Musculoskeletal Notes PDF

Musculoskeletal Cydnee Seneviratne PhD, RN Twyla Ens BSN, RN Shelley Deboer MN, RN Catherine Fox MN, RN Kaleigh McCartney MN, RN  Identify safe, effective nursing management of pharmacotherapeutic regimes for individuals...

Musculoskeletal Cydnee Seneviratne PhD, RN Twyla Ens BSN, RN Shelley Deboer MN, RN Catherine Fox MN, RN Kaleigh McCartney MN, RN  Identify safe, effective nursing management of pharmacotherapeutic regimes for individuals across the lifespan and their families Lecture experiencing chronic musculoskeletal disorders. Identify nursing outcomes and nursing Objectives interventions (therapeutics) related to chronic musculoskeletal disorders Osteoarthritis Osteoarthritis: Collaborative Care Focuses on: Managing pain and inflammation Preventing disability Maintaining and improving joint function Foundation for OA management is nonpharmacological interventions Drug therapy serves as an adjunct Osteoarthritis: Collaborative Care CT and MRI can lead to earlier diagnosis than X-ray Collaborative and Nursing interventions: Early on: rest relieves symptoms Heat and cold applications Nutritional therapy and exercise Complimentary therapies: yoga, massage, acupuncture Medications Long-term: surgery arthroscopic surgery removes debris Osteoarthritis: Medications Acetaminophen: max 4 g/day Topical agents: capsaicin or diclofenac diethylamine (Voltaren Emulgel) NSAIDs (as the disease progresses): Celecoib (Celebrex), diclofenac(Voltaren), ibuprofen, indomethacin, ketoprofen, ketorolac, meloxicam, nabumetone, paroxen, piroxicam, sulindac Antibiotics: doxycycline or minocycline Corticosteroids: methylprednisolone acetate, triamcinolone, dexamethasone, hydrocortisone sodium succinate, methylprednisolone sodium succinate, prednisone, triamcinolone Osteoarthritis: Medications Disease-Modifying Antirheumatic Drugs (DMARDs): methotrexate, sulphasalazine, leflunomide, D-penicillamine Gold compounds: oral--auranofin, parenteral—gold sodium aurothiomalate Antimalarials: hydroxychloroquine Immuno-suppressants: azathioprine, cyclophosphamide JAK (Janus Kinase) inhibitors: tofacitinib Biological and Targeted Therapies: tumour necrosis factor inhibitors, interleukin-1 receptor antagonist, interleukin-6 receptor antagonist  1 in 3 Canadian women and 1 in 5 Canadian men will experience a fracture due to osteoporosis. Definition: low bone density and deterioration of bone tissue Supplemental Calcium and Vitamin D helps Osteoporosis prevent osteoporosis Calcium: women over the age of 50yrs: 1200 mg of calcium/ day with diet or supplementation Vitamin D: 800-2000 units/ day for adults over 50 years or high-risk young adults Exercise: Weight-bearing activities build and maintain bone mass  Bisphosphonates Alendronate Etindronate disodium with calcium carbonate (Didrocal and Etidroncal) Risondronate Sodium Demipentahydrate (Actonel, Actonel DR) Osteoporosis Zoledronic Acid Medications SERMS Raloxifene Tamoxifen Calcitonin and teriparatide (stimulates bone formation) Denosumab (prevents bone resorption)  Bisphosphonates: drug of choice for osteoporosis Inhibit osteoclast mediated bone resorption SERMs: stimulates estrogen receptors in bone Mechanism of Action Teriparatide: only drug available that stimulates bone formation. Modulates the body’s metabolism of calcium and phosphorus Denosumab: monoclonal antibody that blocks osteoclast activation (prevents bone resorption)  Ralixofene: prevention Osteoporosis Bisphosphonates and calcitonin: for Drugs: prevention and treatment Teriparatide: high risk osteoporosis Indications  Bisphosphonates: drug allergy, hypocalcemia, esophageal dysfunction, inability to sit upright for 30 min after taking the med SERMs: known allergy, who are or may Osteoporosis: become pregnant, women with a history of venous thromboembolic disorder Contraindications Teriparatide: known drug allergy Denosumab: hypocalcemia, kidney impairment and infection  SERMs: hot flashes, and leg cramps; increased risk of venous thromboembolism and are teratogenic; puts pt at risk for leukopenia Osteoporosis: Bisphosphonates: headache, GI upset, joint pain. A chance for esophageal burn: take with Adverse Effects a full glass of water and remain sitting for 30 minutes. Teriparatide: chest pain, dizziness, hypercalcemia, nausea and