Care of Musculoskeletal Disorders

Objectives of Musculoskeletal Disorders Care

• Identify pathophysiology and clinical manifestations of musculoskeletal disorders.
• Recognize diagnostic tests and develop/evaluate a plan of care.
• Discuss pharmacological interventions and identify complications.

Musculoskeletal System Overview

• Comprises the skeletal (bones and joints) and muscular systems.
• Bones store calcium and phosphorus, and protect vital organs.
• Red marrow in bones generates blood cells.
• Muscle issues often follow bone-related problems.

Osteopenia & Osteoporosis

• Osteopenia: reduced bone density.
• Osteoporosis: severe osteopenia leading to significant bone deterioration.
• Falls in older patients commonly result in major health declines.

Osteoporosis Terminology

• Osteomalacia: softening of bones due to calcification issues.
• Osteoporosis is characterized by decreased bone mass.
• Bone remodeling involves osteoblasts (build bone) and osteoclasts (consume bone).
• Peak bone mass is typically reached by age 30, influenced by estrogen levels.

Types of Osteoporosis

• Generalized (Primary: due to aging, hormonal changes; Secondary: due to medications like glucocorticoids).
• Regional (localized, often after fractures or seen in astronauts).

Risk Factors for Osteoporosis

• Family history, age (increased risk after age 50), and inadequate nutrition (calcium and Vitamin D deficiency).
• Lack of weight-bearing exercise increases risk.
• Smoking, alcohol use, hormone deficiencies, low body weight, and certain medications (diuretics, steroids) contribute to risk.

Signs and Symptoms of Osteoporosis

• Often asymptomatic until fractures occur.
• Symptoms include bone pain, height loss, neck/lower back pain, and stooped posture.

Diagnostic Testing for Osteoporosis

• Lab tests: Calcium and Vitamin D levels.
• Imaging: Dual-energy X-ray absorptiometry (DXA) for assessing bone mineral density.

Prevention and Treatment of Osteoporosis

• Adequate vitamin D from sunlight; limited dietary sources.
• Engage in weight-bearing exercises (30 min, 3-4 times/week).
• Estrogen therapy can help but carries risks of thrombosis.

Osteomyelitis

• Infection of bone caused by bacteria, viruses, or fungi.
• Can be exogenous (external source), endogenous (from bloodstream), or contiguous (originating from nearby tissue).
• Common in diabetes patients and IV drug users.

Clinical Manifestations of Osteomyelitis

• Acute: fever, chills, swelling, tenderness, erythema, localized pain.
• Chronic: may exhibit foot ulcers, drainage, pain depending on blood circulation.

Risk Factors for Osteomyelitis

• Immunosuppression, malnourishment, chronic illnesses, certain medications, and presence of wounds or artificial joints.

Diagnosis of Osteomyelitis

• Laboratory tests indicating leukocytosis.
• Cultures from blood or infected area.
• Imaging via X-ray, MRI, and bone biopsy for definitive diagnosis.

Treatment of Osteomyelitis

• Nonsurgical: Antibiotic therapy (often IV), pain control, hyperbaric oxygen therapy.
• Surgical: Debridement, excision of infected bone, possible amputation.

Fractures Overview

• Classifications: Complete (all the way through) and incomplete; closed (skin intact) and open (skin broken).
• Pathologic fractures occur from minimal trauma due to underlying conditions like osteoporosis.

Clinical Manifestations of Fractures

• Pain, loss of function, deformity, crepitus (crunching sound), ecchymosis, and edema noted.

Complications of Fractures

• Acute: Increased risk of venous thromboembolism, infection, acute compartment syndrome, and fat embolism syndrome.
• Chronic: Delayed healing and chronic pain.

Acute Compartment Syndrome (ACS)

• A medical emergency; occurs when swelling compromises artery and nerve function in limbs.
• Early signs include severe pain, paresthesia, weak pulses, pallor, increased pressure, and potential paralysis.

