Musculoskeletal Stressors

1. MusculoskeletalStressors NUR240 JBorrero 10/10

2. Arthritis • Degenerative Joint Diseases • Arthritis= joint inflammation. • Arthralgia= joint pain • Different types of arthritis: • Osteoarthritis • Rheumatoid arthritis • Gouty arthritis

3. Osteoarthritis • Most common form of arthritis, noninflammatory, nonsystemic disease • One or many joints undergo degenerative and progressive changes, mainly wt. bearing joints. • Stiffness, tenderness, crepitus and enlargement develop. • Deformity, incomplete dislocation and synovial effusion may eventually occur. • Treatment: rest, heat, ice, anti inflammatory drugs, decrease wt. if indicated, injectable corticosteroids, surgery.

4. Osteoarthritis- Risk Factors • Age • Decreased muscle strength • Obesity • Possible genetic risk • Early in disease process, OA is difficult to dx from RA • Hx of Trauma to joint

5. OA- Signs and Symptoms • Joint pain and stiffness that resolves with rest or inactivity • Pain with joint palpation or ROJM • Crepitus in one or more joints • Enlarged joints • Heberden’s nodes enlarged at distal IP joints • Bouchard’s nodes located at proximal IP joints

6. Assessment: • ESR, Xrays, CT acans • Pain • Degree of functional limitation • Levels of pain/fatigue after activity • Range of motion • Proper function/joint alignment • Home barriers and ability to perform ADLs

7. Osteoarthritis- Tx • Pharmacotherapy- tylenol, NSAIDS, ASA, Cox-2 inhibitors • Intra-articular injections of corticosteroids • Glucosamine- acts as a lubricant and shock absorbing fluid in joint, helps rebuild cartilage • Balance rest with activity • Use bracing or splints • Apply thermal therapies • Arthroplasty- joint replacement can relieve pain and restore loss of function for patients with advanced disease.

8. Auto-Immune Disease • Inflammatory and immune response are normally helpful • BUT these responses can fail to recognize self cells and attack normal body tissues. • Called an auto-immune response • Can severly damage cells, tissues and organs • EG. RA, SLE, Progressive systemic sclerosis, connective tissue disorders and other organ specific disorders

9. Rheumatoid Arthritis • Chronic, systemic, progressive inflammatory disease of the synovial tissue, bilateral, involving numerous joints. • Synovitis-warm, red, swollen joints resulting from accumulation of fluid and inflammatory cells. • Classified as autoimmune process • Exacerbations and remissions • Can cause severe deformities that restrict function

10. RA- Risk Factors • Female gender • Age 20-50 years • Genetic predisposition • Epstein Barr virus • Stress

11. Rheumatoid Arthritis- Dx • Rheumatoid Factor antibody- High titers correlate with severe disease, 80% pts. • Antinuclear Antibody (ANA) Titer- positive titer is associated with RA. • C- reactive protein- 90% pts. • ESR: Elevated, moderate to severe elevation • Arthocentesis- synovial fluid aspirated by needle

12. RA – Signs and Symptoms • Joints- bilateral and symmetric stiffness, tenderness, swelling and temp. changes in joint. • Pain at rest and with movement • Pulses- check peripheral pulses, use doppler if necessary, check capillary refill. • Edema- observe, report and record amt. and location of edema. • ROM, muscle strength, mobility, atrophy • Anorexia, weight loss • Fever- generally low grade

13. RA- Sign and Symptoms 1. Fatigue- unusual fatigue, generalized weakness 2. Morning stiffness lasting longer than 30 minutes after rising, subsides with activity. 3. Red, warm, swollen, painful joints 4. Systemic S&S 5. Pain- at rest and with movement What should we monitor?

14. Rheumatoid Arthritis- Tx • Rest, during day- decrease wt. bearing stress. • ROM- maintain joint function, exercise –water. • Medication- analgesic and anti-inflammatory (NSAIDS), steroids,Gold therapy, topical meds. Immunosuppressive drugs- Imuran, Cytoxan, methotrexate. Monitor for toxic effects • Biological response modifiers (BRM):Inhibit action of tumor necrosis factor (Humira, Enbrel, Remicade) • Ultrasound, diathermy, hot and cold applications • Surgical- Synovectomy, Arthroplasty, Total hip replacement.

16. Nursing Interventions • Assist with/encourage physical activity • Provide a safe environment • Utilize progressive muscle relaxation • Refer to support groups • Emotional support • CAM • Assistive devices • Home care needs

17. Complications • Sjogrens’s syndrome • Joint deformity • Vasculitis • Cervical subluxation

18. Gouty Arthritis • Very painful joint inflammation, swollen and reddened • Primary-Inborn error of uric acid metabolism- increases production and interferes with excretion of uric acid • Secondary- Hyperuricemia caused by another disease • Excess uric acid – converted to sodium urate crystals and precipitate from blood and become deposited in joints- tophi or in kidneys, renal calculi • Treatment: • Meds- colchicine, NSAIDS, Indocin (indomethacin), glucocorticoid drugs, • Allopurinol, Probenecid-reduce uric acid levels • Diet- excludes purine rich foods, such as organ meats, anchovies, sardines, lentils, sweetbreads,red wine • Avoid ASA and diuretics- may precipitate attacks

19. Systemic Lupus Erythematosus • SLE- Chronic Inflammatory disease affecting many systems. • Women between 18-40, black>white, child bearing years • Autoimmune process- antibodies react with DNA, immune complexes form- damage organs and blood vessels. • Includes: vasculitis; renal involvement; lesions of skin and nervous system, photosensitivity, oral ulcers • Initial manifestation- arthritis, butterfly rash, weakness, fatigue, wt. loss • Symptoms and tx. depend on systems involved.

