nursing: Musculoskeletal System Part 2

This is the second part of Musculoskeletal System lecture. More nursing lectures about this system at http://nursinglectures.blogspot.com

Below the knee amputation
Nursing Intervention
- Preoperative
Post-operative Care
- Prevent edema
- Prevent hip/knee contractures
- Pain medication as ordered (phantom limb pain)
- Ensure that stump bandages fit tightly and are applied properly to enhance prosthesis fitting
Inflammatory Disorders of the Musculoskeletal System
- Rheumatoid arthritis
- chronic systemic inflammatory disease
- destruction of connective tissue and synovial membrane within the joints
- weakens and leads to dislocation of the joint and permanent deformity
- Risk Factors
- exposure to infectious agents
- fatigue
- stress
Rheumatoid Arthritis
- Signs and Symptoms
- Morning stiffness
- Fatigue
- Weight loss
- Joints are warm, tender, and swollen
- Swan neck deformity-late
- Diagnostic Studies
- X-ray
- Elevated WBC, platelet count, ESR*, and positive RF
- Treatment
- No cure for RA
Swan neck deformity
Rheumatoid Arthritis
Pharmacotherapy
- Aspirin- mainstay of treatment, has both analgesic and anti-inflammatory effects
- Nonsteroidal anti-inflammatory drugs (NSAIDs):
- I mmunosuppressives : Methotrexate
Pharmacotherapy
- Gold compounds
- Injectable form: sodium thiomalate, aurothioglucose; given IM once a week; takes 3-6 months to become effective
- Oral form: auranofin- smaller doses are effective; diarrhea is a common side effect
- Corticosteroids
- Intra-articular injections
Rheumatoid Arthritis
- Treatment
- Surgical Procedures: synovectomy, arthrotomy, arthrodesis, arthroplasty
- Nursing Management
- Advised bed rest during acute pain
- Passive ROM exercise of joints
- Splint painful joints
- Heat & Cold application
- Advised warm bath in the morning
- Protect from infection
- Advised well-balanced diet
Arthrotomy Arthrodesis Arthroplasty
Osteoarthritis (Degenerative Joint Disease)
- Progressive degeneration of the joints as a result of wear and tear
- affects weight-bearing joints and joints that receive the greatest stress, such as the knees, toes, and lower spine .
Osteoarthritis
- Risk Factors
- aging (>50 yr)
- rheumatoid arthritis
- arteriosclerosis
- obesity
- trauma
- family history
- Signs and Symptoms
- Dull, aching pain,* tender joints
- fatigability, malaise
- crepitus
- cold intolerance*
- joint enlargement
- presence of Heberden’s nodes or Bouchard’s nodes
- weight loss
Medications
- Aspirin
- inhibits cyclooxygenase enzyme, diminishes the formation of prostaglandins
- anti-inflammatory, analgesic, antipyretic action
- inhibit platelet aggregation in cardiac disorders
- Adverse effects
- Epigastric distress, nausea, and vomiting
- In toxic doses, can cause respiratory depression
- Hypersensitivity
- Reye’s syndrome
- Ibuprofen
- use for chronic treatment of rheumatoid and osteoarthritis
- less GI effects than aspirin
- Adverse effects
- dyspepsia to bleeding
- headache, tinnitus and dizziness
Medications
- Indomethacin
- inhibits cyclooxygenase enzyme
- more potent than aspirin as an anti-inflammatory agent
- Adverse effects:
- nausea, vomiting, anorexia, diarrhea
- headache, dizziness, vertigo, light-headedness, and mental confusion
- Hypersensitivity reaction
Osteoarthritis
- Nursing Intervention
- Promote comfort: reduce pain, spasms, inflammation, swelling
- Prevent contractures: exercise, bed rest on firm mattress, splints to maintain proper alignment
- Weight reduction
- Isometric and postural exercises
- Nursing Diagnosis
- Pain related to friction of bones in joints
- Risk for injury related to fatigue
- Impaired physical mobility related to stiff, limited movement
Gouty Arthritis
- Metabolic disorder that develops as a result of prolonged hyperuricemia
- Caused by problems in synthesizing purines or by poor renal excretion of uric acid.
- Acute onset, typically nocturnal and usually monarticular, often involving the first metatarsophalangeal joint
- Risk Factors
- Men
- Age (>50 years)
- Genetic/familial tendency
Gouty Arthritis
- Signs and Symptoms
- extreme pain
- swelling
- erythema of the involved joints
- fever
- Tophi
- Laboratory Findings
- elevated serum uric acid (>7.0 mg/dl)*
- urinary uric acid
- elevated ESR and WBC
- crystals of sodium urate aspirated from a tophus confirms the diagnosis*
Treatment
- Allopurinol
