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Osteoporosis, Osteopenia, Fractures and complications, sprains/strains

arthroscopy

diagnostic test- figeroptic tube inserted into a joint for direct visualization of ligaments, menisci, and articular surfaces of the joint.

What 2 patients cannot have knee athroscopy?

-pt with infection of knee
-pt who cannot flex knee at 40 degrees

What is the priority NI after athroscopy?

Neurovascular status of affected limb (pulses,warmth, color, temperature, etc)

Osteoporosis

Chronic metabolic disease in which bone loss causes decreased density and possible fracture.

Why is osteoporosis called a "silent disease"?

symptoms often only appear after a fracture.

What 2 bone diseases occur when osteocalstic (bone resorption) activity is greater than osteoblastic (bone building) activity?

Osteoporosis and osteopenia

What hormone does not rebuild bone, but helps decrease bone loss?

Estrogen

What type of bone is lost first in osteoporosis?

Trabecular or cancellous (spongy)

What type of bone is lost after spongy bone?

Cortical/compact

Type of generalized osteoporosis that results from other medical conditions, such as hyperparathyroidism, long term therapy of corticosteroids, or long term immobility

Secondary

Type of generalized osteoporosis that commonly affects women in the 7th or 8th decade of life, or women after menopause, due to decreased estrogen production

Primary

Classification of osteoporosis which involves many structures in the skeleton. 2 Types: Primary and secondary

Generalized

Type of osteoporosis that occurs when a limb is immobilized related to a fracture, injury, or paralysis. (this is also a type of secondary osteoporosis)

Localized

What is the focus of NI to prevent osteoporosis?

Education about modifiable risk factors

What are modifiable risk factors in prevention of osteoporosis?

-dietary Ca: milk, dark and leafy greens
-Vitamin D: sun, intake
-exercise: especially weight-bearing

S/S of osteoporosis (3)

- "dowagers hump"
-pt c/o of becoming shorter
-back pain, worse with activity and relieved by rest

What may indicate a compression vertebral fracture?

back pain accompanied by tenderness and voluntary restriction of spinal movement suggests what?

what is the most common type of osteoporotic fracture?

compression vertebral fracture - most often occurring between T8 and L3

Where are 2 other common places where fractures may occur due to osteoporosis?

-distal radius
-upper third of femur/hip

DX of osteoporosis: Imaging that can detect decreased bone density, but only after a 25-40% bone loss. Can also detect fractures

XRay

What is the most commonly used and best imaging tool for assessing BMD?

dual x-ray absorptiometry (DXA)

What are some nonpharmological NI for the pt with osteoporosis?

-educate about intake of minerals needed for bone formation
-encourage exercise
-avoid high-impact recreational activities
-d/c tobacco use
-fall precautions, both in hospital and at home

What are some pharmological NI for the pt with osteoporosis?

-Calcium and vit. D supplements
-HRT
-PTH (Forteo- bone rebuilding agent)
-Biophosphates (Actonel, Fosamax, Boniva)
-selective estrogen receptor modulators (Evista)
-calcitonin

What are some NI for Biophosphates?

-Take early in morning with 8 oz of water
-Remain upright for 30 minutes after
-Report any difficulty swallowing, esophagitis or gastric ulcers asap

What is the function of biophosphates?

prevent bone loss and increase density

What patients should NOT receive Ca supplements?

-Pt with a hx of stones

What patients should NOT receive HRT?

-hx of tumors, hypertension, thromboembolytic disease, liver or gall bladder disease

Why should HRT patients be observed for vaginal bleeding?

Vaginal bleeding is a se of HRT, but may also be a symptom of endometrial cancer.

What are 2 surgical interventions that may be used for vertebral body compression and fractures caused by osteoporosis?

vertebroplasty and kyphoplasty

Loss of bone related to Vitamin D deficiency causing softening of the bone caused by inadequate deposits of calcium and phosphorus

Osteomalacia

How does osteomalacia differ from osteoporosis?

-vit D deficiency / CA deficiency
-pseudofractures, loosers zones, fractures/ osteopenia, fractures

What are some causes of osteomalacia?

-anything that inhibits vit. D
-kidney disease
-familial metabolic error (hypophosphatemia)

Any disease or condition involving the musculoskeletal system

rheumatic disease

Chronic, progressive, systemic disease process that affects primarily the synovial joints. Most common connective tissue disease, most destructive to the joints

Rheumatoid arthritis

systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation

gout

most common type of gout- results from one of several inborn errors of purine metabolism. End product of purine is uric acid, usually excreted by kidneys. Production of uric acid exceeds excretion capability of kidneys and inflammation develops. (underexcretion)

primary gout

type of gout resulting from excess uric acid in the blood (overproduction). May be seen with renal insufficiency, diuretics, crash diets, chemotherapic agents

secondary gout

traumatic injury to tendons, ligaments,and muscles around a joint

sprain

damage due to excessive muscle use

strain

Tx of sprains

RICE

Tx of strains

Heat
Rest

What type of fracture goes through the skin?

compound

What type of fracture is a greenstick fracture?

incomplete

Bone does not break thru skin in what type of fracture?

simple closed

What is stage 1 of the fracture healing process?