arthralgia Denosumab: infections  Raloxifene: decreased absorption with cholestyramine and ampicillin’ decreases the absorption of warfarin sodium Osteoporosis: Bisphosphonates: absorption interfered by Drug calcium supplements and antacids; aspirin and NSAIDs may irritate GI symptoms Interactions  Many commonalities between fibromyalgia and SEID Fibromyalgia: Collaborative Interventions: symptom management Medications: pregabalin and duloxetine; antidepressants Ongoing support of healthcare team support important for patient and family Connective Many alternate therapies are helpful: massage, yoga, tai chi, low-impact exercise, biofeedback, Tissue Disease mindfulness, CBT therapy. Systemic exertion intolerance disease (SEID) (chronic fatigue syndrome) Diagnosis is by exclusion of other diseases Supportive management is essential as loss of livelihood is common due to fatigue, cognitive impairment Musculoskeletal Traumas  Sprains (ligaments) and Dislocation and subluxation strains (muscles) (thumb, elbow, shoulder, hip and patella) Most common symptoms: deformity, Musculoskeletal Most common symptoms: Edema, decreased function, bruising, pain pain, tenderness, loss of function and swelling trauma Immediate care: RICE Movement of joint while supported Nursing interventions: dislocation is an orthopaedic emergency: priority is to realign the joint Soft tissues Nursing interventions: warm up exercises Nursing management: pain relief, support of joint; extensive rehab program injuries Patient will be at increased risk of repeat dislocation  Carpal tunnel Rotator cuff injury and syndrome meniscus issues Nursing and collaborative care: Nursing and collaborative care: prevention is best; wrist treated with ice and heat, rest, splints, special keyboards. NSAIDS, corticosteroids Corticosteroid injections; surgery (open and physio. Musculoskeletal release or endoscopic carpal Surgery may be required. Avoid ‘frozen’ shoulder. Recovery tunnel release); outpatient trauma procedure may take 6 months Months of recovery needed; neurovascular assessment of hand important  Anterior Cruciate Ligament injury: most common sports injury Nursing and collaborative care: a positive Lachman test; MRI- shows co-existing conditions. Treatment of intact ACL includes: ice, rest, NSAIDS, elevation Reconstructive surgery: for complete tear in active patients. Allograft or autograft (hamstring or patellar ) ligament used. Rehab is crucial for functional return of knee—6-8 month recovery Musculoskeletal trauma Musculoskeletal fractures Goal of fracture treatment: Realignment of bone fragments Immobilization to maintain realignment Restoration of normal function of injured parts  Hip fracture 70-90% caused by osteoporosis; 95% result from a fall 10% die within the 1st month; 20% at 4 months; 30% at 1 yr Buck traction may be applied pre-surgery Surgery options: internal fixation devices; partial hip replacement (replacement of femur with prosthesis); total hip replacement (involves both femur and acetabulum)  Facial Fractures Pelvic Fractures High mortality rate​ **Ensure patent airway** May be missed on initial triage​ Treat pt also for c-spine injury (often Possible damage to abdominal, concurrent) until proven otherwise GI/ GU organs​ Nutrition a priority high pain levels​ Mandible fx may also be therapeutic for Pt at high risk for DVT, sepsis or malocclusion fat embolism syndrome (FES) Post-op care: ensure oral hygiene, Facial/Pelvic communication, pain management Wire cutters required in close proximity Fractures  Closed Reduction Open Reduction Musculoskeletal Nonsurgical, manual realignment of Correction of bone alignment through Fractures: bone fragments. Traction surgical incision. and countertraction utilized Internal fixation requires Nursing while pt under general wire, screws, Interventions anesthesia. Casting immobilizes the injured plates, pins. Infection a risk. Continuous passive ROM and part to allow healing machines may aid healing. Collaborative Care Musculoskeletal fractures Open reduction: external fixation Internal fixation MSK assessment How are limbs wrapped/ casted? Why? Musculoskeletal fractures Casts: typical with closed reduction; immobilizes joint above or below the fx. Upper extremities: sugar- tong splint, short arm, long arm, posterior splint Vertebral