Care+of+persons+with+musculoskeletal+disorders.pptx

Care of persons with musculoskeletal disorders Brooke Eisele MSN, RN  Functions of Bones Provide structure and shape for our bodies Protect internal organs Movement: Acts as levers and connection points for muscles. Produce blood cells (hematopoiesis) in the bo...

Care of persons with musculoskeletal disorders Brooke Eisele MSN, RN  Functions of Bones Provide structure and shape for our bodies Protect internal organs Movement: Acts as levers and connection points for muscles. Produce blood cells (hematopoiesis) in the bone marrow Storage of minerals Osteoblasts- cells responsible for bone building Osteoclasts- Cells responsible for bone resorption  Bones Flat bones. Short bones  Bones Sesamoid bones Sesamoid bones are bones imbedded in a tendon, patella is Irregular Bones the main example, but they can also form in muscle and tendons as a result of stress  Hormonal influences on Bones Estrogen: - Induces chemicals in osteoclasts to stimulate self-destruction and slow the rate of bone destruction - Menopause makes women prone to bone loss Calcitonin and thyroid-stimulating hormone (TSH): - Inhibit activity of osteoclasts Parathyroid hormone: -Promotes the activity of and amount of osteoblasts; regulates calcium resorption Growth hormone: - Initiates the growth of bone until adult size is achieved 5 Overview of Muscle Tissues Skeletal Muscle Movements Skeletal Muscle Movements  Joints Nonsynovial joints  are joined by fibrous tissue or cartilage and are immovable.  Example is vertebral body, sagittal sutures, Synovial joints  are freely moveable because of the lubricating liquid called synovial fluid that fills the joint space.  Examples include elbow, wrist, and knee, hip  Cartilage  Receives nutrients from synovial fluid, Provides cushion to bone  Examples of cartilaginous joints: pubic symphysis, intervertebral disc 9 Ligaments, Tendons, and Fascia Ligaments: Fibrous connective tissues present at joints to help provide stability to the joint Tendons: Fibrous connective tissues that connect muscle to bone or structures such as the eye. Where ligaments provide stability, tendons facilitate movement Fascia: Layer of interconnected fibers of connective tissue with elastic properties that encloses, stabilizes, and separates muscles and internal organs Assessment  Past medical history and history of present illness Pain Temperature changes Swelling Altered sensation Stiffness Associated symptoms Deformity Responses to Weakness treatment Instability Loss of function  Physical assessment Posture- note curvature of the spine, position of the shoulders Gait- watch the patient walk Joint mobility- Ask the patient to perform ROM 12 Physical assessment  Take note of sensation  Pulses- Checked bilaterally.  Muscle tone- degree of tension, What is their ROM?  Muscle strength- Tested bilaterally. Pt is asked to push or pull against the assessor. 13 Diagnostics  Labs:  Xray, CT, MRI  Vitamin D  Bone mineral density studies  Calcium  Bone scan  Electromyography  Estrogen level, parathyroid, calcitonin  Arthroscopic examination arthroscopy  Arthrocentesis- aspiration of fluid from a joint 14 Muscular dystrophies  an inherited group of progressive myopathic (muscle) disorders that are caused by imperfections in normal muscle function  Can happen from infancy to any age.  Is a progressive disorder  Onset and progression depend on type  Symptoms include progressive weakness of voluntary muscle groups, leg pain, foot deformities, scoliosis, enlarged calf muscles, cognitive decline, severe contractures 15 Treatment of MDs  Goal: Prevention of deterioration  Supportive measures to improve functional capacity, Pain management  Diagnostics: Muscle Biopsy, serum Enzymes (Creatinine Kinase, AST, ALT, Lactate Dehydronase)  Medications: glucocorticoids, beta blockers (cardiomyopathy), antiepileptics (if seizures are present), Pain is treated with Tylenol and NSAIDs  Physical therapy, occupational therapy, speech therapy and nursing care can offer support in preserving function 16 Osteoporosis  Chronic deterioration of bone density, occurs when bone resorption is greater than rebuilding activity  Signs/Symptoms: pathologic fracture, loss of height, back pain 17 18 Nursing care  Diagnosis: Bone density scan, DEXA  Treatment: scan, Ultra sound Calcium(1200mg/day) ,  Safety: PREVENT FALLS