Adult Health Musculoskeletal Disorders PDF

Musculoskeletal Disorders Also ATI Musculoskeletal Chapters  Review Functions Structural framework Protection of internal organs Allows movement of muscles Stores calcium, phosphorus, magnesium Manufactures blood cells in the red bone...

Musculoskeletal Disorders Also ATI Musculoskeletal Chapters  Review Functions Structural framework Protection of internal organs Allows movement of muscles Stores calcium, phosphorus, magnesium Manufactures blood cells in the red bone marrow  Assessment--Subjective Joints Muscles Bones Functional assessment Self-care behaviors Numbness  Assessment--Objective Body alignment and symmetry Edema Pulses Color Ability to do ADLs ROM Muscle Strength 5 P’s  Diagnostic Tests ESR Men—0-15 mm/hr Women—0-20 mm/hr CBC RBC WBC HCT Hgb Platelets RF 40-60 units/mL normal. High indicates autoimmune disease such as rheumatoid arthritis  Diagnostic Tests Calcium 9-10.5 mg/dL Phosphorus 2.5-4.5 mg/dL ANA Uric Acid Males: 2.1-8.5 mg/dL Females 2.0-6.6 mg/dL  Diagnostic Tests X-rays Arthroscopy Arthrocentesis Arthrogram MRI CT EMG Bone Scan DXA Scan Myelogram  Patient Positioning  Necessary to prevent complications R/T limited mobility  AROM/PROM  Isometric exercises—tighten/relax muscle, but no movement—quad setting, gluteal setting—contract muscle hold for 10 secs for up to 10 times every hour while awake  Turning  Neurovascular Integrity Facts: Assessment Unrelieved Compare one side to impairment may result the other in loss of limb Sensation, color, pain, Arterial and Venous pulses, capillary refill impairment—edema, Done every 30 minutes cool, pallor, cyanosis, after surgery or cast pain, numbness, application tingling Trauma, tight bandages, surgery, splints, casts  Pain Assessment Fractures—acute, deep pain at least until fracture is reduced Fractured hip—severe because of muscle spasms Recurrence of pain after reduction is sign that something is wrong Spinal column disorders may produce chronic pain interspersed with sudden sharp pain; may extend down one or both extremities Arthritic and Rheumatic Problems  Rheumatoid Arthritis  Facts ◦ Most serious form ◦ Autoimmune disorders ◦ Affects synovial membrane first ◦ Most common ages 30-60 ◦ Affects mostly joints of fingers, feet, wrist ◦ Women more than men ◦ May develop insidiously or have an acute onset ◦ Remissions with exacerbations  Rheumatoid Arthritis  Assessment ◦ Weight loss, muscle aches, fever, malaise, swollen tender joints ◦ Joint stiffness upon arising in the morning ◦ Muscles spasms ◦ Deformities of joints in later stages  Diagnostic Tests ◦ Elevated rheumatoid factor titer (RF) ◦ Elevated ESR ◦ Anti-CCP antibody test ◦ Anti-nuclear antibody ◦ C-reactive protein ◦ RBC count ◦ Synovial fluid aspiration ◦ Synovial fluid biopsy ◦ X-rays show damage to joints  RA Treatment Anti-inflammatory meds and Disease modifying anti-rheumatoid drugs (DMARDs) Pain relief Reducing clinical symptoms in days to weeks with rapid anti-inflammatory effect of methotrexate Prolonging joint function Slowing progression of joint damage by promoting activities of daily living, exercise regimen, and weight  Nursing Interventions, RA Positioning Straight ext. without pillows under knees Trochanter roll to prevent external rotation Back straight with small pillow under head Avoid hip and knee flexion Drugs Give with food to reduce GI upsets Monitor for side effects of drugs Assess functional ability and assist as needed Planned activity with rest periods Exercise to prevent joints from freezing and muscles from weakening Encourage independence as tolerated  Ankylosing Spondylitis Chronic progressive rheumatic disorder affecting primarily the spine It’s a type of arthritis in the group of rheumatic disorders If other joints are involved it is the sacroiliac and hip joints Psoriatic arthritis is also in this group. Affects fingers, toes (edema), back pain and stiffness, changes in finger and toe nails (indentations or discoloration and psoriatic lesions  Clinical Manifestations The spine will fuse Kyphosis can occur (grow together) This fusion is called May have difficulty ankylosis and is usually expanding rib cage in an abnormal position. Can affect neck, jaw May have IBS. shoulders, knees, and