Questions and Answers
What is osteoporosis characterized by?
What causes osteomalacia?
Lack of calcification in bone.
Primary osteoporosis has a direct cause.
False
The peak bone mass is reached by age ___.
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Which of the following is a risk factor for osteoporosis? (Select all that apply)
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Match the medications with their purposes:
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What is osteomyelitis?
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Chronic osteomyelitis typically presents with significant pain.
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Which method can be used for the diagnosis of osteomyelitis?
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An acute complication of fractures can include __________.
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What are the 6 P's of Acute Compartment Syndrome (ACS)?
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What is Fat Embolism Syndrome (FES)?
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Which are clinical manifestations of FES? (Select all that apply)
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FES occurs only after 48 hours post injury.
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The treatment for FES includes ______ and cardiovascular support.
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What common prevention methods for FES are suggested?
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What does the acronym '6 P's' relate to in the context of neurovascular checks?
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What are some examples of external immobilization methods for fractures?
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What are potential complications of amputations? (Select all that apply)
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Rheumatoid Arthritis (RA) has a known cure.
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The goal of treating RA is to prevent ______.
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What are steps involved in the diagnosis of RA? (Select all that apply)
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What is the primary goal of Osteoarthritis (OA) treatment?
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Obesity is a risk factor for developing Osteoarthritis.
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What types of medications are typically used to treat Osteoarthritis? (Select all that apply)
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Total Knee Arthroplasty (TKA) is performed when ______ management methods have failed.
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Which of the following statements best describes the purpose of using a CPM machine in postoperative care?
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What is the primary concern during the first few months after a total hip replacement (THA)?
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Which symptom is NOT typically associated with a hip dislocation post-surgery?
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What should be avoided to prevent dislocation following a total hip arthroplasty?
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During discharge planning after a total hip or knee arthroplasty, which key point must be emphasized to the patient?
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After surgery, what is an appropriate method for managing deep vein thrombosis (DVT) risk?
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What is the role of the neurovascular checks in postoperative care?
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Which instruction is critical for the patient regarding hip position after a total hip replacement?
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What is the primary purpose of utilizing an abduction pillow postoperatively?
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Study Notes
Musculoskeletal Disorders
- Musculoskeletal system consists of skeletal system (bones and joints) and muscular system (involuntary and skeletal)
- Bones store calcium and phosphorus, protect vital organs, and produce blood cells through red marrow
- Muscular system issues are often related to bone problems
Osteopenia and Osteoporosis
- Osteopenia: decreased bone density, often seen in older patients
- Osteoporosis: severe osteopenia, increasing risk of fractures, especially in older patients
- Identify people with osteoporosis and start interventions to prevent complications
Osteoporosis Terminology
- Osteomalacia: bone softening, often seen in adults with vitamin D deficiency
- Bone remodeling: ongoing process of bone formation and resorption
- Osteoblasts: build bone, osteoclasts: consume bone
- Peak bone mass: reached at 30 years of age
Types of Osteoporosis
- Primary osteoporosis: no direct cause, but many risk factors
- Secondary osteoporosis: caused by other conditions or medications
- Regional osteoporosis: localized to one area, such as astronauts' legs due to lack of gravity
Risk Factors
- Age: older patients are at higher risk
- Family history: especially if mother had osteoporosis
- Nutrition: lack of calcium and vitamin D
- Exercise/immobility: not enough weight-bearing activity
- Smoking/alcohol: increase risk of osteoporosis
- Hormone deficiency: menopause, radical hysterectomy
- Weight: being underweight, taking diuretics and steroids
Signs and Symptoms
- Bone pain, loss of height, neck/back pain, stooped posture
- ADLs are affected
Diagnostic Testing
- Labs: calcium and vitamin D levels
- Imaging: dual x-ray absorptiometry (DXA) to measure bone density
Prevention and Treatment
- Vitamin D and calcium supplements
- Exercise: weight-bearing activities, 30 minutes, 3-4 times a week
- Limit alcohol and tobacco
- Drug therapy: bisphosphonates, estrogen agonist/antagonists for postmenopausal women or men over 50 with low bone density
Medications
Calcium
- Used to treat mild hypocalcemia, supplement dietary calcium, and prevent osteoporosis
- Administer with vitamin D, take with water or after a meal
- Monitor calcium, vitamin D, and phosphorus levels
- Adverse effects: kidney stones, hypercalcemia, hypophosphatemia
Vitamin D
- Used to treat osteomalacia, prevent osteoporosis
- Administer with calcium, evaluate calcium, vitamin D, and phosphorus levels
- Adverse effects: hypercalcemia, hypophosphatemia
- Monitor for improvement in osteomalacia, stabilization of osteoporosis, and no new fractures
Bisphosphonates
- Used to treat osteoporosis
- Report dysphagia, dyspepsia, pain, or swelling in the mouth
- Adverse effects: osteonecrosis of the jaw, esophagitis
- Monitor for stabilization of osteoporosis and no new fractures
Raloxifene (Evista)
- Used to prevent and treat postmenopausal osteoporosis
- Monitor for symptoms of venous thromboembolism
- Adverse effects: deep vein thrombosis, pulmonary embolism### Thrombotic Stroke
- Estrogen can help with bone density and prevent osteoporosis in postmenopausal patients, but its adverse effects include stroke, clotting (DVT), and PE.