- - a purine analog
- - reduces the production of uric acid by competitively inhibiting uric acid biosynthesis which are catalyzed by xanthine oxidase.
- Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies).
- Adverse effects : hypersensitivity reactions, nausea and diarrhea
- Colchicine
- Effective for acute attacks
- Anti-inflammatory activity alleviating pain within 12 hours
- Adverse effects : nausea, vomiting, abdominal pain, diarrhea, agranulocytosis, aplastic anemia, alopecia
- Probenecid/Sulfinpyrazone
- uricosuric agents
- increases the renal excretion of uric acid
- Sulfinpyrazone used as a preventive agent.
- Adverse effects: nausea, rash & constipation
Nursing Implementation
- Maintain a fluid intake of at least 2000 to 3000 ml a day to avoid kidney stone.
- Avoid foods high in purine such as wine, alcohol, organ meats, sardines, salmon, anchovies, shellfish and gravy.
- Take medication with food.
- Have a yearly eye examination because visual changes can occur from prolonged use of allopurinol
- Caution client not to take aspirin with these medication because it may trigger a gout attack and may cause an elevated uric acid levels.
- Encourage rest and immobilize the inflamed joints during acute attacks
- Avoid excessive alcohol intake
- Notify physician if rash, sore throat, fever or bleeding develops.
Osteomyelitis
- Infection of the bone
- Staphylococcus aureus is the most common pathogen.
- Other organisms include Proteus, Pseudomonas and E. Coli
Osteomyeliti s
- Risk Factors
- poorly nourished, elderly or obese
- impaired immune systems
- chronic illnesses
- long term corticosteroid therapy
- Clinical Manifestation
- area appears warm, swollen and extremely painful
- systemic manifestations (fever, chills, tachycardia)
- Diagnostic Studies
- X-ray
- Bone Scan
- Blood and wound culture
Nursing Management
- Promote comfort
- Immobilized affected bone by maintaining splinting.
- Elevate affected leg
- Administer analgesics as needed.
- Control infectious process
- Apply warm, wet soaks 20 min. several times a day.
- Administer antibiotics as prescribed.
- Use aseptic technique when dressing the wound.
- Encourage participation in ADL within the physical limitations of the patient.
Osteoporosis
- reduction of total bone mass
- change in bone structure, which increases susceptibility to fracture
- bone becomes porous, brittle, and fragile
Risk Factors
- Menopause
- aging
- long term corticosteroid therapy
- high caffeine intake
- smoking
- high alcohol intake
- sedentary lifestyle or immobility
- insufficient calcium intake or absorption
- hereditary predisposition
- coexisting medical conditions (hyperparathyroidism, hyperthyroidism)
Osteoporosis
- Clinical Findings
- loss of height
- fractures of the wrist, vertebral column and hip
- lower back pain
- kyphosis
- Respiratory impairment
- Diagnostic Findings
- X-rays
- Dual-energy x-ray absorptiometry (DEXA)
- Serum calcium
- Serum phosphatase
- Urine calcium excretion
Medical Management
- Pharmacologic Therapy
- Hormone replacement therapy
- Alendronate (Fosamax)
- Calcitonin- ↓ plasma levels of Ca, ↑ deposition of Ca in the bone
Nursing Management
- Prevention
- Adequate dietary or supplemental calcium
- Regular weight bearing exercise
- Modification of lifestyle
- Calcium with vitamin D supplements
- Administer HRT, as prescribed
- Relieving pain
- Improving bowel elimination
- Preventing injury
- Nursing Activities
- Encourage use of assistive devices when gait is unstable
- Protect from injury (side rails, walker)
- Encourage active/passive ROM
- Promote pain relief
- Encourage good posture and body mechanics
Bone Tumors
- Osteosarcoma
- Most common primary bone tumor
- Occurs between 10-25 years of age, with Paget's disease and exposure to radiation
- Exhibits a moth-eaten pattern of bone destruction.
- Most common sites: metaphysis of long bones especially the distal femur, proximal tibia and proximal humerus
Osteosarcoma
- Clinical Manifestation
- local signs – pain ( dull, aching and intermittent in nature), swelling, limitation of motion
- palpable mass near the end of a long bone
- systemic symptoms: malaise, anorexia, and weight loss
- Diagnostic Findings
- Biopsy- confirms the diagnosis
- X-ray
- MRI
- Bone Scan
- Increase alkaline phosphatase
Medical Management
- Radiation
- Chemotherapy
- Surgical management