injury: body jacket Lower extremity: long cast, short cast, cylinder cast, Jones dressing or splint. Hip spica cast used in pediatric setting Musculoskeletal Fractures: Traction Skin traction Skeletal traction  Musculoskeletal fractures: Interventions Pain Nutritional Cast Ambulation is medication, therapy: care: neuro- important: muscle adequate vascular non-weight relaxants protein (1g/kg assessments, bearing, (Robaxin), of body observe for touch down tetanus weight); edema, weight immunization vitamins, calc compartment bearing, toe- and ium, syndrome, NO touch weight- antibiotics phosphorus, scratching or bearing, (cefazolin) and putting partial weight This Photo by Unknown author is licensed under CC BY-SA. may all be magnesium objects inside bearing , required necessary for the cast, keep weight healing cast dry. Cast bearing as removal in tolerated, full outpatient weight setting bearing  Bone infection Bone malunion or nonunion Avascular necrosis Complications Compartment syndrome of Fractures Deep vein thrombosis Fat embolism Traumatic or hypovolemic shock Complications of fractures Infection High incidence in open fractures and soft tissue injuries Devitalized and contaminated tissue is the ideal medium for pathogens.  Two basic types of compartment syndrome ↓ compartment size Resulting from restrictive dressing, splints, casts, excessive traction, or premature COMPARTMENT closure of fascia ↑ compartment size SYNDROME Related to fracture, bleeding, edema, chemical response to snakebite, or IV filtration  Compartment Syndrome Pain: Distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle travelling through compartment Pressure: ↑ in compartment Paresthesia: Numbness and tingling Pallor: Coolness and loss of normal coloyr of extremity Paralysis: Loss of function Pulselessness: Diminished/absent peripheral pulses Compartment Syndrome Urine output must be assessed because there is a possibility of muscle damage. Myoglobin released from damaged muscle cells precipitates as a gel-like substance. Common signs of myoglobinuria Dark reddish brown urine Clinical manifestations associated with acute renal failure Compartment Syndrome Surgery FAT EMBOLISM SYNDROME (FES) Early recognition crucial in preventing potentially lethal course as clinical course of fat embolus may be rapid and acute Most patients manifest symptoms 24 to 48 hours after injury. Patient frequently expresses a feeling of impending disaster. In a short time, skin colour changes from pallor to cyanosis. This Photo by Unknown author is licensed under CC BY-NC-ND.  Elective versus emergency surgery Day surgery: procedures lasting 2 hours or less; requires 3-4 hour stay in post anesthesia care unit (PACU) Pre-Op clinic: decreases surgical delays, reduces patient anxiety through education and answering questions Preoperative Instructions for: routine medications on day of surgery, which care medications or herbal remedies to stop (e.g., anticoagulants), NPO instructions, pain management options, infection prevention, post-op discharge and care Day of surgery: OR checklist and consents signed; pre-op meds and IV insertion Hair clipped; NOT shaved Intraoperative Care Circulating nurse role: interprofessional time-out Not scrubbed, gowned or wearing sterile gloves; documents Scrub nurse role: scrubbed, gowned, with sterile gloves. Assists with surgery, instruments, surgical count of equipment Surgeon and Assistant Anesthesiologist: medications for pain and sedation; intubation Electrocautery: common equipment used for incisions and cauterizing blood vessels. Requires grounding— pad often placed on thigh of patient This Photo by Unknown Author is licensed under CC BY-ND Intraoperative Care: Anesthesia General anesthesia: loss of consciousness, skeletal muscle relaxation, amnesia and analgesia Local anesthesia: loss of sensation in a specific area, no loss of consciousness; may be achieved through topical, SC, or intracutaneous administration route. Regional anesthesia: spinal, epidural, peripheral nerve blocks Procedural (conscious ) sedation: mild depression of consciousness. Patient maintains their airway  Some definitions: Arthroplasty is the ________________ Surgical Procedures Hemiarthroplasty is the_____________ Surgical Procedures: Hip Fracture Surgical Fixation