Hematoma formation - at 48-72h

What is stage 2 of the fracture healing process?

Fibrocartilage formation: clot doesn't reabsorb and granulation tissue forms a "collar" around edges of break, eventually forming a bridge. (3d-2w)

What is stage 3 of fracture healing process?

Callus formation: result of vascular and cellular proliferation. beginning of a non bony union (2-6w).

What happens in stage 4 of fracture healing process?

Callous is reabsorbed and transformed into bone/Ossification: 3w-6m after break, permanent bone callus forms (aka "woven bone"). Bone ends knit together.

What happens in stage 5 of fracture healing process?

Consolidation and remodeling: gap closes between broken ends. Immature bone cells replaced by mature. (6w-1y)

What are some signs and symptoms of a fracture?

-Pain
-deformity
-crepitus
-edema
-ecchymosis
-visible bone

What are 3 key things to remember if treating a fracture away from clinical setting?

-Splint it where it lies
-Immobilize joints above and below
-Maintain normal body alignment as much as possible

What are emergency nursing interventions for a fracture in the clinical setting?

-Assess: pulse, temp, color, tingling, numbness, vitals
-Pain meds (only after head injury ruled out)
-Xray or CT prep
-If open fracture, Tetanus status and administration

What are some possible complications of fracture?

-hypovolemic shock
-fat embolism
-avascular necrosis
-joint stiffness and contractures
-Malunion/Delayed union/Nonunion
-DVT
-infection: osteomyelitis
-compartment syndrome
-post traumatic arthritis

What are some s/s that a fracture pt may be experiencing a fat embolism?

Respiratory distress: sob
Altered mental status
Increased HR and Resp
Petichiae over arms, neck, chest, abdomen

What are 2 methods of preventing contracture?

-positiong and exercise

What are some LOCAL s/s of osteomyelitis?

-drainage
-severe one pain
-swelling

What are some SYSTEMIC s/s of osteomyelitis?

-fever
-chills
-NV

What is the typical tx for osteomyelitis?

Agressive ABX: IV for 4-6w, then oral for 4-6 wk

Internal or external pressure on an affected site, caused by trapped fluid/blood

Compartment syndrome

How long after the beginning of s/s of compartment syndrome can permanent damage occur?

4-6 hours

What are some s/s of compartment syndrome?

-numbness
-parasthesias
-edema
-pallor
-uneven pulses

What is the common tx for external compartment syndrome?

removal of source

what is the common tx for internal compartment syndrome?

surgery/fasciotomy

What is a possible complication of post-traumatic arthritis?

non union of joint

What are some possible serious complications of compartment syndrome?

-paralysis
-loss of limb

What are some NI for a pt who is post closed reduction?

-elevate
-5 Ps
-Ice
-remove rough cast edges
-pain mgmt
-observe for s/s infection, such as odor

What are some NI for a pt who is in skeletal traction?

-ropes unobstructed
-weights freee
-s/s of infection at pin sites
-body alignment

What are some NI for pt in skin traction?

-back care/skin integrity
-90 degrees if using trapeze
-alignment
-comfort

skin traction

This type of traction is a nonsurgical method of providing necessary pull for shorter periods. This is frequently used to temporarily immobilize a part or stabilize a fracture. Applied by using elastic bandages or adhesive. Types: Cervical, Buck's (extension), Russell's & Pelvic

skeletal traction

surgical insertion of pins or wires thru the bones is continuous and is used most frequently for fractures of the femur, tibia and cervical spine-aid in realignment- Crutchfield tong, Halo vest, 90-90.

What are some NI/pt education for casts/splints/immobilizers?

-call MD if cast/immobilizer breaks
-Isometric exercises
-Clean with damp cloth and dry cleanser
-don't insert objects (for itching, etc)
-plenty of fluids
-increase protein, FE, minerals, vitamins in diet

What are some NI/Pt education points for a pt with hip surgery?

-Positioning: Abduction, wedge
-Don't flex hips more than 90: elevated toilet seats, straight back chair
-avoid crossing legs and ankles, no pillows under legs or large pillows behind head (this is for DVT prevention as well as protection of repaired joint)

What is a common complication of hip surgery?

DVT

Inflammation of tissues- joint tisues, such as cartilage, tendons, ligaments, bone. Even organ damage if severe.

Rheumatoid arthritis

What are some s/s of RA?