Medications for Rheumatoid Arthritis (RA)

• NSAIDs for inflammation, steroids for flare-ups, and disease-modifying anti-rheumatic drugs (DMARDs) including methotrexate and etanercept.
• Monitor liver enzymes and patient education on teratogenic effects and infection risks.### Joint Management
• Joint positioning and body posture are crucial, requiring active movement.
• Heat and cold applications can alleviate pain.
• Platelet-rich plasma (PRP) treatment uses the patient’s own platelets to aid local tissue repair.
• Addressing obesity is vital for promoting weight loss and reducing joint stress.

Physical Therapy and Support

• Physical therapy strengthens muscles to support skeletal stability.
• Assistive devices like walkers and canes enhance mobility.
• Over-the-counter supplements such as glucosamine and chondroitin support joint health.
• Medical marijuana may provide pain relief for some patients.

Joint Replacement Overview

• Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) are common orthopedic procedures.
• Considered when conservative management fails.

Total Knee Replacement (TKA)

• Cartilage degradation leads to pain; replacing cartilage alleviates discomfort.

Nursing Management for TKA

• Emphasizes infection prevention during and after surgery.
• Implement effective pain control measures, including catheters for targeted infusion.
• Mobilization is critical; patients should ambulate on the day of surgery.
• Continuous Passive Motion (CPM) devices enhance range of motion post-surgery.
• Deep Vein Thrombosis (DVT) prevention includes mobility encouragement and anticoagulant therapy.

Post-Operative Guidelines for TKA

• Use an incentive spirometer and encourage coughing and deep breathing to prevent respiratory issues.
• Advise against kneeling to protect the knee incision.
• Avoid hyperflexion and hyperextension to prevent dislocation risks.

Total Hip Replacement (THA)

• Replaces the femur's ball and pelvis socket; a complex procedure with extensive implications.

Nursing Management for THA

• Post-operative care includes dislocation prevention measures.
• Use abduction pillows to maintain leg positioning.
• Prohibit adduction and severe flexion at the hip.
• Elevate toilet seats and monitor dressing integrity.
• Collaborate closely with physical therapy for strength recovery.
• Continuous Strain Devices (SCDs) and compression stockings may be necessary for circulation.

Preventing Hip Dislocation After THR

• Maintain straight leg positioning with no internal rotation.
• Avoid bending the hip beyond 90 degrees or moving the knee past the midline.
• Provide support between legs to prevent dislocation.

Signs and Symptoms of Hip Dislocation

• Sudden increased pain and swelling at the surgical site.
• Acute groin pain and possible audible “popping” sounds.
• Observed abnormal foot rotation and reduced mobility of the affected limb.

Discharge Planning for TKA/THA

• Arrange for ongoing physical therapy.
• Focus on prevention of infections, DVT, and dislocation.
• Establish follow-up appointments and define red flags that warrant immediate medical attention, such as chest pain or breath shortness.

Potassium Overview

• Normal serum potassium levels range from 3.5 to 5.0 mEq/L.
• Potassium serves as an intracellular cation vital for muscle contraction, cardiac function, nerve impulses, and acid-base regulation.

Potassium Balance and Kidney Function

• Proper kidney function is essential for potassium balance; it adjusts potassium levels via excretion or reabsorption.
• Significant changes in serum potassium levels are seen with renal failure, reflected by increased potassium.

Hypokalemia Causes

• Occurs with excessive intake, deficient intake, kidney failure, loss of body fluids, medications, or hypomagnesemia.
• Diuretics significantly contribute to hypokalemia, leading to potential hyponatremia.
• Insulin administration lowers serum potassium by driving potassium into cells.

Hyperkalemia Causes

• Caused by excessive potassium intake, kidney failure, or tissue/crush injuries that release potassium from cells.

Dietary Considerations

• Patients with renal disease need careful monitoring of potassium intake; holiday foods often contain high potassium levels.

Signs and Symptoms of Hypokalemia

• Cardiac: Dysrhythmias and bradycardia.
• CNS: Lethargy, confusion, irritability, and anxiety.
• Muscular: Weakness, paralysis, shallow respirations.
• GI: Nausea, vomiting, constipation, and paralytic ileus.