- Clotting is a significant concern with this medication.
- Patients with a history of stroke are usually prohibited from taking birth control.
Osteomyelitis
- Osteomyelitis is an infection in the bone tissue caused by bacteria, viruses, parasites, or fungi.
- It can be bacterial, viral, or fungal, and is typically seen in diabetics due to poor blood flow and PAD.
- Neuropathy and PAD can influence this condition.
- IV drug abusers are also at risk due to dirty tools and infected blood.
- Exogenous osteomyelitis occurs when an external source (e.g., trauma) introduces bacteria directly to the bone.
- Endogenous osteomyelitis occurs when an internal source (e.g., sepsis) settles in the bone.
- Gangrene can lead to osteomyelitis due to skin infection leading to deeper infection.
Osteomyelitis Clinical Manifestation
- Acute phase: fever, chills, swelling, tenderness, erythema, heat, and pain.
- Chronic phase: may not feel pain, but could have drainage, pain depending on circulation, or bone surgery.
Risk Factors: Osteomyelitis
- Immunosuppressed individuals (e.g., HIV, elderly, or immunosuppressive meds).
- Malnourishment (insufficient nutrients for healing).
- Chronic illnesses (e.g., diabetes).
- Medications (e.g., steroids, diuretics).
- Bloodstream infection.
- Wounds.
- Artificial joints (prone to infection).
Osteomyelitis Diagnosis
- Labs: nonspecific leukocytosis (high WBC).
- Cultures: blood, wound, or areas near the wound.
- X-ray: changes in bone structure.
- MRI: detailed diagnosis.
- Biopsy: most optimal, confirming the diagnosis.
Treatment
- Nonsurgical:
- Antibiotic therapy (used often for bacterial cases).
- Pain control (extremely painful).
- Hyperbaric Oxygen Therapy (HBO) (increases oxygen in the bone, promoting healing).
- Surgical:
- Debridement or bone excision (removing infected bone).
- Amputation (in severe cases).
Fractures
- Complete: a complete break in the bone.
- Incomplete: does not completely sever the bone, more common in kids.
- Closed: skin is still intact with the fracture.
- Open: skin is open, exposing the bone (aka compound fracture).
Types of Fractures
- Pathologic Fracture (Spontaneous fracture):
- Underlying disease causes weak bones (e.g., osteoporosis, osteomalacia, bone cancer).
- Stress Fracture (Fatigue fracture):
- Results from excessive stress or strain on the bone (e.g., repetitive motions).
Fracture Complications
- Acute:
- Venous Thromboembolism (VTE).
- Infection.
- Acute Compartment Syndrome (ACS).
- Fat Embolism Syndrome (FES).
- Chronic:
- Delayed bone healing.
- Chronic pain.
Acute Compartment Syndrome (ACS)
- A circulatory concern that can lead to loss of limb if not treated.
- Compression on arteries and nerves can cause paresthesia, pulse changes, and paralysis.
- 6 P's of ACS: pain, paresthesia, pulse, pallor, pressure, and paralysis.
Medical Management ACS
- Contact surgeon immediately.
- Keep the extremity at heart level.
- Remove dressings or casts.
