Musculoskeletal Disorders Part II

1. Musculoskeletal DisordersPart II Osteoporosis Fractures Degenerative Joint Disease/Osteoarthritis Total Hip and Knee Prostheses Bone Infections / Osteomyelitis Gout

2. Concept Map: Selected Topics in Musculo-Skeletal Nursing PATHOPHYSIOLOGY Fracture Osteoporosis Degenerative Joint Disease Osteoarthritis Osteomyelitis Gout Amputation Total Joint Replacement ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation “Neuro / Circ Checks” --”The 6 P’s” Lab Monitoring PHARMACOLOGY Opioids NSAIDs Antibiotics Disease Specific Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more…based On Nursing Process: A_D_O_P_I_E NURSING DIAGNOSES THAT APPLY…. Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary

3. Nursing Diagnoses That (Might) Apply Pain, acute Comfort, impaired Mobility, altered Self-care deficit –feeding, grooming; bathing, hygeine; toileting Falls, risk for Skin breakdown, risk for Constipation, risk for Diversional activity, risk for Mobility, Physical, impaired Mobility, bed, risk for Walking, impaired, Tissue perfusion, impaired peripheral Peripheral neurovascular dysfunction, risk for Knowledge, deficient Body image, disturbed Grieving More……

5. Degenerative Joint Disease

6. Musculoskeletal Disorders • Degenerative Joint Disease (DJD) • a degenerating arthritic condition that affects any joint in the body, including the spine (then it is called DDD – Degenerative Disc Disease) • Risk Factors: • Obesity (More in the weight – bearing joints) • Poor nutrition, low in calcium or vitamin D • Genetics – familial arthritis • Overuse injuries or manual labor • Sports injuries which affect the bursae or tendon - meniscal tissues that cushion the joint • Smoking – as it dehydrates and constricts tissues

7. Musculoskeletal Disorders • Degenerative Joint Disease (DJD) • Pathophysiology - the bone and supporting tissues start to degenerate, causing atrophy of tendons, and bone spurring, with degeneration of menisci and bursa which would normally protect the joint. Main symptoms are “stiffness in the morning” and pain. Eventually the bone spurring and breakdown will cause joint deformities.

8. Musculoskeletal Disorders • Degenerative Joint Disease (DJD) • Also called OA – Osteoarthritis • Diagnosis: • Symptoms and history • Arthroscopy • X-rays • MRI – for soft tissue visualization, i.e of menisci or bursae • Bone scan if cancer has to be ruled out

9. Musculoskeletal Disorders • Degenerative Joint Disease (DJD) • Note the loss of joint space with bone on bone

10. Musculoskeletal Disorders • Degenerative Joint Disease (DJD)

11. Musculoskeletal Disorders • Degenerative Joint Disease (DJD) • Treatments – heat and cold therapy • Preventative exercises – to strengthen supporting muscles • Joint Injections – Hydralan, cortisone, etc. • Analgesics/Anti-inflammatories – • COX – 2 inhibitors i.e. Mobic, Celebrex • Tylenol – contraindicated for liver patients • Indocin - more risk for peptic ulcers • Aspirin – more risk for peptic ulcers • Partial or complete surgical repair • Joint prosthesis

12. Musculoskeletal Disorders • Degenerative Joint Disease (DJD) –

13. Musculoskeletal Disorders • Hip Prosthesis

15. Musculoskeletal Disorders • knee prosthesis

16. Musculoskeletal Disorders • Care of Patients – • Pain control • Ambulation with assistance - only • Prevent falls • Exercise; usually has physical therapy from 6 - 8 weeks • Non-smoking • Encourage adequate intakes of vitamin C • Post-op anti-coagulants, whether Lovenox, coumadin, heparin, or aspirin

17. Musculoskeletal Disorders • Hip prosthesis – NEVER adduct the leg (letting the hip and leg cross the other one will pop the prosthetic ball out of the pelvis) • Only allow hip flexion to 90 degrees • Turn patients using an adductor pillow while aligning the spine

18. Musculoskeletal Disorders • Adductor pillow between knees

19. Musculoskeletal Disorders • Bone infections • Causes: • Immunological problems • Diabetes, nutritional problems • Injury which allows pathogens into the bone • fractures • coral cuts • trauma • post-operative surgery

20. Musculoskeletal Disorders • Bone infections • Chronic Osteomylitis in a diabetic

21. Musculoskeletal Disorders • Bone infections • Diagnosis: • Bone scan • X-rays • MRI for soft tissue view • Blood cultures – need to be done 15 minutes apart from two different sites • Wound cultures – if drainage is apparent

22. Musculoskeletal Disorders • Bone infection symptoms: • Foul smelling drainage • Fever • Lethargy • Swelling • Redness • Increased WBC’s on CBC with differential • With increased neutrophils on the CBC, sometimes called PMN’s or polymorphic neutrophils. These cells in particular replicate to fight infection. If the WBC is not elevated with these symptoms, the patient is immunosuppressed and at risk for sepsis.

