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Nursing Assessment

Nursing Assessment. Physical Assessment. Chief complaints and activity level Health history: medical and surgical Physical signs or symptoms Examination for: Bone integrity Posture Joint function Muscle strength Gait ADL’s. Physical Signs and Symptoms. Deformities Crepitus Scoliosis

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Nursing Assessment

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  1. Nursing Assessment

  2. Physical Assessment • Chief complaints and activity level • Health history: medical and surgical • Physical signs or symptoms • Examination for: • Bone integrity • Posture • Joint function • Muscle strength • Gait • ADL’s

  3. Physical Signs and Symptoms • Deformities • Crepitus • Scoliosis • Kyphosis • Lordosis • Contractures • Dislocations

  4. Common Structural Disorders • Scoliosis • Kyphosis • Lordosis • Cleft Palate • Flatfoot

  5. Scoliosis • S curve

  6. Kyphosis • Forward curve

  7. Lordosis • Forward curve at lumbar spine

  8. Cleft Palate • Congenital defomity • Opening in roof of mouth • Mouth communicates with nasal cavity • Infant difficulty nursing (sucks in air) • Surgical correction

  9. Flatfoot • Tendons and ligaments that support arch of foot are weak • Foot flattens • Caused by excess weight, poor posture, hereditary failure of arch to form • Difficulty or pain walking

  10. Assessing Articular Joints • Deformities • Nodes • Pulses in extremities • ROM • Edema • Fever

  11. Range of Motion • Ability to change position • Muscular strength • Coordination • Size of muscles • Active • Passive

  12. Neurovascular Assessment • Following trauma, surgery, casting, splinting, bandaging: Assess the 7 P’s • Pulselessness • Paresthesias • Paralysis or paresthesias • Polar temperature • Pallor • Puffiness (edema) • Pain

  13. Skeletal Changes in Aging • Loss of calcium salts • Loss of protein in bone • Decreased collagen in bone, tendons and ligaments • Loss of height (0.5 in/20y) • Chest diameter decreases about 1 in and less flexible

  14. MEDICATIONS

  15. Medications • Skeletal muscle relaxants • Antigout medications • Antiarthritic medications • Osteoporosis prevention and treatment

  16. Skeletal Muscle Relaxants • Used to prevent/relieve muscle spasms, treat spasticity associated with spinal cord lesions, painful musculoskeletal disorders • Contraindicated in severe liver, renal, heart disease • Should not be taken with CNS depressants

  17. Skeletal Muscle Relaxants • Act directly on neuromuscular junction • Act directly on muscle OR • Act indirectly on the CNS • Depress neuron activity in the brain or spinal cord

  18. Skeletal Muscle Relaxants • Side effects: • Dizziness/hypotension • Drowsiness • Dry mouth • GI upset • Photosensitivity

  19. Skeletal Muscle Relaxants • Baclofen (Lioresal) • Causes CNS effects • Frequently causes nausea, constipation, retention • Can be given by physician through intrathecal pump

  20. Skeletal Muscle Relaxants • Dantrolene (Dantrium) • Acts directly on skeletal muscles to relieve spasticity • Liver damage most serious adverse effect • Monitor LFT’s • Can cause GI bleeding, impotence, photosensitivity, rash

  21. Skeletal Muscle Relaxants • Cyclobenzaprine (Flexeril) • Contraindicated in clients who have taken MAOI s within 14 days of initiation (can lead to ↑BP, HTN crisis) • Caution in clients with hx urinary retention, glaucoma, or increased intraocular pressure • Short term (2-3 weeks) use

  22. Skeletal Muscle Relaxants • Methocarbamol (Robaxin) • May cause urine to turn brown, black or green • Notify MD if blurred vision, nasal congestion, urticaria occur • Parenteral form can cause hypotension, bradycardia, anaphylaxis, seizures

  23. Skeletal Muscle Relaxants • Chlorzoxazone (Paraflex, Parafon Forte) • Monitor for hypersensitivity reactions • May cause malaise and urine discoloration • Carisoprodol (Soma) • Take with food to prevent GI upset • Report hypersensitivity to MD

  24. Antigout Medications • Decrease inflammation • Reduce uric acid production, increase uric acid secretion • Use cautiously in clients with GI, renal, cardiac or hepatic disease • Allopurinol can increase effect of warfarin and oral hypoglycemic agents

  25. Antigout Medications • Side effects • HA • N/V • Blood dyscrasias • Flushed skin, rash • Uric acid kidney stones • Sore gums • Metallic taste

  26. Nursing Considerations • Monitor serum uric acid levels • Monitor I&O • Monitor CBC and LFT’s • Do not give large doses of Vitamin C with Allopurinol • Avoid foods high in purines; ie wine, alcohol, organ meats, sardines, salmon, gravy • Concurrent ASA; increased uric acid level, gout attack