-painful, swollen, stiff joints
-symmetrical
-usually worse in a.m. upon rising
-formation of nodules in pressure joints
-fatigue, malaise
-fever
-wt loss/ dec. appetite

What are some SE & NI of 1st generation NSAIDs?

GI upset/GI bleed
Take with food

What are some examples of 1st generation NSAIDs?

aspirin, ibuprofen

What is an example of 2nd generation NSAIDs?

celebrex

What are some NI for 2nd generation NSAIDs?

Assess for sulfa, aspirin allergy
Assess for pain prior to, during, and after admin.

What are 2nd gen. NSAIDs also known as?

Cox 2 inhibitors

What is the difference in 1st gen and 2nd gen NSAID SE?

2nd generation less likely to cause GI problems

What is the peak onset age of RA?

30-60

Nursing interventions for Rheumatoid Arthritis

Medications
Rest, 8-10 hours of sleep a night, 2 hour nap
Exercise: Range of motion 2-3 times per day
Heat
Rehabilitation/ PT

Uses special xray to determine how many gms of CA and other minerals are present in a segment of bone

Bone density test

What are some NI for the BRI Fosamax?

-take 1st thing in a.m. with plain water
-take before any other meds/beverages/coffee
-remain upright for 30 minutes after taking

What are some risk factors for osteoarthritis?

-obesity
-occupational stress
-poor posture

"wear and tear" disease- wear of articular cartilage, causing bones to rub together. causes complications such as bone spurs, pain, etc

osteoarthritis

What are some pt education points for osteoarthritis?

-isometric exercise
-take pain meds routinely, NOT prn
-adequate rest
-wt loss if needed
-affected joint in functional position

What are some s/s of osteoarthritis

-usually none at first
-joint enlargement
-joint pain, relieved by rest. will progress to rest pain.
-limited ROM

How is osteoarthritis diagnosed?

Osteoarthritis is diagnosed by viewing progressive changes on the xray such as narrowing of the joint space, presence of osteophytes (bone cysts), and subluxation and deformity of the joint.

osteoarthritis medications

-NSAIDs
-Steroids

Treatments for osteoarthritis

No known cure
Physical therapy
Surgery

What are 2 surgeries that may be done for osteoarthritis, if other remedies fail?

-TJR
-osteotomy

This type of arthritis is an inflammatory condition

RA

This type of arthritis is NOT an inflammatory condition

Osteoarthritis

Nursing interventions for total joint replacement

-pain level
-positioning
-incision/skin care
-neurovascular status of limb
-Resp. status
-vitals
-Ambulation
-I&O
-Assess capability of completing ADLs, and need for home assistance

signs and symptoms of gout

-intense pain on joints: commonly affects joints of the big toe
-swelling
-tophi
-low gr. fever
-increased uric acid levels
-HA

what are some high purine foods that should be limited/avoided with gout?

aged cheese, organ meats, shellfish, lentils, asparagus, spinach, beef, chicken and pork, beer/wine/alcohol

What dietary elements should be increased with gout?

-fluid intake
-dairy
-citrus

Treatment of gout

BED REST, elevation, IMMOBILIZE JOINTS, HEAT AND COLD, COLCHICINE, ANALGESICS

Medication that prevents exacerbations of gout

Colchicine

What pt ed. is important when taking colchicine?

daily fluid intake of 3-4L

Prodericid

treats gout- decreases UA excretion

Allopurinol

treats gout- decreases UA production

What pt education should be given to pts using Prodericid or Allopurinol

-Avoid cranberries/limit vit. C
-rash is common
-take with food
-2.5-3L fluids/day
-Avoid caffeine and alcohol

Gout stage 4

4) Tophaceous gout (late complication of urate deposits - tophi)

Gout stage 2

2) Acute gouty arthritis (abrupt onset) - pain of 1 or more small joints (Often the big toe)

Gout stage 1

1) Increase UA production, but usually no sx until attack occurs

Stage 3 gout

3), Chronic Gouty Arthritis - progressive urate crystals into synovial linings = synovial proliferation and pannus formation = destrxn of cartilage and erosion of bone

What is osteomalacia called in children?

Ricketts

What are common s/s of osteomalacia?

bone pain (esp with bearing wt)
bone deformity
low back pain
progressive muscular weakness
wt loss

Lyme disease

an infection caused by a bacteria carried by deer ticks and transmitted to humans by the bite of an infected tick; symptoms vary but may include abullseye rash at the site of the bite and flulike symptoms such as fever, headache, joint pain, and fatigue

How is Lyme disease diagnosed?

serology using ELISA followed by western blot

What is the primary cause of osteomalacia?

Vitamin D deficiency

What vitamin D rich foods should be increased in the diet to treat osteomalacia?

Chicken
Dairy
Swordfish
Breads

How is Lyme disease treated?

