Chapter 63: Caring for Clients With Orthopedic and Connective Tissue Disorders PDF

Timby’s Introductory Medical- Surgical Nursing, 13e Chapter 63: Caring for Clients With Orthopedic and Connective Tissue Disorders Copyright © 2018 Wolters Kluwer Health | Lippincott Williams & Wilkins Objectives  Explain the difference between rheumatoid arthritis and deg...

Timby’s Introductory Medical- Surgical Nursing, 13e Chapter 63: Caring for Clients With Orthopedic and Connective Tissue Disorders Copyright © 2018 Wolters Kluwer Health | Lippincott Williams & Wilkins Objectives  Explain the difference between rheumatoid arthritis and degenerative joint disease (osteoarthritis).  Describe nursing management of clients with arthritis.  Summarize the clinical manifestations of temporomandibular disorder (TMD).  Define the pathophysiology of gout, fibromyalgia, bursitis, and ankylosing spondylitis.  Delineate the nursing care required for clients with gout, fibromyalgia, bursitis, and ankylosing spondylitis.  Discuss the multisystem involvement associated with systemic lupus erythematosus. Copyright © 2022 Wolters Kluwer · All Rights Reserved Objectives  Identify the causes of osteomyelitis.  Explain the inflammatory process associated with Lyme disease.  Identify risk factors for development of osteoporosis.  Distinguish the pathophysiology of osteomalacia and Paget disease.  Differentiate between bunions and hammer toe.  Discuss characteristics of benign and malignant bone tumors. Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorder Arthritis  Arthritis: Characterized by inflammation and or degeneration of the joints  Osteoarthritis: Degenerative – Wear and tear  Rheumatoid Arthritis (RA): Autoimmune inflammatory disorder of connective tissue structures/joints of unknow origin o Characterized by chronicity, remissions, and acerbations o Most common sites are hands, wrists, knees, ankles o Symmetrical, proximal joints in hands.  Onset is acute typically 20-40’s. Genetic predisposition - mostly women and very disabling  Stiffness, joint pain, warmth around joints Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorders: Rheumatoid Arthritis (RA)  Pathophysiology and Etiology: Immune system attacks joint synovial tissue. Release chemicals called cytokines - that cause immune response. Can affect eyes, heart, lungs etc.  Assessment Findings: o Subcutaneous nodules, muscles atrophy, flexion contractures, classic deformities, warmth of joints, chronic pain worse in morning, weight loss  Diagnostic Findings: radiography, serum protein, RA factor electrophoresis, arthrocentesis, CRP/ANA tests  Medical and Surgical Management: decreasing joint inflammation, relieving discomfort, preventing deformities, restoring function (see Drug Therapy Table 63-1) DMARDS  Rheumatoid Arthritis RA Copyright © 2022 Wolters Kluwer · All Rights Reserved Joint changes Copyright © 2022 Wolters Kluwer · All Rights Reserved Rheumatoid Blood Tests  Rheumatoid factor (RF) o Type of antibody found in patients autoimmune disease  Estimated - 80% found in RA clients  Erythrocyte sedimentation rate (ESR) measures inflammation in body  C-reactive protein – measures inflammation  Antinuclear Antibody test – antibodies contained in nucleus of cell; identifies an auto immune disorder Copyright © 2022 Wolters Kluwer · All Rights Reserved Deformity of Fingers Early stages Late stages Copyright © 2022 Wolters Kluwer · All Rights Reserved RA Continued  Nursing Management  Teaching clients about the disease: management o Anti-inflammatory drugs (NSAIDS, DMARDS) o Steroids o Immunosuppressants calm the immune system o Physical therapy o Nutrition o Maintain Independence o Adaptive devices o Relaxation techniques o Sleep strategies Copyright © 2022 Wolters Kluwer · All Rights Reserved RA Remission Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorders: Degenerative Joint Disease/Osteoarthritis (OA)  Pathophysiology and Etiology: repeated trauma; degenerative joint changes (see Table 63-1) usually after 40 o Primary without cause o Secondary a know cause such as injury or congenital  Assessment Findings: Signs and Symptoms o Stiffness, pain, painless nodules, Heberden’s nodes, Bouchard’s nodes; distal joints of fingers o Degenerative process of cartilage wears away  ROM; crepitus, deformity of joint, limitations, bone spurs  Diagnostic Findings: radiography Copyright © 2022 Wolters Kluwer · All Rights Reserved Osteoarthritis Medical and Surgical Management: rest, exercise program, TENS unit, drug therapy, joint surgery, intra-articulation injection Nursing Management: Teaching ways to reduce inflammation and pain. Client Teaching: Medication, weight loss, dietary changes, avoid stress on joints Copyright © 2022 Wolters Kluwer · All