Vitamin D (800 to 1,000 IU),  Prevention: Medications: Bisphosphonates Weight bearing exercise, healthy (alendronate), Calcitonin, diet including protein and estrogen therapy, parathyroid increased amounts of vegetables hormone (Table 53.5 Medications Maintain a normal weight Used in the Treatment of Abstain from alcohol, do not smoke Osteoporosis) 19  Things to consider: osteomyelitis - Virulence of infectious agent  Infection of the bone. can spread from - Patient immune status other infections in the body, from an - Underlying pathology open fracture, of from a chronic wound - Location and vascularity 20  Osteomyelitis  Diagnosis:, XR, CT, MRI, Bone biopsy  Treatment: IV antibiotics, Pain medication, Surgical Debridement 21 Nursing care Vital signs (Fever? Tachy?) Administer medications as Pain ordered Wound assessment (Is it getting Apply thermal/ cold therapy worse?) Range of motion Neurovascular assessment Education for safe movement (compromised circulation) Nutritional support (Multivitamin Laboratory tests (Draw BC prior to and Protein) antibiotics) Home health referral (Long term ABZ therapy)  Scoliosis  Risk factors Smoking Obesity Older age Occupational Sedentary lifestyle  Scoliosis  Medical management—Treatment Thermal therapy Physical and occupational therapy Progressive exercise regimen Pain management (Tylenol and NSAIDS for mild pain, Opiates are only for severe pain) Spinal fusion Assessment and interventions Pain  Pain management Kyphosis Meds, or thermal therapy Asymmetry of hip and shoulder  Assess for gait disturbances, Prominence of thoracic rib or promote safety scapula on one side  Assist pt into comfortable positions Asymmetrical leg length  Maintain orthotic device as ordered Cardiopulmonary compromise  Joint replacement  Intervention used to promote  Major complications: independence when there is Hypotension destruction of the joint that limits Bleeding mobility or causes pain. Hypovolemia  Is a Major surgery Wound site infection  Care is similar no matter what joint Deep vein thrombosis is replaced Pulmonary embolism Nursing care Administer medication as  Pre/Post op teaching: ordered  DVT prophylaxis Wound care  Pain med/ Bowel plan Early mobilization  Wound care (S/S of infection) Antiembolic stocking  Physical therapy/ Nursing care follow up Continuous passive range of  Maintain mobility per orders, Joint motion machine precautions (specific by joint) Proper positioning and turning  Incentive spirometer schedule  Use of adaptive equipment  Bone cancer  One of the more common childhood cancers  Treatment: Remove tissue, kill cancer cells (radiation & chemo), salvage the limb Bone Cancer- Nursing interventions— Assessments Level of consciousness Pain Weak pulses, pallor, pain, Neurovascular assessment paresthesia, paresis, and/or paralysis indicates a compromise in Palpation of mass neurovascular status Level of activity Bone Cancer- Nursing interventions—Actions Administer pain medication as ordered Chemotherapy and radiation Support and position affected extremities Apply thermal therapy as ordered Support the client’s psychosocial needs as cancer is a difficult diagnosis Musculoskeletal injuries Strain—Injury to muscle or tendon Sprain—Injury to ligament  Fracture- disruption in the bone 31 Fractures  Medical management—Treatment Nonsurgical  Closed reduction- Dr. Physically moves the broken bones into position  Casting for non-displaced fractures Surgical  Open reduction Internal fixation- hardware is inserted during surgery External fixation- hardware remains external to keep bones in alignment Fractures Traction is the practice of pulling on a broken bone or dislocated body part in a slow steady manner to realign it into proper position and keep it stabilized. The weights on traction should always be off the floor and freely hanging Fractures  Complications Neurovascular compromise- decreased blood flow Venous thromboemboli Fat embolism- bone marrow gets into circulation Traumatic rhabdomyolysis, compartment syndrome Hypovolemia Infection Malunion and nonunion Fractures- Nursing interventions—Assessments Vital signs- low bp, high HR, High RR = shock Physical assessment- pain, pressure, paralysis, pallor, paresthesia, and pulselessness. Check pulses on newly applied casts, swelling = risk of circulatory compromise. Verify proper positioning- traction, immobilizers Laboratory tests- myoglobin, CK, CBC, Urine appearance- dark if Rhabdomyolysis Intake and output- prevent or treat hypovolemic shock Fractures patient Teaching Treatment process Overview of healing process Consume adequate calories (protein, carbs, calcium Vits A, D, C) Appropriate use of analgesia- keeps people mobile! Wound care- prevents infection Exercise and ambulation- prevents loss of function Proper use of slings, splints, casts, and traction Self-care activities Injuries of the spine  Immobilize!  