Penicillins
Chloramphenicol

surgeries for rheumatioid arthritis

-synovectomy
-athroplasty
-arthrodesis

synovectomy

Removal of synovial membrane- used to treat RA

Arthrodesis

the surgical fusion (joining together) of two bones to stiffen a joint, such as an ankle, elbow, or shoulder - used in tx of RA

Athroplasty

a surgical procedure used to remove affected joints, replacing them w/ artificial joints. (improves mobility, releives pain, improves joint function)

what is the biggest risk factor for OA?

age

What dietary supplement can be used to help s/s of OA?

glucosamine

prior to a hip athroplasty, what drugs may be started/stopped?

-NSAIDs/ HRTs or any drugs that may increase clotting may be stopped 1 wk prior to surgery.
-LMWH may be started before or after surgery to help prevent VTE/DVT

What position should a pt be placed in after returning from hip surgery?

supine with head slightly elevated/leg abducted

What are some other NI for a pt who is post athroscopy? (5 listed)

-encourage to perform exercises taught before procedure
-analgesics for pain relief, such as Tylenol (opioid analgesic such as percocet if surgery performed)
-Ice for 1st 12h
-elevation for 12-24h
-short-term activity restrictions if surgery

What resource may pt need to use prior to athroscopy, if there is to be a surgery?

PT- pt should be taught exercises prior that can be done after procedure, such as SLR and quadriceps setting (isometrics)

What serious problem has been linked to biophosphates?

esophagitis- be sure to take with water and remain upright for 30 min to prevent this. If chest discomfort occurs, d/c and contact dr.

Who should NOT take biophosphates? (3 listed)

-poor renal fx
-hypocalcemeia
-GERD

What are 2 recent additions to biophosphates, given IV, that may be used if oral bps not effective?

-Reclast (q 12m)
-Aredia (q 3-6m)

What is one important thing a pt should be taught to do before beginning bp therapy?

-have a complete oral exam and preventitive dentistry- because bps have been linked with osteonecrosis of the jawbone. Also, pt should inform dentist of bp therapy before any dental procedure.

What is currently the only SERM approved for the prevention and tx of osteoporosis?

Evista

What thyroid hormone inhibits osteoclactic activity, and is used for tx of osteoporosis, pagets, and hypercalcemia r/t cancer? Also can be used as an analgesic after vertebral fracture.

Calcitonin- given sub q or intranasal

procedure for tx of vertebral body compression fracture- injection of bone cement into vertebral body to fill fracture or fill a space created by osteoporosis

vertebroplasty

in conjunction with vertebroplasty; helps to contain cement using a balloon

kyphoplasty

What is the classic means of diagnosing osteomalacia

Looser's lines: radiolucent bands that represent stress fractures that have not mineralized.Often appear symmetrically in the medial areal of femoral neck, ribs, and pelvis. May progress to complete fractures with minimal trauma.

What should be monitored for early signs of ACS?

-6 P's

What is the earliest manifestation of fat embolism syndrome after a fracture?

Altered mental status due to decreased arterial 02- assess for altered LOC and drowsiness

Aside from altered mental status, what other s/s suggest FES?

-respiratory distress
-tachycardia, tachypnea
-fever
-hemoptysis
-petichiae

complication of fractures, esp hip fractures, in which blood supply to the bone is disrupted, leading to death of bone tissue

avascular necrosis

In an emergency situation, away from a clinical setting what is the first thing that should be assessed?

ABC

tightening of the skin/results in taut, shiny skin, with increased thickness. progressively fatal condition. chronic, multi system autoimmune d/o of unknown origin

Scleroderma

What are s/s of scleroderma?

-taut shiny skin
-reflux
-raynaulds
-wt loss
-a.m. stiffness
-pericarditis
-renal insufficiency
-dysphagia

what does CREST stand for in relation to scleroderma?

Calcinosis
Raynaulds
Esophageal reflux
Sclerodactyly
telangiectasis

What are NI for scleroderma?

-PT consult
-Meds as ordered
-eliminate causes of vasospasm (stress, smoking, extreme temperatures)

What are s/s of bursitis?

-extreme pain, esp. hip and shoulder
-limited ROM in affected joint

What is the tx for bursitis?

-NSAIDs
-Splinting
-Cold for 1st 24h, then heat
-Lidocaine/steriod injections

What are some postop care factors for TJR? (8 listed)

-ensure adequate tissue perfusion (CR, pulses)
-treat pain
-encourage ventilation: cough, deep, breathe
-turn q 2 hrs to unoperative side
-prevent complications
-encourage self care/ambulation/exercise when ok
-prevent adduction
-I&O
-diversion

what are some possible complications of TJR? (5)

-shock/hemorrhage
-immobility
-delayed or nonunion
-aseptic necrosis of femoral head
-deformities

herniation of intervertebral disc into spinal column, causing pain and nerve compression

herniated disc

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