Rights Reserved  Degenerative Joint Disease Osteoarthritis cont. Osteoarthritis o Exacerbated from overuse. Wear and tear disease o Weight –bearing joints. Asymmetrical o See comparison pf RA am Osteoarthritis 63-1 o More common after 40 o Develops slowly over years o Usually only pain with motion in beginning o Stiffness localized to involved joints, hips, back o Not systematic o No remissions Copyright © 2022 Wolters Kluwer · All Rights Reserved Heberden Nodes Bouchard Nodes Copyright © 2022 Wolters Kluwer · All Rights Reserved Joint Changes in Osteoarthritis Degenerative Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorders: Temporomandibular Disorder (TMD)  Pathophysiology and Etiology: degenerative arthritis, malocclusion of the teeth, bruxism (grinding of the teeth), dislocation of the jaw during endotracheal intubation, or other jaw injuries and trauma  Assessment: jaw pain, pronounced muscle spasm, and tenderness of the masseter and temporalis muscles, headache, tinnitus (ringing in the ears), and ear pain accompany the localized discomfort.  Medical and Surgical Management: dentist referral, NSAIDs, mouth guard, TENS, muscle relaxant, tricyclics, reconstructive surgery, bite guard.  Nursing Management: Nutrition, teaching on foods that can easily consumed without chewing. Nutrition consult Copyright © 2022 Wolters Kluwer · All Rights Reserved Temporomandibular joint Copyright © 2022 Wolters Kluwer · All Rights Reserved Gout Hyperuricemia  Primary: inflammatory disorder with accumulation of uric acid in the blood (hyperuricemia) o Excessive ingestion of purines (organ meats, steak, shellfish, sardines), heredity, starvation  Secondary: hyperuricemia Abnormal purine metabolism Increased rate of protein synthesis with overproduction or underexcretion of uric acid Increased cellular turnover, as in leukemia, multiple myeloma, and other cancers; some anemias; and psoriasis Decreased excretion of uric acid, as a result diuretics, salicylates, and/or excessive alcohol intake, particularly beer Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorders: Gout  Pathophysiology and Etiology: Inherited; painful metabolic disorder; inflammatory reaction in joints; affects men > women.  Assessment Findings: edema, recurring jaw pain, tenderness of one joint, fever, tophi (urate crystals) may be palpated, hyperuricemia (uric acid) can cause renal stones.  Diagnostic Findings: clinical signs, urine test, arthrocentesis, radiography or ultrasound. Elevated uric acid levels  Medical and Surgical Management: uricosuric drugs, decreased ingestion of purine, NSAIDs, colchicine, phenylbutazone, steroids surgery (see Drug Therapy Table 63-2)  Nursing Management (see Nutrition Notes 63-2) and Meds. o Management of pain, side effects of meds, fluids, diet Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Diet The prescribed diet includes: o Adequate protein, with limitation of purine-rich foods to avoid contributing to the underlying problem. o Relatively high in complex carbohydrates and low in fats because carbohydrates increase urate excretion and fats retard it. o Overweight clients are encouraged to lose weight o Fluid is encouraged to flush out uric acid Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? Gout affects more women than men. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: Gout is a very painful metabolic disorder, which causes inflammatory reactions in the joints, usually the feet, hands, elbows, ankles, and knees. Gout affects more men than women. Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorders: Fibromyalgia Syndrome  Pathophysiology and Etiology: widespread inflammatory illness cause unknown  Assessment Findings: o Chronic syndrome of musculoskeletal pain, fatigue, sleep disturbances; most common in middle-aged women  Affects muscles, ligaments, and tendons  Diagnostic Findings: diagnosis difficult; rule out other conditions to diagnose. Widespread chronic pain for 3 months.  Medical and Surgical Management: analgesics; steroids nontraditional therapies (see Evidence-Based Practice 63- 1) Rheumatologist Copyright © 2022 Wolters Kluwer · All Rights Reserved Fibromyalgia Syndrome and Treatment  Nursing Management: Goal decrease pain improve sleep  Antiseizure medication can help with sleep, reduce pain and fatigue. Antidepressants can also be used for sleep, muscle relaxers  Complementary alternative therapies (CAM) o Massage therapy, acupuncture, biofeedback, water therapy, guided imagery, meditation and mindfulness o Counseling to restructure lives. How to work around the chronic pain. Work, play o Nurses role is education, support, resources encouragement to live a healthy life style. Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorders: Bursitis  Pathophysiology and Etiology: Inflammation of the bursae, or adventitious physical trauma o Repetitive motion, trauma, infection, and effects RA or gout  Assessment Findings: painful movement of joint; elbow, knee or shoulder - distinct lump (bursa)  Diagnostic Findings: radiograph, fluid aspiration  Medical and Surgical Management: rest; salicylates, NSAIDs; corticosteroids; mild ROM exercises  Nursing Management: Support, teaching and resources Copyright © 2022 Wolters Kluwer · All Rights Reserved Bursitis of the Knee Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorders: Ankylosing Spondylitis (inflammation in spine)  Pathophysiology and Etiology: Chronic connective tissue disorder  progressive immobility, fusing of the vertebrae - etiology unknown  Assessment Findings: Inflammation of the spine o Low back pain, flattened lumbar curve, aortic regurgitation, permanently flexed neck, reduced lung sounds if Kyphosis develops (hunchback spinal curve).  Diagnostic Findings: ESR, CT scan, radiographs, CX - SF  Management: Mainly supportive treatment including medications, back brace, sleeping instructions, prescribed exercise, hip replacement. No cure on supportive measures  Nursing Management: Education and support, increase flexibility and strength Copyright © 2022 Wolters Kluwer · All Rights Reserved Spondylitis Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? There is no cure for ankylosing spondylitis. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 True There is no cure for ankylosing spondylitis. The aim of supportive treatment is to maintain functional posture. Medications are prescribed to relieve inflammation and pain. Copyright © 2022 Wolters Kluwer · All Rights Reserved Inflammatory Disorders: Systemic Lupus Erythematosus (SLE) #1  Pathophysiology & Etiology: autoimmune disease of unknown etiology - triggering mechanism; causes destruction of diffuse connective tissues; affects multiple body systems such as skin, joints, kidneys, heart lungs, brain, and lymph nodes. Systemic and chronic  Assessment Findings: o “Great Imitator” (Box 63-2) mimics other inflammatory diseases, i.e. Lyme disease - making it hard to diagnose. o More common in Black American women, Hispanic or Asian o Clinical signs; facial rash, proteinuria, hematuria, EKG changes, pulmonary changes, enlargement spleen, Raynaud’s, and musculoskeletal issues. Arthritis, joint swelling and pain Copyright © 2022 Wolters Kluwer · All Rights Reserved Lupus cont.: Other types of manifestations see Box 63-2 o Discoid Lupus  Chronic rash, red papules and scaling o Subacute Cutaneous Lupus  Papulosquamous lesions. o Behavioral Disturbances and other:  Confusion, hallucinations, irritability, o Chest pain (pericarditis), fluid retention, renal complications o Exposure to ultraviolet can reactivate the disease Copyright © 2022 Wolters Kluwer · All Rights Reserved Systemic Lupus Erythematosus (SLE) #2  Medical Management: producing remission; prevent/treat exacerbations or fares; medications o Renal, cardiac, GI, CNS symptomatic treatment  Diagnostic Findings: presenting symptoms; blood tests, renal biopsy, urinalysis. Anemia, thrombocytopenia, leukopenia, or positive ANA shows stimulated immune system. Anti-dsDNA is more specific.  Other test that indicate multi-system involvement. I.e. cardiac changes, GI, Repertory. Epstein Barr virus  Nursing Management: Client and family teaching (63-1) Focus on exacerbations to alleviate symptoms. Support, education, mobility issues, safety, skin o Reduce exposure to triggering factors, stress, cigarette smoke, sunlight Copyright © 2022 Wolters Kluwer · All Rights Reserved Classic Butterfly Rash Copyright © 2022 Wolters Kluwer · All Rights Reserved MUSCULOSKELETAL INFECTIOUS DISORDERS: Osteomyelitis  Pathophysiology and Etiology: pathogens; complications of bone (staphylococcus aureus). Bone infection  Assessment Findings: Sudden acute or chronic infection  Diagnostic Findings: ↑ leukocyte count and ESR; positive blood culture; anemia; radiographs; bone scans, MRI  Medical and Surgical Management: immobilization; surgical debridement, closed saline irrigation, antibiotic- impregnated bead application; bone or muscle flap grafts. Amputation as a last resort  Nursing Management: Supportive care, manage infection, amputation surgery Copyright © 2022 Wolters Kluwer · All Rights Reserved MUSCULOSKELETAL INFECTIOUS DISORDERS: Lyme Disease  Pathophysiology and Etiology: ticks act as vectors to transmit bacteria to humans; chronic inflammatory and multisystem disease. Joints, brain, cardiac, skin  Assessment Findings: 3 stages o First stage: localized distinctive rash resembles a bulls eye. Feelings of being unwell. May have numbness and tingling. May experience chills, fatigue. o Second stage all symptoms from first but worse. Spreads to other parts of the body. Short term memory loss o Late stage: mental health issues, MS, fibromyalgia Think your going crazy because misdiagnosed. Copyright © 2022 Wolters Kluwer · All Rights Reserved ‘Bulls eye rash Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2022 Wolters Kluwer · All Rights Reserved Lyme Disease cont.  