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Med Surge Chapter 53

Terms in this set (31)

Med Surge Chapter 53
Exam 5
Care of Patients with Musculoskeletal Problems
Osteoporosis
Decreased Bone Mass from lack of calcium.
Chronic metabolic disease, in which bone loss causes decreased density and possible fracture.
Osteopenia & osteoporosis (low bone mass), occur when osteoclastic (bone resorption) activity is greater than osteoblastic (bone building) activity
Diagnosed by Bone Mineral Density (BMD) or Bone Densitometry; DXA
Often seen in hip, wrist & spine
Classification of Osteoporosis
Generalized primary osteoporosis occurs most commonly in postmenopausal women and men (in their 70s and 80s).
Generalized Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility.
Regional osteoporosis occurs when a limb is immobilized related to a fracture, injury, for paralysis for longer than 8-12 weeks.
Osteoporosis (Cont'd)
Etiology and genetic risk - primary osteoporosis is caused by a combination of risk factors and genetic changes
Cultural considerations - Dark skinned women have increased bone density, but increased lactose intolerance puts them at the same risk as all women
Health Promotion/Illness Prevention
Teaching should begin with young women who begin to lose bone after 30 years of age.
The focus of osteoporosis prevention is to decrease modifiable risk factors.
Ensure adequate calcium intake.(dairy & dark green leafy vegetables)
Sun exposure or adequate dietary Vit. D
Limit carbonated beverages
Health Promotion/Illness Prevention
Avoid sedentary lifestyle- weight bearing exercise. Avoid activities that jar
Limit caffeine-causes loss of calcium in urine
Limit alcohol and tobacco
Walking for 30 minutes three to five times a week is the single most effective exercise for osteoporosis prevention
Can also occur in anorexia or bulimic pts
Decrease potential for falls
Assessment
Physical assessment - inspect and palpate the vertebral column, dowager's hump or kyphosis of the dorsal spine is usually present. Pt will state that they have gotten shorter. May have back pain, which often occurs after lifting, bending, or stooping.
Assessment
Psychosocial assessment -
Laboratory assessment
Imaging assessment:
DXA: dual x-ray absorptiometry
Best tool for dx of osteoporosis.
QCT: Quantitative Computed Tomography
QUS: Qualitative Ultrasound - of the heel
Osteoporosis: Interventions
Nutrition therapy - adequate amounts of protein, magnesium, vit k, calcium, vit D.
Avoid excessive alcohol & caffeine.
Pts who have had fracture: protein, vit c and iron to promote bone healing
Lactose intolerant: soy/rice products fortified with calcium and vit d
Look for Calcium and vit D in fruit juices, bread and cereals.
Osteoporosis: Interventions
Exercise:
walk 30 minutes 3 to 5 times/week is the single most effective exercise for osteoporosis prevention
Other lifestyle changes
Avoid tobacco
Prevent Falls
Promote hazard-free environment: avoid scatter rugs, cluttered rooms & wet floors
Osteoporosis: Drug Therapy
Estrogen or hormone therapy: Primarin
have previously been used as primary prevention strategies for reducing bone loss in the postmenopausal women, but long term use causes a greater risk for cardiovascular disease, breast cancer, and venous thrombeoembolism.
Hormones should not be used only for prevention of osteoporosis.
Osteoporosis: Drug Therapy
Parathyroid Hormone: Forteo
teriparatide (rDNA origin) is a bonebuilding agent approved for treatment of osteoporosis in postmenopausal women with high risk for fracture.
SubQ daily.
SE - dizziness or leg cramping
Osteoporosis: Drug Therapy
Calcium and vitamin D supplements
intake of calcium alone is not a treatment for osteoporosis, but calcium is an important part of a prevention program to promote bone health
take 1/3 at night
Citrical for people with gastric upset
Os-Cal & Os-Cal Ultra (contains Vit. D)
Osteoporosis: Drug Therapy
Bisphosphonates: slow bone resorption by binding with crystal elements in bone
take on empty stomach 30 minutes before a meal with at full glass of water, sit up after taking for 30 minutes
Osteoporosis: Drug Therapy
Fosamax (alendronate) - oral
Boniva (Ibandronate)- oral & IV
Actonel (Risedronate) - oral
Aredia (Pamidronate)- IV- given every 3-6 months
Reclast (Zoledronic acid) -IV-given x1/year.