23. Musculoskeletal Disorders Bone Infections Most common organisms: StaphlococciAureus– MRSA in the hospital post- operatively (a drug resistant organism) Enterococcifrom wounds/trauma Clostridium Perfringens– gangrene E-Coli – fecal contamination

24. Musculoskeletal Disorders • Osteomylitis Treatments/Interventions • #1 Pain control • Monitor Vital signs every 4 hours and prn • (Observe for signs of sepsis or drug reaction) • Monitor skin integrity and site - intravenous antibiotics to get rid of infection (need a physician’s order) • Surgical repair or debridement • Removal of infected prostheses • Sometimes it is necessary for amputation

25. Musculoskeletal Disorders • Ewing’s Sarcoma of the bone – usually malignant with mets, often treated with amputation

27. Musculoskeletal Disorders • Osteosarcoma – • most common type of malignant bone tumor, most often in males between 10 and 30 y.o. or in older patients with Paget’s Disease

28. osteosarcoma

29. Chondrosarcoma • This is a photograph of 70 year old woman who first presented like this with a massive chondrosarcoma of her right upper humerus of 8 months duration. She refused all treatment, and she died of a massive haemorrhage when the tumour burst the following week. http://worldortho.com/dev/index.php?option=com_content&task=view&id=1814&Itemid=328

30. Musculoskeletal Disorders Chondroma

31. Amputation

32. Musculoskeletal Disorders • Types of amputations • Simple Toe – uncomplicated, most often due to injury and diabetes

33. Musculoskeletal Disorders • Amputations – BKA • Below the knee • Treatments for amputations will be further covered in Adult Health Care II

34. Musculoskeletal Disorders • Types of Amputations • AKA – above the knee – a surgical technique for saving a person’s life from an infected prosthesis or necrotic limb

35. Musculoskeletal Disorders • Amputations - facts and figures: • More than 100,000 amputations are performed in the USA every year. • The most common cause of amputations is diabetes & infection • Of the 9,985 nonfatal workplace amputations in 1999, more than 1 in 3 cases required 31+ days away from work to recuperate (OSHA study) • The third most common cause today is war-related.

41. http://www.peglegbiker.com/index.html

42. Musculoskeletal Disorders • Assessment must include: • Pain as a no. 1priority • Proper patient assessment must include pain intensity, radiation, relief, medication side effects, and reassessment on a regular basis. • Skin integrity • Tissue Perfusion • Prevention of infection • Promotion of nutrition • Exercise & ROM • Body Image

43. Gout

44. Musculoskeletal Disorders • Gout – • Pathophysiology • Gout isa disease caused by the kidneys not clearing the uric acid out of the blood stream. Uric acid is the end product of purines in our diet (one of the amino acids in the body). This causes a hyperuricemia (high levels of uric acid in the blood) and initiates an inflammatory response in the joints. The urate crystals deposit into a joint and/or subcutaneous tissues.. This deposit and inflammation causes “gouty arthritis” and may appear the same as OA on X-ray. The deposits can also cause kidney stones, as deposits build up in the kidneys. Renal stones are `1000 times more common in people with gout.

46. Musculoskeletal Disorders Gout Symptoms: • Tophi - white crystalized deposits in the tissue, usually seen on the hands or toes. • Heat & Redness • Pain – Severe & sudden onset • Swelling • Inflammation – usually on one side of the body first, a ankle joint, knee, or toe • May become an acute inflammation after an injury, i.e. stubbing your toe on the sprinkler

47. Musculoskeletal Disorders Gout – Diagnosis: - X-ray of limb to rule out regular arthritis, or osteomylitis/cellulitis - blood test for a uric acid level normal is 4.0-5.2 (lab values may differ based on the age of the patient) - Anything over 6.0 is consider high - An aspiration of the fluid in the joint will demonstrate crystalline deposits by microscope

48. Musculoskeletal Disorders • Treatments • Anti-inflammatories STAT – drugs of choice are colchicine and indocin – Patients need to be educated to side effects and dosing. • Sometimes, doctors will give Toradol IM for immediate pain relief, as it acts like injectable aspirin and reacts quickly • Pain control • Maintenance on daily allopurinol – to allow the kidneys to secrete the acid • Educate patient to avoid high purine foods

49. Musculoskeletal Disorders • gout

50. Musculoskeletal Disorders • Gout tophi