Signs and Symptoms of Hyperkalemia

• Increased irritability and anxiety.
• Muscle twitching that may progress to paralysis.
• Bradycardia resulting from altered nerve impulses in muscles.

Treatment for Hypokalemia

• Identify and correct the underlying cause.
• Potassium replacement therapy can be oral or IV.
• Nutritional therapy with potassium monitoring.
• Cardiac and respiratory functions must be carefully monitored.

Treatment for Hyperkalemia

• Dialysis is often required for severe hyperkalemia.
• Medications like Kayexalate can help remove excess potassium.
• Insulin administration can push potassium back into cells for quick action.

Administering Intravenous Potassium

• Administer slowly, no faster than 10 mEq/hr, using a pump to avoid vein irritation.
• Always be cautious, as excessive potassium can cause fatal cardiac dysrhythmias.
• Monitor blood sugar when giving insulin with potassium.

Protocol Guidelines

• Familiarize yourself with protocols and contraindications; do not memorize them as they may change.
• Monitor patients on potassium; assess creatinine levels and dietary restrictions.
• Ensure proper administration techniques and patient safety checks prior to administering potassium.

Special Considerations

• Avoid potassium administration in patients with creatinine levels above 2 or those weighing less than 40 kg if normal creatinine.
• Check potassium levels frequently if critically low; follow up within four hours post-dose as needed.

Potassium Overview

• Normal serum potassium levels range from 3.5 to 5.0 mEq/L.
• Potassium serves as an intracellular cation vital for muscle contraction, cardiac function, nerve impulses, and acid-base regulation.

Potassium Balance and Kidney Function

• Proper kidney function is essential for potassium balance; it adjusts potassium levels via excretion or reabsorption.
• Significant changes in serum potassium levels are seen with renal failure, reflected by increased potassium.

Hypokalemia Causes

• Occurs with excessive intake, deficient intake, kidney failure, loss of body fluids, medications, or hypomagnesemia.
• Diuretics significantly contribute to hypokalemia, leading to potential hyponatremia.
• Insulin administration lowers serum potassium by driving potassium into cells.

Hyperkalemia Causes

• Caused by excessive potassium intake, kidney failure, or tissue/crush injuries that release potassium from cells.

Dietary Considerations

• Patients with renal disease need careful monitoring of potassium intake; holiday foods often contain high potassium levels.

Signs and Symptoms of Hypokalemia

• Cardiac: Dysrhythmias and bradycardia.
• CNS: Lethargy, confusion, irritability, and anxiety.
• Muscular: Weakness, paralysis, shallow respirations.
• GI: Nausea, vomiting, constipation, and paralytic ileus.

Signs and Symptoms of Hyperkalemia

• Increased irritability and anxiety.
• Muscle twitching that may progress to paralysis.
• Bradycardia resulting from altered nerve impulses in muscles.

Treatment for Hypokalemia

• Identify and correct the underlying cause.
• Potassium replacement therapy can be oral or IV.
• Nutritional therapy with potassium monitoring.
• Cardiac and respiratory functions must be carefully monitored.

Treatment for Hyperkalemia

• Dialysis is often required for severe hyperkalemia.
• Medications like Kayexalate can help remove excess potassium.
• Insulin administration can push potassium back into cells for quick action.

Administering Intravenous Potassium

• Administer slowly, no faster than 10 mEq/hr, using a pump to avoid vein irritation.
• Always be cautious, as excessive potassium can cause fatal cardiac dysrhythmias.
• Monitor blood sugar when giving insulin with potassium.

Protocol Guidelines

• Familiarize yourself with protocols and contraindications; do not memorize them as they may change.
• Monitor patients on potassium; assess creatinine levels and dietary restrictions.
• Ensure proper administration techniques and patient safety checks prior to administering potassium.

Special Considerations

• Avoid potassium administration in patients with creatinine levels above 2 or those weighing less than 40 kg if normal creatinine.
• Check potassium levels frequently if critically low; follow up within four hours post-dose as needed.

This quiz covers the care of patients with musculoskeletal disorders, including pathophysiology, clinical manifestations, diagnostic tests, and developing a plan of care.