- Prepare for surgery (fasciotomy).### Fat Embolism Syndrome (FES)
- Fat enters bloodstream, especially in long bone fractures
- Occurs 12-48 hours post-injury
- Clinical manifestations:
- Respiratory changes
- Neurological changes
- Skin: petechial rash
- Fatty bone marrow enters bloodstream, causing symptoms like breathlessness, hypoxia, and neurological changes
- Can lead to seizures, confusion, and agitation if fat enters arterial circulation and reaches the brain
- Skin manifestations: petechial rash (pinpoint spots) due to increased pressure in capillary beds causing pinpoint bleeding
Management of FES
- Prevention:
- Early fracture immobilization
- Careful repositioning of patients
- Special surgical techniques to decrease the chance of fat embolism
- Recognize and report it right away
- Supportive care:
- Respiratory support: oxygen, ventilator
- Cardiovascular support: fluids, DVT prophylaxis, vital signs monitoring, meds to regulate heart rhythm
- Corticosteroids for inflammation (not shown to reduce mortality, but used in practice to prevent systemic response)
Management of Fractures
- ABC's (Airway, Breathing, Circulation)
- Neurovascular check (6 P's)
- Pain management
- Reduction and immobilization
- Elevation to prevent inflammation and reduce edema and ACS
Immobilization of Fractures
- External immobilization: casts, splints, boots
- Internal immobilization: screws, plates, rods (surgical management)
Cast Care
- Nothing under the cast, even if it gets itchy
- Keep it clean and dry
- Educate patient about 6 P's (neurovascular issues)
Traction
- Way to reduce bones
- Weight keeps traction
- Assess for pain, neurovascular status, and pressure points
External Fixation
- Advantages: alignment, early mobilization, wound care
- Disadvantages: increased infection, osteomyelitis, altered body image
- Pins go into skin and bone, requiring careful pin care
Open Reduction Internal Fixation (ORIF)
- Open procedure to realign bones and fix them internally
Amputations
- Types: below knee (BKA), above knee (AKA), upper extremity
- Complications:
- Hemorrhage
- Infection
- Phantom limb pain
- Flexion contractures
Health Promotion
- Education: wound care, prosthetics, exercises
- Assistive devices: prosthetics
- Exercises: range of motion, strengthening
- Community resources: support groups, risk factor modification
Rheumatoid Arthritis (RA)
- Chronic, progressive, inflammatory, autoimmune disease
- No cure, goal is to prevent damage
- Pathophysiology: chronic joint inflammation, cartilage erosion, pannus formation, joint changes, systemic disease
Clinical Manifestations of RA
- Early disease: joint inflammation, fever, weakness, anorexia, weight loss
- Late disease: pain and morning stiffness, deformed joints, osteoporosis, severe fatigue, weight loss, vasculitis, kidney disease, pericarditis, fibrotic lung disease, Sjogren syndrome
Diagnosis of RA
- History and physical exam
- Rheumatoid Factor (RF)
- Anti-cyclic citrullinated peptide (anti-CCP)
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- X-rays
- Arthrocentesis
Medications for RA
- Analgesics (review from surgical lecture)
- Anti-inflammatory or analgesic actions
- Disease-modifying anti-rheumatic drugs (DMARDs):
- Methotrexate (Rheumatrex)
- Etanercept (Enbrel)
- Infliximab (Remicade)
- Nursing implications: monitor liver enzymes and creatinine, decrease ability to fight off infection, discuss contraception (teratogenic)
Osteoporosis
- Osteoporosis can cause fractures
- Limiting alcohol and tobacco can help prevent osteoporosis
- Drug therapy, including calcium and estrogen, may be recommended for postmenopausal women and men 50+ with low bone density or those who have already experienced a hip fracture
Calcium
- Calcium is used to treat mild hypocalcemia, supplement dietary calcium, and treat or prevent osteoporosis/osteopenia in combination with other therapies
- Nursing implications:
- Monitor calcium, vitamin D, and phosphorus levels
- Administer with vitamin D
- Take with water or after a meal
- Signs that the medicine is working:
- Stabilization of osteoporosis/osteopenia
- No new fractures
- Adverse responses to the medication:
- Kidney stones
- Hypercalcemia
- Thrombotic stroke
Estrogen
- Estrogen helps with bone density and can prevent osteoporosis
- Adverse effects:
- Stroke
- Clotting (DVT, PE)
- Not recommended for transgender patients; typically used for postmenopausal women
Osteomyelitis
- Osteomyelitis is an infection in bone tissue caused by bacteria, viruses, parasites, or fungi
- Types of osteomyelitis:
- Exogenous (from outside the body)
- Endogenous (from within the body)