Use a back board for a spinal injury  Immobilize with a neck brace for neck injuries  Get imaging ASAP 38 Amputations Severing, or removal, of part of the body Traumatic (emergency to save a life) or elective (planned due to injury or disease process).  Complications: Hemorrhage, Infection, Contractures, Phantom limb pain, Neuromas. Priorities: maintain circulation, prevent infection, pain relief, promote independence, teach coping skills 39 Phantom limb pain  Pain felt in the residual stump  Lessens over time, but can be exacerbated by touch. Weather changes, stress, nervousness, exhaustion, and further sickness can also worsen the pain  Nerve signals from inflamed nerves get rerouted in the spinal cord, so the sensation is still felt where there is no limb.  Medications that work on neurotransmitters such as gabapentin are useful in phantom limb pain. 40 Nursing care Large bore intravenous line (IV) Vital signs Transfuse as ordered Complete blood count Administer analgesia Pulses nearest to the Alternative pain management injury Refrain from using pillow under lower Pain extremity Wound/incision site Application of ice for no longer than 15 to 20 minutes  Phantom pain feels real, and Nutrition needs to be treated with nerve Range of motion pain meds such as gabapentin Application of splint 41 Procedure for Wrapping the Residual Limb PREVENT FALLS DC teaching for new amputation  All caregivers of the site should practice hand hygiene.  Apply the figure-8 compression wrap and apply a splint if ordered.  How to assess pulses, color, and temperature of the residual limb.  Do not place a pillow under the leg causing the leg to bend, this leads to contracture. Instead, elevate the residual limb on a gradual incline.  Practice ROM to prevent atrophy and contracture.  How to safely take pain meds.  Community resources for support. 43 Carpal tunnel syndrome  Compression neuropathy of the hands  S&S: Sharp pain, numbness, tingling of the hand, reduced Grip strength  Risk factors: repetitive motion, female gender  Diagnostics: Patient history Phalen’s test Tinsel’s sign Nerve conduction studies MRI, US 44 Carpal Tunnel Syndrome Medical management— Treatment Diagnosis Modification of work Patient history environment -ergonomics Phalen’s test Ultrasound therapy Nerve conduction studies NSAIDs Steroid injections Night splinting Practice  The RN is assessing discharge needs of the patient diagnosed with osteoporosis prior to leaving the SAR facility. Which intervention is most important? A. Sending the patient with a script for a walker B. Telling the patient to avoid small animals C. Ordering a home environment evaluation D. Teaching the patient how to read a BMI chart. 46  Practice  The nurse asks a clarifying question after a teaching session for a patient with a new diagnosis of muscular dystrophy when he makes which statement? A. “I will focus on what I can do with my diagnosis, not what I can’t”. B. “I will need to start getting my affairs In order ASAP with this news”. C. “ I might have difficulty swallowing normal foods in the future and will have to plan my meals accordingly” D. “I will need to take Tylenol and Motrin for my pain if my contractures are acting up”. 47  Practice  The nurse provides care to a patient who experienced a femur fracture. Which clinical manifestation requires immediate notification of the healthcare provider? A. Pain B. Edema C. Nausea D. Restlessness 48  Practice  The nurse cares for a patient who had a cast placed 4 hours ago after a traumatic fracture to the lower leg. The patient tells the nurse that their toes feel numb on the affected side. What action should the nurse take first? A. Assess the toes for temperature and movement B. Notify the doctor C. Assess a set of vital signs D. Reassure the patient that this is normal 49 Match the abnormality A: Kyphosis B. Scoliosis C. Lordosis 3 1 2 50