20. Systemic Lupus Erythematosus Pathologic changes-Autoimmune process 1. Vasculitis in arterioles and small arteries 2. Granulomatous growths on heart valves- non bacterial endocarditis. 3. Fibrosis of the spleen, lymph node adenopathy 4. Thickening of the basement membrane of glomerular capillaries. 5. 90% swelling and inflammatory infiltrates of synovial membrane. 6. Renal- Lupus nephritis 7. Pleural effusion or PN 8. Raynaud’s phenomenon- about 15% cases 9. Neuro- psychosis, paresis, migraines, and seizures

21. SLE Dx ANA- hallmark test, + in 98% pts. Medications- NSAIDS Antimalarial meds- hydroxychloroquine (Plaquenil) Immunosuppressive agents- pt teaching corticosteroids, methotrexate, cyclophosphamide Antidepressants Resources: http://www.lupus.org http://www.arthritis.org

22. Systemic Lupus- Education Encourage to avoid undue emotional/ physical stress and to get enough rest • Alternate exercise + planned rest periods. • Teach how to recognize the symptoms of a flare • Teach how to prevent and recognize infection • Avoid sunlight, use sunscreen • Eat a well balanced diet,vitamins and iron. • Establish short term goals • Teach re: meds. • Meds avoid- Pronestyl, Hydralazine.

23. Charting Chuckles • On the second day, the knee was better, and on the third day, it had completely disappeared. • While in the emergency department, she was examined, X-rated, and sent home • The patient will need disposition, and therefore, we will get Dr. Blank to dispose of him. • Patient was admitted through the emergency department. I examined her on the floor.

24. Indications for Total Hip Replacement. . . • Traumatic Arthritis • Decrease range of motion • Deformity of the hip joint • Chronic and Progressive pain • Decreased ability to perform ADL’s. • Rheumatoid Arthritis • Osteonecrosis

25. Pre-op Assessment • Assess medication history. • Assess Respiratory, neurovascular, nutritional and integumentary status. • Presence of other diseases- COPD, CAD, Hx. Of DVT or pulmonary embolism. • Discuss surgical procedure, informed consent. • Prepare for autologous blood donation.

26. Pre-op teaching • Presence of drains and hemovac postoperatively. • Pain management (epidural/PCA). • Coughing and deep breathing. • Use of incentive spirometer • ROM exercises to unaffected extremities. • Post-op restrictions: Need to avoid bending beyond 90 degrees Importance of leg abduction post-op.

28. Post-op Management of THR • Assess neurovascular status of involved extremity. • Incision site, wound drains, hemovac. • Note excessive bleeding or drainage • Respiratory status- elderly population. • Position of affected joint and extremity • Mental alertness • Assess Hgb and Hct • Pain management

29. Total hip replacement-Complications • Dislocation of hip prosthesis • Thromboembolism • Infection • Avascular necrosis • Loosening of the prosthesis

30. Dislocation of prosthesis • Increased pain, swelling • Acute groin pain • Shortening of the leg • Abnormal internal or external rotation • Restricted ability or inability to move leg • Reported popping sensation in hip.

31. Impaired physical mobility r/t joint replacement and pain • Maintain bed rest with affected joint abducted with wedge pillow. • Perform passive and teach active ROM to unaffected joints, quad, isometric, gluteal exercises. • Ambulate with assistance, WB restrictions • Turn pt. as ordered, monitor skin for breakdown

32. Altered Tissue perfusion r/t reduced flow and immobilization • Administer parenteral fluids with electrolytes to increase tissue perfusion. • Monitor VS q4h and prn, I and O. • Assess NV status q1h for first 12 hrs., then q4h. Color, temp., pulse, sensation. • Ambulation and exercises • Monitor CBC, electrolytes, PT/INR • Administer anticoagulants - phlebitis

33. Pain r/t surgical intervention and impaired mobility • Assess location, intensity, quality pain. • Administer analgesics, sedatives, anti-inflammatories, assess effectiveness, • Monitor PCA or continuous epidural • Change position frequently, back rubs. • Provide diversional activities- reduce attention on pain. • Monitor - severe chest, affected joint pain.

34. Knowlwdge deficit R/T… • Stress importance of rehab program and exercises, no flexion greater than 90 degrees. • Discuss and demonstrate incision care • Medication teaching- especially anticoagulants, instruct pt to be checked, observe for bleeding, etc. • High protein, high fiber and increased fluid to prevent constipation. • Pain Management

35. Discharge/home care • Safety: stairs with hand rails, no scatter rugs, grab bars tub and toilet, good light. • Height of bed and chair for easy transfer. • Elevated toilet seat, fracture pan, urinal • Ability to care for wound, correct supplies and hand washing technique. • Correct transfer techniques, ability to follow rehab plan and exercises.