- Risk factors:
- Immunosuppressed
- Malnourishment
- Chronic illnesses
- Medications
- Bloodstream infection
- Wounds
- Artificial joints
- Clinical manifestations:
- Acute: fever, chills, swelling, tenderness, erythema, heat, pain
- Chronic: foot ulcer, bone surgery, drainage, pain
- Diagnosis:
- Labs: nonspecific leukocytosis
- Cultures: blood, wound, areas near wound
- X-ray: changes in bone structure
- MRI: detailed diagnosis
- Biopsy: most optimal diagnosis
- Treatment:
- Nonsurgical:
- Antibiotic therapy
- Pain control
- Hyperbaric oxygen therapy
- Surgical:
- Debridement or bone excision
- Amputation
- Nonsurgical:
Fractures
- Types of fractures:
- Complete: complete break in bone
- Incomplete: does not completely sever bone
- Closed: skin is still intact with fracture
- Open: skin is open, exposing bone (compound fracture)
- Clinical manifestations:
- Pain
- Loss of function
- Deformity
- Crepitus
- Ecchymosis
- Edema
- Complications:
- Acute: venous thromboembolism, infection, acute compartment syndrome, fat embolism syndrome
- Chronic: delayed bone healing, chronic pain
Acute Compartment Syndrome (ACS)
- Caused by swelling in a closed space, compromising blood flow and nerve function
- Symptoms:
- Pain
- Paresthesia
- Pulselessness
- Pallor
- Pressure
- Paralysis
- Treatment: medical emergency, requires prompt intervention to prevent permanent damage### Altered Hepatic and Kidney Function
- Always check the last menstrual period
- Check creatinine and urine output
- Decreases people's ability to detect infections
- Not the best time to start medications if someone is recovering from bone marrow suppression (anemia, low RBC)
Teaching for RA Patients
- Rest and mobility promotion
- Energy conservation and rest in mobility spurts
- Heat/cold treatment and complementary/integrative health (acupuncture, meditation, hypnosis)
- Follow-up appointments and support groups for chronic or traumatic conditions
Osteoarthritis (OA)
Pathophysiology
- Wear and tear on cartilage, leading to bone grinding
- Two types: primary and secondary
Etiology
- Primary: genetic, age-related, high-use joints (athletes, workers)
- Secondary: from trauma or injury
Goals
- Reduce pain and maintain mobility
Risk Factors for OA
- Gender: males under 55, females over 55
- Age: older age increases risk
- Genetic factor: family history
- Obesity: increased weight increases risk
- Trauma: injury increases risk
- Occupation: athletes, workers with repetitive jobs
Signs and Symptoms of OA
- Localized pain
- Crepitus: grinding sensation in the legs
- Joint stiffness, especially after sitting
- Joint effusion: fluid buildup in joint space
- Skeletal muscle atrophy: decreased muscle mass
- Decreased function and mobility
- Depression and anxiety: emotional impact of limited daily functioning
Diagnostic Tests for OA
- Laboratory tests: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to rule out systemic inflammation
- Imaging tests: X-ray, MRI, and CT studies
Medications for OA
- Acetaminophen: no anti-inflammatory effect
- Topical medications: lidocaine, salicylates, and NSAIDs for localized pain
- Oral NSAIDs and opioid analgesics for severe pain
- Steroid injections for severe pain and inflammation
Nonpharmacologic Interventions for OA
- Rest and exercise: periods of rest and mobility promotion
- Joint positioning and heat/cold application
- Assistive devices and supplements (glucosamine and chondroitin)
- Weight loss and medical marijuana (cannabis)
Total Hip Replacement (THA)
- Ball and socket joint replacement
- Prevent dislocation and promote routine postoperative care
Nursing Management of Care: THA
- Prevent dislocation: abduction pillow, avoiding adduction, flexion, and leg crossing
- Dressing care and physical therapy
- SCDs/TED hose and pain management
- Neurovascular checks: 6 Ps (pain, pallor, pulselessness, paralysis, paresthesia, and poikilothermia)
Prevention of Hip Dislocation after THA
- Avoid internal rotation, bending past 90 degrees, and knee movements past the belly button
- Use supportive devices between the legs to prevent dislocation
Signs and Symptoms of Hip Dislocation
- Increased pain and swelling at the surgical site
- Acute groin pain and report of hearing a "popping" sensation
- Internal/external rotation, shortening, and restricted movement of the affected extremity
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Assess your knowledge on the care of patients with musculoskeletal disorders, including pathophysiology, clinical manifestations, and diagnostic tests. Develop and evaluate a plan of care for these patients.
