Nursing of Adult Patients with Medical & Surgical Conditions

1. Nursing of Adult PatientswithMedical & Surgical Conditions Musculoskeletal Disorders

2. Assessment • Scoliosis • Lateral curvature of the spine

3. Assessment • Kyphosis • A rounding of the thoracic spine • Hump-backed appearance

4. Assessment • Loradosis • An increase in the curve at the lumbar region

5. Assessment • Blanching Test • Capillary nail refill • Signals circulation status • Compress each fingernail or toenail, release the pressure, and note how quickly the pink color returns to the nail bed. • Should return to normal color within 2 seconds

6. Diagnostic Tests • Myelogram • Injection of a radiopaque dye into the subarachnoid space at the lumbar spine to determine the presence of herniated disk or tumors. • Assess for allergies to iodine and seafood • Oil-based dye • Removed to prevent meningeal irritation • Flat for 12 hours (keeps air space in lower spine) • Water-soluble dye • Not removed; absorbed by body • Semi-fowler’s position for 8 hours (keeps dye in lower spine) • Encourage fluids to assist with absorption of dye

7. Diagnostic Tests • Nuclear Scanning • Given a low dosage of radioactive isotopes • Scanner or camera detector is used to record images • Nursing Measures • Written consent • Informing the patient about radioacive isotopes; will not affect others • Follow instrucitions by nuclear medicine dept.

8. Diagnostic Tests • Magnetic Resonance Imaging • Involves the use of magnetism and radio waves to make images of cross sections of the body • Gives detailed picture of fluid filled soft tissue and blood vessels • Patient must remove any metal objects • patients with metal prosthesis (heart valves, othopedic screws) cannot undergo and MRI • Sedatives may be given for anxiety due to claustrophobia

9. Diagnostic Tests • Computer Axial Tomography (CAT scan) • 3-D picture of the structure (Soft tissue & bones) • More sensitive than standard x-rays • Iodine contrast may be used • Nursing Measures • Written consent • Ask about allergies to iodine and seafood • NPO 3-4 hours before test • Baseline vital signs • Remove jewelry, etc. • Teach pt. about procedure

10. Computer Axial Tomography (CAT scan)

11. Diagnostic Tests • Bone Scan • Detects metastatic and inflammatory bone disease • Radioisotopes administered IV 2-3 hours before test • Encourage fluids • A scanning camera is used to reveal the degree of uptake • Areas of uptake may indicate a tumor or other abnormality

12. Diagnostic Tests • Arthroscopy • Direct visualization of a joint • exploration of joint • drainage of fluid from the joint • removal of damaged tissue or foreign bodies • Involves insertion of a large-bore needle into the suprapatellar pouch. • Patient may be given a general or local anesthetic • Activities may be limited for several days

13. Diagnostic Tests • Synovial Fluid Aspiration • The puncture of a joint with a needle and the withdrawal of synovial fluid • Used for diagnosis of trauma, systemic lupus, gout, osteoarthritis, and rheumatoid arthritis • Normally straw colored, clear, or slightly cloudy • After procedure • support extremity • joint rest for 12 hours • ice to joint for 24 - 48 hours • assess for s/s of infection

14. Diagnostic Tests • Electromyogram (EMG) • Insertion of needle electrodes into the skeletal muscles to record the electrical activity • Muscles do not produce electrical charge at rest • Unusual patterns may be observed for neuropathy and myopathy

15. Rheumatoid Arthritis • Etiology/Pathophysiology • Most serious form of arthritis • Chronic, systemic disease • Most common in women of childbearing age • Autoimmune disorder, but may also be genetic • Agents that should protect the body attack joint tissues • Can affect lungs, heart, blood vessels, muscles, eyes and skin • Chronic inflammation of the synovial membrane of the diarthrodial joints (movable)

16. Rheumatoid Arthritis • Signs & Symptoms • Characterized by periods of remission and exacerbation • Malaise • Muscle weakness • Loss of appetite • Generalized aching • Edema & tenderness of joints • Limited range of motion (morning stiffness)