  27. Antigout Medications • Examples: • Allopurinal (Zyloprim) • Colchicine • Losartan (Cozaar) • Probenecid

  28. Osteoporosis Prevention • Calcium and Vitamin D supplementation • Estrogen replacement therapy after menopause • Calcitonin (Calcimar)

  29. Antiarthritic Medications • (Source: ATI Testing Tutorial) • Types of Drugs • NSAIDS • Tx. Pain and inflammation • Glucocorticoids • Tx. Pain and inflammation • Disease-Modifying Antirheumatic Drugs • Target: Musculoskeletal system

  30. Antiarthritic Medications • Disease-Modifying Antirheumatic Drugs • “DMARD” • ↓ joint inflammation • ↓ joint damage • Initially given with NSAIDS  slow onset of therapeutic effects. NSAIDS may be discontinued when DMARDs begin exerting therapeutic effect

  31. Antiarthritic Medications • DMARD I • Category: Major Non-biologic • Antimetabolite Drug: interferes with normal metabolic process • Protogype Drug: Methotrexate (Rheumatrex • Other: Leflunomide(Arava) • NOTE: DMARDs suppress the immune system (a primary effect)

  32. Antiarthritic Medications • DMARD I (cont.) • Can slow or stop progression of RA • Can tx. Cancer in larger doses • Adverse effect/side effects: • Liver damage • Bone marrow suppression (↓platelets, RBCs, WBCs) • ↑ risk for infection • GI ulceration • Pulmonary Fibrosis

  33. Antiarthritic Medications • DMARD I(cont.) • Methotrexate = Cat. D Pregn. (can damage developing fetus & can pass through breast mild) • Leflunomide = Cat. X pregn.

  34. Antiarthritic Medications • DMARD I(cont.) • Nursing considerations: • Monitor for: ↓ platelets, wbc’s, rbc’s • S/sx. Infection • LFT, Observe for jaundice • GI bleed (Methotrexate) • Respiratory distress, ↓ oxygenation

  35. Antiarthritic Medications • DMARD I(cont.) • Nursing considerations (cont.) • Dosing and Administration: • Methotrexate – 1x / week (po, sq, im) • Weekly folic acid supplement (↓ risk toxicity) • Drink 8-12 8oz. Glasses water/day • Report: jaundice skin/eyes; s/sx infection; ulcerations of mouth, tongue; abdominal bldg, bruising, petechaeie; blood in vomit or stool; dyspnea, SOB

  36. Antiarthritic Medications • DMARD I(cont.) • Nursing considerations (cont.) • Avoid: 1. giving DMARD I drugs during pregnancy and for 6 months after completion of treatment • 2. ingestion of alcohol • Precautions: (while on DMARD I tx.) • ↑ risk for active bacterial or viral infection • Peptic Ulcer Disease • Ulcerative Collitis • Contraindications: (to DMARD tx.) • Liver Insufficiency • Hepatitis • Renal Insufficiency • Women who are pregnant

  37. Osteoarthritis Prevention and Treatment • Biphosphonates • Inhibit osteoclast mediated bone resorption, increases total bone mass • Examples • Etidronate (Didronel) • Alendronate (Fosamax) • Pamidronate (Aredia) • Risedronate (Actonel)

  38. Osteoporosis Prevention • Biphosphonates • Fosamax-taken after rising in AM with full glass water • No eating/drinking for 30 min after taking med, do not lie down for 30 min after taking med

  39. Osteoporosis Prevention • Estrogen receptor modulators (Evista) • Mimic effect of estrogen in bone by reducing bone resorption • Teriparitide (Forteo) • Stimulates new bone formation • Used to treat osteoporosis in men and post menopausal women at high risk for fractures

  40. Laboratory and Diagnostic Examinations

  41. Radiographic Studies • Most common • X-ray • Diagnostic imaging

  42. Laboratory and Diagnostic Examinations • Radiographic studies • Myelogram • Electromyography • Bone scan • Bone mineral density • X-ray • Endoscopic examination • Arthroscopy

  43. Radiographic Studies • Reveals presence of fluid in joint, irregularity of joint, spur formation, and changes in size or contour of the joint • Visualizes fractures, length, tumors, and cavities of bone • Pregnant women should not have an x-ray, unless it is absolutely necessary, to prevent potential damage to the fetus

  44. Radiographic Studies • Laminography/planography or body section roentgenography • Locates small cavities, foreign bodies and lesions that are overshadowed by opaque structures

  45. Radiographic Studies • Scanography • Uses a series of parallel beams that eliminate size distortion when producing a radiograph of internal body organs • Allows accurate measurement of the length of the bone

  46. Myelogram Used to determine the presence of herniated discs or tumors

  47. Myelogram • An x-ray study in which dye is injected into the spinal fluid. (The spinal cord is not visible on a normal x-ray.) • Injection of this dye outlines the spinal cord, and makes it visible on the x-ray.

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