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168 terms

105 Musculoskeletal set 1

Osteoporosis, Osteopenia, Fractures and complications, sprains/strains
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)
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?
What type of bone is lost first in osteoporosis?
Trabecular or cancellous (spongy)
What type of bone is lost after spongy bone?
Type of generalized osteoporosis that results from other medical conditions, such as hyperparathyroidism, long term therapy of corticosteroids, or long term immobility
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
Classification of osteoporosis which involves many structures in the skeleton. 2 Types: Primary and secondary
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)
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
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
-PTH (Forteo- bone rebuilding agent)
-Biophosphates (Actonel, Fosamax, Boniva)
-selective estrogen receptor modulators (Evista)
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
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
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
damage due to excessive muscle use
Tx of sprains
Tx of strains
What type of fracture goes through the skin?
What type of fracture is a greenstick fracture?
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?
-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
-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?
-severe one pain
What are some SYSTEMIC s/s of osteomyelitis?
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?
-uneven pulses
What is the common tx for external compartment syndrome?
removal of source
what is the common tx for internal compartment syndrome?
What is a possible complication of post-traumatic arthritis?
non union of joint
What are some possible serious complications of compartment syndrome?
-loss of limb
What are some NI for a pt who is post closed reduction?
-5 Ps
-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
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?
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
-usually worse in a.m. upon rising
-formation of nodules in pressure joints
-fatigue, malaise
-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?
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?
Nursing interventions for Rheumatoid Arthritis
Rest, 8-10 hours of sleep a night, 2 hour nap
Exercise: Range of motion 2-3 times per day
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?
-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
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
Treatments for osteoarthritis
No known cure
Physical therapy
What are 2 surgeries that may be done for osteoarthritis, if other remedies fail?
This type of arthritis is an inflammatory condition
This type of arthritis is NOT an inflammatory condition
Nursing interventions for total joint replacement
-pain level
-incision/skin care
-neurovascular status of limb
-Resp. status
-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
-low gr. fever
-increased uric acid levels
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
Treatment of gout
Medication that prevents exacerbations of gout
What pt ed. is important when taking colchicine?
daily fluid intake of 3-4L
treats gout- decreases UA excretion
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?
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?
How is Lyme disease treated?
surgeries for rheumatioid arthritis
Removal of synovial membrane- used to treat RA
the surgical fusion (joining together) of two bones to stiffen a joint, such as an ankle, elbow, or shoulder - used in tx of RA
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?
What dietary supplement can be used to help s/s of OA?
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
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?
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
in conjunction with vertebroplasty; helps to contain cement using a balloon
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
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?
tightening of the skin/results in taut, shiny skin, with increased thickness. progressively fatal condition. chronic, multi system autoimmune d/o of unknown origin
What are s/s of scleroderma?
-taut shiny skin
-wt loss
-a.m. stiffness
-renal insufficiency
what does CREST stand for in relation to scleroderma?
Esophageal reflux
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?
-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
what are some possible complications of TJR? (5)
-delayed or nonunion
-aseptic necrosis of femoral head
herniation of intervertebral disc into spinal column, causing pain and nerve compression
herniated disc
What types of surgery are done for herniated discs?
-spinal fusion
in what surgery is the herniated part of a disc removed?
donor bone (commonly from person's hip) into area bt involved vertebra. after healing, fusion immobilizes affected section of the spine.
spinal fusion
What is the primary NI after spinal fusion/laminectomy?
maintain proper spinal alignment at all times until healing has occured
amputation thru a joint
common method of amputation used for infections- wound open for 5-10d, then closed once infection is cleared.
open/guillotined method
method of amputation where bone is severed shorter than skin and flap is sewn over with stitching over top (NOT at pressure point). Goal is to create a residual limb.
Closed amputation
What is the cause of Phantom limb pain?
stimulation along a nerve path in which sensory endings were in the amputated part- more common if pt had pain in the part prior to amputation.
What are some complications of amputation? (8)
-phantom pain
-wound dehiscense
How can contracture risk be minimized?
-avoid prolonged immobilization and prolonged elevation
-chg position frequently
What are some important things to consider when a pt is set for amputation? (4)
-lifestyle (diet, usual activities)
-hx of heart disease
-cultural/religious preferences
-vascular and neuro status
What are some important education points for a pt set for amputation?
5-14d hospital stay
PT/ exercises
support resources
availability of pain meds
phantom pain
psychological prep: ant. grief, stress of loss
What are some postop NI for amputation?
-prevent further loss of circulation
-stump/wound care: elevate 1st 24-48h to prevent contracture/ do NOT remove compression bandage
-encourage use of prosthesi when rising to prevent stump swelling
-if amputation above knee, discourage stump swelling
NI for traumatic amputation
-assess airway and breathing
-proper handling of amputated part
-stop bleeding: tourniquet if necessary
-elevate part above heart
What is the proper handling of an amputated part?
-wrap in clean cloth, keep wet and moist
-place in sealed bag
-place bag inside another bag filled with ice
-if part is only partially amputated, keep it cool
What are NI prior to replantation surgery?
Prepare pts quickly:
-pain meds
-blood cross and type
What NI are necessary after replantation surgery?
-LMWH: 24hx5d
-Heparin: 5000u sq q 4-12h
-promote circulation: heat lamps (intermittent)/heparin soaks/leech therapy/avoid vasoconstriction/elevate, but not above heart
-No caffeine or nicotine for 7-10d after surgery
foods to avoid/limit with gout
Organ meats Asparagus Beef
Beer Mushrooms Pork
Anchovies Oatmeal Trout
Sardines Dried beans Lentils/peas
What are some foods that are low in purines?
Breads Pasta
Grains Carbonated drinks
Rice Coffee
Cereals Milk and milk products
Vegetables Fruits
Tomatoes Cheese
Some green vegetables
Olives Chocolate
Eggs Sugar