Musculoskeletal Stressors

1. MusculoskeletalStressors NUR240 JBorrero 10/08

2. Arthritis Degenerative Joint Disease 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. What to assess for: 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.

15. Nursing Interventions Assist with/encourage physical activity Provide a safe environment Utilize progressive muscle relaxation Refer to support groups Emotional support

16. Complications Sjogrens’s syndrome Joint deformity Vasculitis Cervical subluxation

17. 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

18. 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. Initial manifestation- arthritis, butterfly rash, weakness, fatigue, wt. loss Symptoms and tx. depend on systems involved.

19. 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.

20. SLE 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. Joint Replacement Indications Rheumatoid arthritis Trauma Congenital deformity Avascular necrosis

25. Total Hip Replacement Indications for surgery: Arthritis Femoral neck fractures Congenital hip disease Failed prosthesis

26. Pre-op management 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.

27. 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. 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/

39. Post-op: 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 Phantom limb pain Immobility complications

40. 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

41. 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

42. 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

43. 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

44. Osteoporosis Diagnosis: Physical assessment: Psychosocial assessment:

45. 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.

46. Patient teaching- Meds HRT-Raloxifene (Evista) PTH- Forteo Subcut Bisphosphonates- Fosamax,Boniva, Actonal Reclast, Zometia Calcitonin, Vit D NSAIDs

47. Osteomyelitis Infection of the bone Endogenous: Extension of soft tissue infection- infected pressure ulcers or incision. Blood borne (spread from other body sites) At risk- poorly nourished, elderly, obese, impaired immune systems, corticosteroid therapy, chronic illnesses. Prevention- proper tx. of infections, aseptic post op wound care Exogenous: Organism enters from outside the body. Eg. Open fx

48. Osteomyelitis Signs and symptoms- High fever, chills, increased HR, general malaise, swelling, tenderness, heat and erythema, painful movement. Draining ulcers, bone pain Dx- increased WBCs, elevated ESR, positive blood cultures, X-rays, bone scan, MRI.

49. Osteomyelitis Tx Long term IV antibiotics Hickman or other CVAD catheter Strict sterile technique for tx Hyperbaric oxygen tx Surgery- bone exposed and necrotic tissue removed, debridement, bone grafts, amputation

50. Contusions, Strains, Sprains Contusion-soft tissue injury, hematoma, ecchymosis. Strain- “muscle pull” over use over stretching. Sprain – an injury to ligaments surrounding joint, caused by twisting. Management- RICE = rest, ice, compression, elevation.