17. Rheumatoid Arthritis

18. Rheumatoid Arthritis • Diagnostic Tests • Radiography studies show loss of articular cartilage and change in bone structure • Laboratory Tests • Erythrocyte Sedimentation Rate (ESR) • increase indicates inflammation • Rheumatoid Factor (RF) • elevation indicates abnormal serum protein concentration • Latex agglutination test • detects presence of IgM version of rheumatoid factor (anti-IgG antibodies) • Synovial fluid aspiration • fluid is cloudy, yellow, less viscous and increased protein

19. Rheumatoid Arthritis • Treatment • Medications • Salicylates (Aspirin) • Nonsteroidal Anitinflammatory Drugs (NSAID’s) • indomethacin (Indocin) • ibuprofen (Motrin) • naproxen (Naprosyn) • piroxicam (Feldene) • nabumetone (Relafen) • Potent Antiinflammatory Agents • adrenocorticosteroids (prdnisone) • phenylbutazone (Butazolidin) • Slow-Acting Antiinflammatory Agents (6-12 mo.) • hydroxychloroquine (Plaquenil)

20. Rheumatoid Arthritis • Rest • 8-10 hours of sleep a night; 2 hour nap during day • Exercise • Range of motion 2-3 times per day • prevents joints from “freezing” and muscles from weakening • Heat • Hot packs, heat lamp, and/or hot paraffin • Relaxes and soothes muscles • Rehabilitation • Help pt. to adapt to physical limitaions and promoting normal daily activities

21. Rheumatoid Arthritis • Prognosis • Remissions and exacerbations are common • Disease normally progresses to include joint deformity, extensive muscle atrophy, soft tissue lesions, bone and cartilage destruction, and fibrous or bony ankylosis (fixed joints)

22. Ankylosing Spondylitis • Etiology/Pathophysiology • Chronic, progressive disorder of the sacroiliac and hip joints, the synovial joints of the spine, and the adjacent soft tissues. • Most common in young men • Strong hereditary tendency

23. Ankylosing Spondylitis • Signs & Symptoms • Low back pain and stiffness • “sciatica pain” lasts for a few days then subsides • worse when standing • May also affect joints in the neck, jaw, shoulders, knees, and hips • Decreased ROM • Elevated temperature • Tachycardia • Hyperpnea

24. Ankylosing Spondylitis

25. Ankylosing Spondylitis • Diagnostic Tests • Hemoglobin and Hematocrit • Low due to anemia • ESR • elevated due to inflammation • Serum alkaline phosphatase • elevated due to immobilization • Radiographic • reveals sacroiliac joint and intervertebral disk inflammation with bony erosion and joint space fusion

26. Ankylosing Spondylitis • Treatment • Analgesics • NSAID’s • Exercise program • swimming and walking • Surgery • replace fused joints • Maintain spine alignment • firm mattress • bed board • back brace • Breathing exercises • Turn and position every 2 hours

27. Ankylosing Spondylitis • Prognosis • Chronic disease • Lasts about 20 years leaving permanent damage

28. Degenerative Joint Disease (Osteoarthritis) • Etiology/Pathophysiology • Nonsystemic, noninflammatory disorder that progressively causes bones and joints to degenerate • Primary • Cause is unknown • Secondary • Caused by trauma, infections, previous fractures, rheumatoid arthritis, stress on weight-bearing joints.

29. Degenerative Joint Disease (Osteoarthritis)

30. Degenerative Joint Disease (Osteoarthritis) • Signs & Symptoms • Joint edema, tenderness, instability, and deformity • Heberden’s Nodes • nodules on the sides of the distal joints of fingers • Bouchard’s Nodes • nodules on the proximal joints of fingers

31. Degenerative Joint Disease (Osteoarthritis)

32. Degenerative Joint Disease (Osteoarthritis) • Diagnostic Tests • Radiographic studies • Arthroscopy • Synovial fluid examination • Bone scans

33. Degenerative Joint Disease (Osteoarthritis) • Treatment • Exercise balanced with rest • Heat applications • Gait enhancers (canes, walkers, etc.) • Medications • Salicylates (aspirin) • NSAID’s (Motrin) • Steriods (cortisone) • Surgery • Osteotomy • Joint replacement

34. Degenerative Joint Disease (Osteoarthritis) • Prognosis • Chronic disease that ultimately causes permanent destruction of affected cartilage and underlying bone.