hips Vision may be The ligaments become affected, leading to ossified blindness. Can cause heart Exacerbations and enlargement and pericarditis Remissions  Diagnostic Tests Decreased H&H Elevated ESR and CRP Elevated serum alkaline phosphatase Elevated HLA-B27 X-rays Sacroiliac joint and intervertebral disc inflammation with bone erosion and joint space fusion  Treatment Oral analgesics and NSAIDs Corticosteroids TNF inhibitors Exercise Surgery Endoscopic microsurgery  Nursing Interventions Firm mattress, bed board, and back brace, no pillow Lie on abdomen for 15-30 minutes QID to extend spine Turn and reposition every 2 hours Postural and breathing exercises Heat and cold treatment Education  Osteoarthritis— Degenerative Joint Disease Facts Non-inflammatory disorder Primary (Cause unknown) or Secondary most common type Consequence of aging Joints of hand, cervical and lumbar vertebrae, hips, knees Loss of articular cartilage  OA Assessment Pain with movement Stiffness in morning; activity will reduce Bouchard’s nodes—proximal joints of fingers Heberden’s nodes—sides of distal joints of fingers Treatment Weight reduction Program of exercise and rest periods Analgesics Hydrocortisone acetate into joint Moist heat for temporary relief  Surgical Intervention for OA  Arthrodesis—surgical fusion of the joint in a functional position  Arthroplasty—surgery that increases joint mobility  Arthroscopy—lighted instrument inserted to observe damage  Total Hip replacement—head of femur and acetabulum is replaced  Complications include: phlebitis, infection, poor circulation to affected limb  Osteotomy  Gouty Arthritis  Facts  Assessment ◦ Results from ◦ Excruciating pain esp. at night, edema, inflammation accumulation of uric acid ◦ Heat, discoloration in blood ◦ Tophi—deposits of uric acid ◦ Primary (hereditary) or in joints (can deposit in secondary kidneys and cause stones) (medications/another  Treatment disease) ◦ Colchicine or Indocin for or idiopathic (unknown) acute attacks ◦ Middle life onset ◦ Zyloprim, Febuoxstat, Benemid as maintenance ◦ Men rather than women drugs ◦ Most attacks occur in a ◦ Corticosteroids joint of the great toe, ◦ Avoid foods high in purines typically at night ◦ At least 2000 mL of water ◦ Diagnosis based on uric daily acid level of > 8.0mg/dl ◦ Bedrest during acute attacks  Osteoporosis  Results in loss in bone density; enough to lose mechanical support function of the bone  Affects vertebrae, neck of femur, pelvis, hands, and wrists  Etiology ◦ Women between ages 55-65 ◦ Cause not completely identified—but believed to be related to loss of estrogen ◦ Small boned, non-obese, menopausal white females  Contributing factors ◦ Sedentary lifestyle ◦ Too much protein, caffeine, sodium intake ◦ Low in calcium, vitamin D, fruits and vegetables ◦ Hyperthyroidism, chronic lug disease, alcoholism, smoking. ◦ Meds: steroids, anticonvulsants, immunosuppressant, heparin  Osteoporosis—S/S First symptom—usually fracture of vertebrae. Loss of height or stooped posture. Backache—low thoracic or lumbar, worsens when sitting, standing, coughing, sneezing, and straining Dowager’s hump Increased lordosis, scoliosis, kyphosis Assess gait r/t changes  Osteoporosis--Diagnosis Lab CBC, calcium, phosphorus, BUN, Creatinine UA, thyroid function Bone density test (densitometry) DXA scan  Cultural Considerations White women have highest incidence than Asian, then African American women. Hispanic and African American women have a lower risk of osteoporosis.  Medical Management 1200 mg Calcium 800 IU Vitamin D Weight bearing exercises Bone resorption inhibitors Alendronate (Fosamax), Risedronate (Actonel), etc First thing in morning with full glass of water, sit upright 30 minutes and give 30 minutes before other medicines, beverages, or food.  