- Prognosis: poor prognosis (rapid growth rate)
Nursing Management
- Promote understanding of the disease process and treatment regimen
- Promote pain relief
- Prevent pathologic fracture
- Assess for potential complications (infection, complications of immobility).
- Encourage exercise as soon as possible (1st or 2nd post-op day)
Total Hip Replacement
- a plastic surgery that involves removal of the head of the femur followed by placement of a prosthetic implant
Nursing Management
- Teach client how to use crutches
- Teach client mechanics of transferring.
- Discuss importance of turning and positioning post-op.
- Place affected leg in an abducted position and straight alignment following surgery
- Prevent hip flexion of more than 90 degrees.
- Apply support stockings
- Advise client to avoid external/internal rotation of affected extremity for 6 months to 1 year after surgery
- Instruct client to avoid excessive bending, heavy lifting, jogging, jumping
- Encourage intake of foods rich in Vitamin C, protein, and iron.
- Administer prescribed medications.
Metallic implant
Complications
- Infection
- Hemorrhage
- Thrombophlebitis
- Pulmonary embolism
- Prosthesis dislocation
- Prosthesis loosening
Dysplasia of the Hip
- condition in which the head of the femur is improperly seated in the acetabulum, or hip socket, of the pelvis.
- Congenital or develop after birth
Assessment
- Neonates: laxity of the ligaments around the hip, allowing the femoral head to be displaced from the acetabulum upon manipulation.
- Implementation:
- Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation (neonatal period)
Pavlik harness
Assessment
- Infants
- Asymmetry of the gluteal and thigh skin folds when the child is placed prone and the legs are extended against the examining table.
- Limited range of motion in the affected hip.
- Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed.
- apparent short femur on the affected side
Congenital Hip Dysplasia
- Implementation
- Traction and/or surgery to release muscles and tendons
- Following surgery, positioning and immobilization in a spica cast until healing is achieved.
Assessment
- The walking child
- minimal to pronounced variation in gait with lurching toward the affected side; positive Trendelenburg sign
- Positive Barlow or Ortolani’s maneuver
Ortolani’s maneuver Barlow maneuver
Scoliosis
- Lateral curvature of the spine
- Surgical and nonsurgical interventions are employed
- The type of treatment depends on the degree of curvature, the age of the child, and the amount of growth that is anticipated.
Assessment
- visible curve fails to straighten when the child bends forward and hangs arms down toward feet.
- asymmetry of hip height
- pelvic obliquity
- inequalities of shoulder height
- scapular prominence
- rib prominence and rib humps
- severe cases, cardiopulmonary and digestive function may be affected because of compression or displacement of internal organs.
Nursing Intervention
- Monitor progression of the curvature
- Prepare the child and parents for the use of a brace if prescribed
- Worn from 23 hours a day
- Inspect the skin for signs of redness or breakdown
- Keep the skin clean and dry, avoiding lotions and powders
- Advise the child to wear soft nonirritating clothing under the brace
- Scoliosis screening: 8 years old*
Nursing Implementation
- Prepare the child and parents for surgery if prescribed.
- Postoperative
- maintain proper alignment; avoid twisting movements
- logroll the child when turning, to maintain alignment
- instruct in activity restrictions
- instruct the child to roll from a side-lying position to a sitting position, and assist with ambulation
Laminectomy
- Surgical incision of part of posterior arch of vertebrae and removal of protruded disc
- Nursing Intervention
- Preoperative
- Postoperative
- Position as ordered
- Lower spinal surgery- flat
- Cervical spine surgery: slight elevation of head of bed
- Proper body alignment- cervical spinal surgery: avoid flexion of neck and apply cervical collar
Laminectomy: Postoperative Care
- Avoid:
- Back- strengthening exercises
- Lie in side- lying with hip flexion
Laminectomy: Postoperative Care
- Patient teaching and Discharge Planning

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Monday, February 16, 2009

Musculoskeletal System Part 2

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