35. Gout (Gouty Arthritis) • Etiology/Pathophysiology • Metabolic disease resulting from an accumulation of uric acid in the blood • Caused by an ineffective metabolism of purines • Primary • hereditary factors • Secondary • use of certain drugs, complication of other diseases, or idiopathic • Affects men more frequently than women • Does not occur before puberty in the male or before menopause in the female

36. Gout (Gouty Arthritis) • Signs & Symptoms • Excruciating pain • Edema • Inflammation • Most common in the great toe • Tophi • calculi deposits

37. Gout (Gouty Arthritis)

38. Gout (Gouty Arthritis) • Diagnostic Tests • Serum and uric acid levels • Complete blood count • ESR • Radiography studies • reveal cysts • Synovial fluid aspiration • contain urate crystals

39. Gout (Gouty Arthritis) • Treatment • Medications • colchicine • decreases uric acid • phenylbutazone (Butazolidin) • indomethacin (Indocin) • antiinflammatory • corticosteroids • allopurinol (Zyloprim) • decreased the production of uric acid • sulfinpyrazone (Anturane) • increases secretion of uric acid by the kidneys

40. Gout (Gouty Arthritis) • Encourage fluid intake • at least 2000 cc/day • Monitor intake and output • Bed rest and joint immobilization • Diet • Avoid high purine foods • organ meats • anchovies • yeast • herring • mackerel • scallops

41. Gout (Gouty Arthritis) • Prognosis • Signs and symptoms are usually recurrent • Can progress to destructive joint changes

42. Osteoporosis • Etiology/Pathophysiology • Reduction of bone mass • Most common in women ages 55-65 • possibly related to lack of estrogen • Contributing Factors • Immobilization • Use of steroids • High intake of caffeine • Diet low in calcium • Smoking • Excessive protein in diet • Sedentary lifestyle

43. Osteoporosis Magnification of: Healthy Bone Bone with Osteoporosis

44. Osteoporosis • Signs & Symptoms • Backache • especially in the thoracic and lumbar regions • worse with sitting, standing, coughing, sneezing, and straining • Bones porous and brittle • pathological or spontaneous fractures • Dowager’s hump • spinal deformity and height loss that develop from repeated spinal vertebral fractures

45. Osteoporosis • Diagnostic Tests • CBC • Serum calcium • Phosphorus • Alkaline phosphatase • Blood urea nitrogen • Creatinine level • Urinalysis • Liver and thyroid function tests • Radiography studies

46. Osteoporosis • Treatment • Calcium supplements • 1000 mg for men • 1500 mg for women • Vitamin D • Weight-bearing exercises • Estrogen • alendronate (Fosamax) • absorbs calcium phosphate crystal in bone • Diet • Milk and dairy products provide the most calcium • Limit caffeine

47. Osteoporosis • Prognosis • Chronic disorder • Prevention should begin before bone loss occurs

48. Osteomyelitis • Etiology/Pathophysiology • Local or generalized infection of the bone and bone marrow • Staphylococci most common cause • Introduced through trauma (injury or surgery) or by the bloodstream from another site in the body to the bone • Bacteria invade the bone and degeneration of bone occurs

49. Osteomyelitis • Signs & Symptoms • Persistent, severe, and increasing bone pain • Wound draining purulent fluid • S/S of infection • temperature, tachycardia, and tachypnea • Edema of affected area

50. Osteomyelitis • Diagnostic Tests • Radiography studies • Bone scan • CBC (esp WBC) • ESR • Cultures of blood and drainage