Medical Management Selective Estrogen Receptor Modulators Raloxifene (Evista) Decrease bone resorption Parathyroid hormone Postmenopausal women who can’t tolerate other meds Daily SQ injection for 24 months max Orthostatic hypotension, nausea, dizziness, leg cramps, hypercalcemia  Osteoporosis--Surgical Surgical Vertebroplasty—injection of type of cement in vertebral spaces to move vertebrae apart Kyphoplasty—involves use of balloon to aid in injecting cement into vertebral spaces— less risky Nursing interventions Keep flat as prescribed (usually first 4 hours) Monitor surgical sites Administer antibiotics and steroid as ordered  Osteoporosis—Nursing Interventions Diet Milk and dairy products Avoid caffeine Decrease excess protein Stop smoking Hormone Replacement Therapy - HRT Safety—handrails, raised toilet seats Weight bearing exercises Exercise – walking, riding bike, swimming at least 3 x week  Osteomyelitis  Inflammation of bone most commonly caused by pathogenic bacteria  Cause can be trauma or bacteria traveling in bloodstream from another site in body  No one uniform treatment  Antibiotics, hyperbaric O2, surgery possible  Watch for S/S new infection—can become septic—sudden temp elevation, tachycardia, pain  Gentle handling affected limb, good alignment, possible absolute rest  Diet high in protein, calories, vitamins  Diversional activities  Fibromyalgia Chronic syndrome, unknown etiology Pain to muscles, bone, or joints, soft tissue tenderness Contributes to poor sleep, headaches, altered thought processes, stiffness or muscle aches, depression, anxiety Women more than men, 20-50 Tension or migraine headaches Paresthesia hands and feet Observe for persistent limb movement, esp at night  No cure Diagnosis is by ruling out other conditions Tricyclic antidepressants, anticonvulsants, muscle relaxants, analgesics Non impact exercise, stretching Maintain regular sleep patterns  Knee Replacement Partial or Total Assess surgical site Aseptic techniques with dressing changes Pain relief measures including comfort measures Box 44.4 Monitor for complications  Hip Fractures S/S Complications Pain at fracture site Atelectasis/Pneumonia Shortening of affected DVT or fat emboli extremity External rotation Decubitus ulcers Inability to move leg Urinary retention voluntarily Constipation Depression  Hip Fractures Treatment Nursing interventions Temporarily Assess Neurovascular immobilized by Assess pain Buck’s or Russell’s traction Assess surgical wound Internal fixation: Monitor for infection Surgical Proper body alignment nailing/pinning Hip replacement Follow doctor’s orders for activity and positioning (Hemiarthroplasty) Monitor for and prevent May need constipation arthroplasty (surgical ROM on all unaffected reconstruction of joints joint)  Hip Replacement  Follow doctor’s orders regarding weight bearing and exercises  Maintain abduction (abduction splint) as ordered  No extreme hip flexion (>60 degrees) for 10 days  No hip flexion >90 degrees for 2-3 months  Avoid adduction of the affected leg beyond midline for 2-3 months  Maintain partial weight bearing status for approximately 2-3 months  Raised toilet seat and high, firm chair  No positioning on operative side  Avoid bending at waist, crossing legs, or sleeping on operative side for 2-3 months  Pain relief measures including comfort measures  High protein, high roughage diet  Apply TEDs as ordered  Aseptic technique with dressing changes  Assess surgical site Nursing interventions for total hip replacement Nursing interventions for total hip replacement Exercises—quad./gluteal setting Maintain abducted position as ordered to prevent dislocation of hip Avoid extreme flexion of hip No weight bearing until ordered  Classifications of Fractures Appearance – dependent on location Pain Crepitus Possible change in sensation Warmth Ecchymosis of surrounding skin Up to a few days later Location—proximal, midshaft, distal Displacement—sideways, override, angulate, rotate, shorten bone, obvious deformity  Classification of Fractures Closed or simple Open or compound Pathological Spiral Oblique transverse Runs along a slant  Classification of Fractures Greenstick Impacted Common type in very One bone end driven into the other bone end young children; incomplete fracture— Shortening seen in broken on one side, intact extremity of long bones on other Colles Complete Fracture of wrist broken through Usually occurs as person tries to break fall with completely hand Comminuted Transverse Splintered bone Runs directly across fragments bone  Treatment of Fractures Immobilize ASAP and Treat pain elevate Reduction 5 P’s Closed Assess for concurrent Open reduction with injuries internal fixation