36. Arthroscopy • Pre-op: lab work- Hgb, Hct, Pt/PTT, urine, PT,exercises • History of underlying problem, meds. • Post-op- N/V assessment, pulses distal to Joint. • Teach: ROM to unaffected extremities, limitations post-op, crutch walking prn, pain management, reinforce explanation of procedure.

37. Total Knee Replacement • Indications:Osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, bleeding into joint. • Post-op compression bandage and ice. • Assess N/V status of leg, active flexion q1h. While awake, CPM machine. • Wound suction drain • OOB within24 hrs., knee immobilizer and elevated while sitting.

38. Think Like A Nurse A young male client complains of severe left knee pain following a ski trip last weekend. The orthopedic surgeon suspects damage to the meniscus and schedules the client for an arthroscopy. 1.As his office nurse, what health teaching will you need to provide to prepare the client for this procedure? 2.What immediate post-test care will the client require? 3.What discharge instructions will the postanesthesia care unit (PACU) nurse need to review?

39. Care of the patient undergoing an amputation • Pre-op monitor N/V status both extremities • Observe for ulceration, edema, necrosis. • Baseline VS and lab data, doppler studies, angiography, ECG, chest x-ray. • Time for verbalization fears, anxieties. • Teach re; overhead trapeze, C and DB, incentive spirometer. http://www.diabetesresource.com/

40. S/P amputation • Stump dressing, amt. and color of drainage, hemovac drain. • Respiratory status and VS. • Presence of phantom limb pain. • Monitor for complications; infection, hemorrhage, phantom pain, contractures, scar formation, abduction deformity. • PT, diet, rest, activity, wound care • Pain management • Immobility complications

41. Body image disturbance r/t loss body part • Allow time for pt. to grieve, assess need for counseling. • Encourage pt. to discuss and view stump • Assist in identifying positive coping strategies, praise strengths observed. • Provide a supportive environment. • Demonstrate positive regard for pt. and acceptance of personal appearance. • Assess religious beliefs re: care of amputated limb • Verbalize feelings re: change in role, job, family, sexual perosn

42. Discharge/ Home care planning Environmental/safety status: • Hand rails- tub toilet, stairs, no scatter rugs. • Wide doorway to accommodate wheelchair, walker, Ht. of bed, chair ok. • Ability to care for wound and has correct supplies. • Ability and desire to follow prescribed rehab plan and exercises. • Prosthesis fitting with orthotist

44. NCLEX Time The laboratory test that the nurse should expect in a diagnosis of RA: • 1. Pancreatic lipase • 2. Antinuclear antibody • 3. Bence Jones protein • 4. Alkaline phosphotase

45. NCLEX Time After Elsie's amputation, the nurse visits her. When Elsie responds with melancholy to the nurse's questions, the nurse recognizes her impending depression over her procedure. Which response by the nurse is most appropriate? A."Why do you feel so depressed?“ B."I know someone who had an amputation too.“ C."You should adjust to it in no time at all.“ D."How do you feel about your loss?"

46. NCLEX TIME Of the following clients, which should the RN assess first? A.The client who was in a motor vehicle accident 4 days earlier who is complaining of a bump over the rib and pain with palpation B.A client receiving morphine via patient-controlled analgesia for osteosarcoma who is complaining of nausea and vomiting C.The client with osteoarthritis and compression fractures of the lumbar spine who is complaining of lack of urge to void D.A client admitted for surgical intervention to treat carpal tunnel syndrome who is requesting pain medication

47. Osteoporosis • Primary or Secondary • Metabolic bone disorder- progressively porous, brittle, fragile bones, low bone density, susceptible to fractures • Occurs in postmenopausal women • Bone resorption (osteoclast) > bone formation (osteoblast) activity • Dowager’s hump – progressive kyphosis – gradual collapse of vertebrae. • Post menopausal lose height, c/o fatigue. • Osteopenia, precursor to osteoporosis • Dx tests: Radiographs, Dexa scans

48. Osteoporosis- Risk Factors • Gerontologic- over 80 yrs. old, 84% have osteoporosis. • Family hx, thin, lean body build • Postmenopausal estrogen deficiency • Hyperparathyroidism – increases bone resorption • Hx of low Ca intake and low levels of Vit D • Long tem corticosteroid use • Lack of physical activity/ prolonged immobility • Hx of smoking, high alcohol intake

49. Osteoporosis Diagnosis: Physical assessment: Psychosocial assessment:

50. Pt. teaching- osteoporosis • Adequate dietary calcium- 1200mg/day with fluids • Exercise, wt. bearing beneficial. • Walking outdoors- vitamin D absorption. • Good body mechanics • Safe home environment, fall prevention • Balanced diet- protein, Mg, Vit K & D, Ca • Modify lifestyle choices- smoking, alcohol and caffeine intake and sedentary lifestyle.