perfusion in tissue and organs. They are common in fx of long bones,ribs, tibia and pelvis. Fat globules from fractures that damage tissue and organs by obstructing perfusion
- Common in fractures of the long bones, ribs, tibia, and pelvis
- **Clinical manifestation of fat embolism
- Chest pain, tachypnea and dsypnea
- Apprehension and feeling of “doom”-something's not right, short of breath..
- Decreases PaO2
- Change in mental status
- Petechiae around neck, anterior chest, face, axilla, and eye’s
- **Collaborative care: Fat Embolism
- Aimed at prevention
- Symptom related and supportive
- Fluids for hypovolemia
- Coughing and deep breathing should be encouraged
- Oxygen to treat hypoxia (in emergency, doesn't have to be ordered and then call a physician)
- Most people survive with few sequelae
**Hip Fractures & Clinical Manifestations.
- Common trauma in older adults due to osteopororis and aging process.
- Higher incidence in women
- Associated with osteoporosis
- High morbidity within one year>25% of survivors lose their ability to walk independently
- 60% do not regain their pre-injury level of ambulating
- **Clinical manifestations
- Muscle spasm
- Shortening of affected limb
- Severe pain and tenderness in the region of the fracture
- Complications from hip fractureHemorrhage and shock
- Immobility complications
- Aseptic necrosis of femoral headDVT
- Other health problems: Because hip fractures occur more commonly in our elderly population you must consider multisystem complications like PVD, CAD, restrictive lung disease like emphysema and COPD, etc.
=> Muscle spasming is the most common cause of pain and can be relieved by Buck’s traction until patient can go to surgery; Shortening of the affected limb, Severe pain and tenderness
**Hip Fractures Collaborative Care
=>Medical management: Initially Buck’s or Russell’s Skin traction applied until stabilization of fx (surgery); Reduce muscle spasms, Immobilize the extremity, Relieve pain, keep them in alignment.
- => Surgical management
- (ORIF)Preferred method of treatment for hip fx
- Permits patient to be out of bed sooner
- Decreases chance of complications from immobility
- Hip may be pinned or prosthesis used
Arthroplasty & Nursing Cares
Surgical procedure performed to:Relieve pain, Improve or maintain ROM, correct deformity; done if bones are too weak to put screws in..
Most common orthopedic operation performed on older adults
- Types of Arthroplasty: Total Hip replacement & Knee replacement
- -hip rooms: completely covered and more sterile, and to protect ourselves because cutting into it makes bone fly everywhereee.
- =>Nursing Care after Hip Arthroplasty
- Avoid extremes for 4-6 weeks post-op
- Internal rotation
- Adduction 90 degree flexion of hip
- Positioning leg in abduction
- Foam abduction/wedge pillow placed between legs: Abductor pillow (Hip abductor pillow is used postoperative to keep the hips from rotating outward potentially causes a dislocation at the new surgical hip site..)
- Turn in bed to keep the operative hip in abduction
- Hip is never flexed >90 degree’s
- Use of fracture pan and trapeze
- Elevated toilet seat
- PT is initiated 1 day post-op with ambulating and weight bearing with walker (cemented prosthesis)
- Administer Heparin/Coumadin
Arthroplasty **Client teaching and discharge planning-
- **Client teaching and discharge planning-
- Protective positioning
- -Avoiding internal and external rotation, hyperextension and flexion because it will pop out! Must get up off a chair from end of chair and keep back straight.
- =At no time cross legs or bend at waist
- -Use of pillow between legs when in supine position
- Generally not to sleep on affected side
- -> DVT, VTE: PREVENTABLE by Heparin
- Assessment for infections and monitoring for pain control
- -no ddriving for 4-6 weeks
- Assess for administration of enoxiparin (Lovenox) 7-10 days after ==> aspirin therapy.
- Know how to safely inject.
- No driving or tub baths allowed for 4-6 wks: soaking in wound will make it easy for patho to go into bone...
- Importance of heparin administration
- Reinforce exercises that are designed to restore strength and muscle tone of hip muscles
-Total Knee Replacement: Total knee replacement is another common arthrosplasty for trauma or severe destructive deterioraton of the knee joint.
**Nursing Care following Joint Replacement of the Knee
- Compression dressing and Jackson Pratt
- Knee immobilizer
- May have a passive-motion machine
- Emphasis on post-op exercise:Isometric quadriceps setting first day post-op, Progresses to straight leg raises and gentle ROM , Increases muscle strength and obtain 90 degree knee flexion, Full weight bearing before discharge!!
Active home and PT program-will use a drain to avoid compartment pressure.
**Complications of Joint Surgery
- =>DVT: Potentially serious complication
- Prophylaxis such as ASA, warfarin, heparin, compression hose
- -"syndrome may also occur after total hip surgery.
- ASA, low molecular weight heparin, warfarin, and compression hose are instituted directly after surgery to decrease the incidence of DVT."
- =>Infection: Serious complication following joint replacement
- Gram+ aerobic streptococci and staphylococci
- Treat with antibiotic therapy
- -"The most common causative agent is gram-positive aerobic streptococci and staphylococci. Efforts to reduce the incidence of infection include the use of specially designed self contrined operating suites, operating rooms with laminar airflow and prophylactic antibiotic administration."
- Clinical indications:
- Traumatic amputation (younger adult); Trauma and thermal injuries
- Malignant tumor (Osteosarcoma)
- Circulatory impairment (middle or older pt): PVC (Arteriosclerosis and Diabetes), HTN, diabetes-necrosis.
- **Collaborative Care-Surgery-Preoperative care
- Reinforce patient information about reason
- Proposed prosthesis
- Mobility training
- Instruction on upper-extremity exercise
- => In the preoperative setting the nurse must have a good understanding of the level of the amputation, the post operative dressing to be used and the type of prostetic to be utilized.
- patient should be informed of upper extremities excerises to promote arm strength if a lower limb is being amputated.
Patients must be instructed on the occurance of Phantom pain. This phenomenon occurs in 80% of amputee’s where pain in felt in the limb that was removed. Pt c/o of feelings of coldness, heaviness, cramping, shooting pain, burning and crushing pain. Phantom Pain usually subsides but not in all cases and can become a chronic problem
=> Bandaging for amputations: This is a picture of post operative bandaging of an above the knee amputation. The bandaging fosters shaping and molding for eventual prosthesis fitting. Other dressings may include:
to support the soft tissue, reduce edema, hasten healing, minimize pain, and promote residual limb shrinkage and maturation
**Expected outcomes for the Amputee.
- Accept change in body image
- Integrate changes into lifestyle
- Absence of skin breakdown
- Reduction or absence of pain
- Mobility within limitations imposed by amputation