Infection, poor External fixation with cast or circulation, poor splint nutrition, improper Traction immobilization will Internal fixation with pins, interfere with healing plates, screws, wires, process prostheses  Complications of Fractures Fat Embolism Pulmonary fat embolism has tissue fat in circulation and occludes capillaries of pulmonary circulation, leading to hypoxia and tissue death Occurs within 48 hours of injury Manifestations Medical Management Nursing Interventions  Complications of Fractures Compartment Syndrome Compartment syndrome—caused by edema,—look for “5 P’s”—Severe, unrelieved pain, pallor, paresthesia, paresis, pulselessness Can occur due to tight cast/dressing Irreversible within 6 hours: Numbness, paralysis, sensory loss and permanent disability within 24-48 hours Arterial compression leads to ischemia Can result in permanent contracture called Volkmann’s contracture (lack of blood flow to forearm) Use proper positioning to prevent Nursing interventions: Elevate affected limb no higher than heart level to maintain arterial pressure Cold packs Remove constricting material Report drainage immediately Treatment fasciotomy (incision in fascia) to relieve pressure and return of blood flow to area. May be left open to heal.  Complications of Fractures Shock Blood loss from fractured bone or severed blood vessels, esp in open fractures, pain and fear (yes they can cause shock) Hypotension, tachycardia diaphoresis, tachypnea, then hypothermia (pale, cool, moist skin), oliguria Restore blood volume with IV fluids: LR and D5NS, blood, oxygen, frequent VS, monitor u.o., keep flat, NPO, keep warm  Complications of Fractures Gas Gangrene Severe infection of skeletal muscle, usually clostridium 1-14 days after injury Produce toxins Gas is produced under skin Wound infection s/s Manifestations Nursing Interventions Medical Management  Complications of Fractures Thromboembolism Clot that formed traveled to vessel and occluded it. Site may become cold, numb, cyanotic In lung (PE) sudden, sharp thoracic or upper abdominal pain, dyspnea, cough, fever, hemoptysis Other locations red, warm, edematous, affected leg larger, Anticoagulants Observe for bleeding Thrombectomy  External Fixation Devices Skeletal Pin External Fixation Immobilizes fractures with pins inserted through bone and attached to rigid external frame Assess q 4 hours for s/s infection Pin care Can shower when wounds healed  Types of Casts Spica Long leg/arm Short Leg/arm Full body—fractured vertebrae, spinal surgery  Cast Care Wet cast—plaster Dry cast May take 48 hrs to dry Petal edges Handle with palms, not fingers Protect from soiling Position and elevated on Neurovascular checks pillows Ice bags to external cast No powder under cast for 48 hours because of heat No object under cast to scratch Do not speed dry with fans or heaters (may use Inspect skin at cast edges cast dryer) Avoid weight bearing for Circle/date/time any 48 hours drainage Neurovascular checks Assess for foul odors Hip Spica & Body Casts  Do not use bar between legs for turning or lifting  Fracture pan  Smaller more frequent meals  Breathing exercises to prevent atelectasis  Monitor for cast syndrome—NV, abdominal pain, intestinal obstruction  Cast Removal Cast cutter vibrates—cannot cut patient Appearance—dead skin, smaller Support extremity carefully Exercises to promote strength and mobility No weight bearing until total bone healing Wash limb gently with soap/water, followed by lanolin or baby oil  Traction Skin Traction Balanced Pulling force by suspension/Skelet weights al Attached to skin with sponge rubber, Screws inserted moleskin, elastic into bone bandage Heavier weights Bryant’s traction Pin care Buck’s traction Russell’s traction  Traction  Skin  Skeletal ◦ Buck’s—temporary ◦ Overhead arm—upper immobilization—lower arm and shoulder extremities—Fx hip fractures or dislocations minor fx lower spine —each are at 90 degree angles and muscle spasms ◦ Russell’s—fracture of ◦ Lateral arm—also for upper arm/shoulder femur, hip and knee fractures and dislocations fractures ◦ Thomas splint with ◦ Bryant’s—fracture of Pearson attachment— femur in children esp. fractures of lower those younger than 2 extremities—do not raise ◦ Pelvic—sciatica, muscle