Diagnostic findings: based on presenting signs and symptoms. ElISA test detects antibodies to B. burgdorferi. Western blot test is done if ESISA is +.  Medical and Surgical Management: antibiotics; supportive measures; prognosis good if Tx in early stages.  Nursing Management (see Client and Family Teaching 63- 2) Educate about preventions of Lyme disease. o Note: tick must be attached for 36 to 48 hours so early removal is important. Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 Is the following statement true or false? Lyme disease is spread via mosquito bites. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 False Rationale: Lyme disease is spread via deer tick bites. It is most common in the northeast and mid-Atlantic states and in other northern areas of the United States. Copyright © 2022 Wolters Kluwer · All Rights Reserved Structural Disorders: Osteoporosis  Pathophysiology and Etiology: loss of bone mass; women > men; causes; risk factors o Women who are small-framed, slim, white or European decent, postmenopausal in any ethnic group, genetic  Assessment Findings: o Lumbosacral, thoracic back pain; kyphosis o Brittle and porous bones. Bone loss and compression of vertebrae are common.  Diagnostic Findings: radiography, DEXA Scan Copyright © 2022 Wolters Kluwer · All Rights Reserved Osteoporosis  Medical and Surgical Management: calcium, vitamin D, drug therapy, HRT (decreasing use), exercise; relieving pain, preventing injury (see Drug Therapy Table 63-3 and Nutrition Notes 63-3)  Nursing Management: Education bone loss o Emphasize need for nutrition well balanced diet Foods high in calcium and supplements. Vit D Dairy products to acquire 100 to 1500 mg a day. o Wt. bearing exercises. o Medications: Bisphosphonates, Calcitonin, Esztergom, HRT Denosumab (slows none loss) Q 6 months o Nutrition Notes 63-3 Copyright © 2022 Wolters Kluwer · All Rights Reserved Osteoporosis and Aging Copyright © 2022 Wolters Kluwer · All Rights Reserved Structural Disorders: Osteomalacia  Pathophysiology and Etiology: insufficient calcium absorption; phosphate deficiency, softening of bones(see Box 63-3)  Assessment Findings: bone pain, weakness, deformities, waddling gait from bowing of legs.  Diagnostic Findings: radiography; serum levels  Medical and Surgical Management: adequate nutrition; exposure to sunlight; exercise; braces or surgery  Nursing Management: Address dietary deficiencies, safety and pain management. Copyright © 2022 Wolters Kluwer · All Rights Reserved Structural Disorders: Paget Disease  Pathophysiology and Etiology: abnormal bone remodeling. Bones grow larger and weaker.  Assessment Findings: bone pain, tenderness, skeletal deformity.  Mostly long bones, spine, pelvis, skull or legs.  Diagnostic Findings: radiography, bone scans  Medical and Surgical Management: drug therapy, surgery if limbs are damaged or misaligned.  Nursing Management (see Nursing Care Plan 61-1 in Chapter 61) Paget's disease Copyright © 2022 Wolters Kluwer · All Rights Reserved Structural Disorders: The Feet  Pathophysiology and Etiology: heredity, arthritis, improperly fitting shoes o Bunions; hammer toes, mallet toe  Assessment Findings: Signs and Symptoms: pain, tenderness, deformity, corns and calluses  Diagnostic Findings: radiography  Medical and Surgical Management: well-fitted shoes, exercises, pads, surgery, bunionectomy.  Nursing Management (see Client and Family Teaching 63- 3) Copyright © 2022 Wolters Kluwer · All Rights Reserved Foot Deformities Copyright © 2022 Wolters Kluwer · All Rights Reserved Benign Bone Tumors  Pathophysiology and Etiology: overgrown clusters of normal bone cells  Assessment Findings: Signs and Symptoms: pain, deformity, swelling  Diagnostic Findings: radiography, bone scans, biopsy  Medical and Surgical Management: surgery, curettage (scraping), bone grafts, splints or casts  Nursing Management Copyright © 2022 Wolters Kluwer · All Rights Reserved Malignant Bone Tumors  Pathophysiology and Etiology: radiation, toxic chemical exposure, heredity  Assessment Findings: Signs and Symptoms: primary tumors, location; pathologic fracture; difficulty in movement; abnormal gait, pain  Diagnostic Findings: radiography, MRI, bone scan, biopsy  Medical and Surgical Management: surgery, radiation, chemotherapy  Nursing Management Copyright © 2022 Wolters Kluwer · All Rights Reserved