Selective estrogen receptor modulators: Evista
Calcitonin: (Miacalcin- intranasal)
Other agents used with varying results
Osteoporosis: Surgical Interventions
Vertebroplasty is the injection of bone cement into the vertebral body to reduce a fracture or fill the space created by osteoporosis
Kyphoplasty- use of a balloon in the vertebral body to contain the bone cement
Osteomalacia
Demineralized bone (Loss of bone) related to vitamin D deficiency causes the bone softens because of inadequate deposits of calcium and phosphorus in the bone matrix
Adult equivalent of rickets- Vitamin D deficiency in children
Collaborative Care
Prevention - Increase Vit. D
Assessment - Most important Hx is Dietary intake of Vit. D
S/S - Muscle weakness in shoulder, pelvis, lower extremities, bone pain aggrevated by activity & worse at night
Diagnostic - Looser's Line/zone - stress fractures that have not mineralzed
The major treatment for osteomalacia is vitamin D
Recommended daily allowance: 400 IU.
Eat foods high in Vitamin D
Sun exposure (5 minutes each day)
Paget's Disease of the Bone
Chronic metabolic disorder in which bone is excessively broken down and reformed; bone is structually disorganized
Acquired - genetic predisposition
Genetic considerations - suspected viral respiratory etiology present for several years
If family hx of disease, educate as to need for genetic counseling
Paget's Disease of the Bone
Assessment - usually seen in age 50 and older
Mild to moderate bone pain
Common sites for pain are the hip and pelvis
Pain is aching, poorly described, deep, and worsened by pressure and weight bearing.
Most noticeable at night or when the patient is resting.
Patients may report redness and warmth at affected sites.
Paget's Disease: Nonsurgical Management
Goal is to relieve pain and to decrease bone resorption
Analgesics
Bisphosphonates: Tx of choice
Fosamax, Actonel Aredia, Reclast
To reduce hypocalcemia: Calcium & Vit D
Calcitonin
Plicamycin
Diet therapy
Nonpharmacologic pain-relief measures
Osteomyelitis
bone infections caused by bacteria, viruses, fungi
underlying disease, nonpenetrating trauma
Hematogenous osteomyelitis most common type
Pt complains of bone pain- constant, localized, pulsating sensation that worsens with movement.
Presents with fever
Infected area swells & is tender with movement
Erythema present
Elevated WBC
Osteomyelitis: Collaborative Care
Assessment
Antibiotic therapy
Management of Wound & drainage
Cover the open wound with a dressing and
use clean technique to for dressing changes to prevent further complications.
Hyperbaric oxygen therapy:
Surgical management: Sequestrectomy (to remove necrotic tissue/bone)
Microvascular bone transfers
Disorders of the Hand
Dupuytren's contracture—slowly progressive contracture of the palmar fascia resulting in flexion of the fourth or fifth digit of the hand
Unknown cause
Occurs in men
Can be bilaterally
Ganglion
Round, benign cyst often found on a wrist or foot joint or tendon
Can disappear and reappear
Usually painless on palpation
Occurs around age 15-50
Aspirated or surgically removed
Disorders of the Foot
Hallux valgus - Seen in patients with rheumatoid arthritis
Hammertoe - ususally 2nd toe, joint flexes
Morton's neuroma - a small tumor in a digital nerve of foot
Plantar fasciitis - inflammation of the plantar fasciitis (arch)
Scoliosis
vertebrae rotate and begin to compress, spinal column begins to move into a lateral curve. Changes in muscles and ligaments on the concave side of the spinal column
Three types
Congenital, neuromuscular, and idiopathic
Scoliosis - congenital
occurs during embryonic development
Scoliosis - neuromuscular
results from a neuromuscular condition in childhood ar adulthood, such as cerebral palsy or spinal cord tumors
Scoliosis - idiopathic
is the most common form of scoliosis, and the cause is unknown
Lordosis
a loss of lumbar curvature "flat back"
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