the HOB > 25--do not let spasms feet press against FOB  Bryant’s traction Bucks traction Russell’s traction Skeletal Traction  Nursing Care of Patients with Traction Maintain proper alignment Weights hang free (don’t lift to move patient). Don’t allow them to touch floor  Avoid lifting or removing weights Assess skin under traction device for pressure/friction areas/infection Monitor for footdrop—from pressure on peroneal nerve Keep ropes in pulley grooves Elevate heels off bed With Bryant’s traction, buttocks should just clear the bed Neuro status q hour x 24 hours then q 4 hours Pulley ropes free of knots, fraying, loosening, improper positioning Heat/massage for spasms TED hose Elevate extremity  Care of Patient in Skeletal Traction Skeletal Assess pin sites Assess skin Keep weights hanging free Do not change weight w/o doctor’s order Neurovascular checks Keep ropes in the grooves of pulley system Maintain proper body alignment Pin Care  Assistive Devices Braces Slings Abduction pillows Knee immobilizers Trochanter roll Cane—for one sided weakness; held on strong side Crutches—weight on hands; unaffected or stronger leg goes upstairs first, going down stairs put crutches on next step and step down with weaker leg first, then stronger. Walker W/C Roll A Bout walker Abduction pillow, Knee Immobilizer and Trochanter roll  Other Orthopedic Devices Splints—support or immobilize—variety of materials; may be preformed; still need to monitor for neurovascular compromise Walking cast—allows greater mobility Air cast—inflatable Neck collars Milwaukee brace—encompasses the entire thoracic cavity—wear T-shirt underneath; used after spinal deformity corrections  Traumatic Injuries  Contusions – most common, simplest Elevation, cold for 15-20 min first 36 hours, then heat application  Sprains—ligaments, tendons, muscles ◦ Avoid weight bearing ◦ RICE ◦ Mild heat after 24 hours ◦ X-rays to R/O fracture ◦ For severe sprain, may need cast  Strain ◦ More severe than sprain ◦ Injury to a muscle or tendon due to overuse or overstretching ◦ If muscle is ruptured requires surgery  Whiplash  Caused by combo of severe flexion and hyperextension of neck  Most do not produce symptoms until days after injury  S/S include: pain that may radiate down arm to fingers, H/A, blurred vision, decreased skeletal function, weakened hand grip.  Treatment includes analgesics, muscle relaxants, intermittent cervical spine traction; immobilization, exercises, heat therapy,  Soft foam rubber neck brace  Traumatic Injuries Dislocation—congenital, trauma, joint disease process—bone temporarily displaced from normal position Severe pain with deformity and limited mobility Manipulated back into place Supported with splints, bandages, or cast Monitor for impaired circulation  Carpal Tunnel Syndrome Painful d/o of wrist and hand Risk factors Obese, middle aged women and people in repetitive movement occupations Pregnant women S/S Relieved by vigorously shaking or exercising hands Altered ability to grasp Paresthesia Hypoesthesia Treatment Splint PT Surgery if severe  Bone Tumors Primary or secondary Benign—may produce pain because of pressure on surrounding nerves/structures Malignant—spread to other areas Osteogenic sarcoma—younger; spreads to lungs; affects primarily long bones Anemia, spontaneous fractures Pain  Bone Tumors--Treatment Surgery with wide excision with resection, bone curettage, or amputation Radiation and Chemotherapy  Nursing Interventions Post op Neurovascular assessment Vital signs Analgesics Cast care or dressing care Assisting PT/OT Education on tumor recurrence and home care  Amputations Preop Intervention Like that of any other surgery Postop Intervention Monitor for bleeding—feel under remaining limb Neurovascular assessment hourly in postop period Prone position—for a period of time each day— helps prevent contractures Don’t elevate stump on pillow Plastic wraps to shrink and reshape residual extremity (stump) into a cone and help fit for prosthesis Prosthesis can be fitted 2-3 weeks post op.  Amputations Phantom limb pain Common-esp. first 6 mo. Rub the residual extremity Analgesics Education for discharge Positioning Exercises Stump wrapping techniques Ambulation techniques Skin care techniques