http://www.ecios.org/ArticleImage/0157CIOS/cios-5-10-g003-l.jpg Surgical Procedures: Indications for joint replacement Relieve Chronic pain Improve Joint mobility Correct Malalignment Remove Intra-articular causes of erosion Surgical Procedures: Total Hip Replacement (THR aka total hip arthroplasty – THA) Surgical Procedures: Hip Resurfacing (“Birmingham”)  Older age group: related to diabetes mellitus: atherosclerosis, vascular changes, PVD Surgical Two types: residual limb and disarticulation Residual limb: closed amputation: anterior skin flap with Procedures: soft tissue padding over the bony prominence. Skin flap is situated posteriorly. Disarticulation: through a joint Amputation Body image: psychological and social implications Phantom limb sensation/pain (neurogenic pain)  Prosthesis: patient may weight bear 3 months post-surgery Prosthetist: fits limb fit for prosthetic Proper residual limb bandaging fosters Surgical shaping and moulding. Procedures: Compression bandage: supports soft tissue, reduces edema, minimizes pain, hastens Amputation healing, promotes limb shrinkage Physiotherapy is essential Walking: below the knee prosthesis requires 40% more energy; above the knee amputation requires 60% more energy Postoperative Care PACU (post anesthesia care unit): Located near the OR Monitor: ABC’s Serial Vital signs Resp: oxygen status Pain assessment Post-op bleeding GU: urine output Cardiac: ECG delayed ambulation Short stay (a few hours) OR---to PACU—patient transferred back to day surgery or surgical unit SBAR handoff report important at each stage Postoperative Care MSK Assessments and Interventions Colour Warmth Sensation Movement Pain Pallor Pulse Paresthesia Paralysis Postoperative Care Postop (Day of surgery) Postop (Day 1) Postop (Discharge) Monitor: Monitor: Monitor: ABC’s Vital signs (including pain Vital signs (including pain Vital signs (including pain assessment) assessment) assessment) Ambulation Ambulation Resp: oxygen status Resp: oxygen status Surgical wounds (infection) Surgical wounds (Post-op Surgical wounds (Post-op Discharge: restricted bleeding, drains) bleeding, drains, infection) activities: ambulating, lifting, GU: urine output GU: urine output driving, work, sex; follow-up GI: N/V, diet GI: N/V, diet with surgeon Limited Ambulation Labs Labs Labs Resp: oxygen status GU: urine output GI: N/V, diet Enhanced Recovery After Surgery (ERAS) Protocol Standardized care for before, during, and after surgery. Created to help shorten hospital stays and reduce surgical complications. Evidence based practice related to nutrition, mobility after surgery, fluid management, anesthesia and pain control. AHS resources  Osteomyelitis: infection of the bone Collaborative care and nursing interventions: IV antibiotics Pain control (NSAIDS, opioid Musculoskeletal analgesics, muscle relaxants) Surgical debridement and Complications: decompression Possible: septic shock Osteomyelitis Debridement: Surgical removal of chronically infected tissue that is not healing Long-term complications: muscle flaps, skin grafting, amputation  Leading cause of lost productivity in the workplace Acute back pain NSAIDs or muscle relaxants Stay active Bed rest should be limited; may be Musculoskeletal harmful Complications: Chronic back pain NSAIDs Back Pain Weight reduction Sufficient rest periods Heat or cold applications Exercise Tricyclic antidepressants Pediatric Musculoskeletal Conditions Deformities of the spine Kyphosis Lordosis Scoliosis Kyphosis Nursing Interventions Empower the adolescent that exercise to strengthen Range from simple shoulder and abdominal exercises to surgery muscles has cosmetic appearance value Brace may be required Regular therapy sessions until muscle maturity occurs Surgery is a last resort for spinal fusion in severe, and painful deformities  Accentuation of the cervical or lumbar curvature May be secondary to a disease process; may be from trauma; or idiopathic Associated with flexion contractures of the hip, scoliosis, obesity, developmental dysplasia of Lordosis the hip, slipped capital femoral epiphysis Often painful Treatment: treat predisposing cause; support garments Scoliosis Diagnosis Adams forward test Scoliometer: measures truncal rotation x-rays are definitive 100 of curvature needed for diagnosis 250 of curvature= mild and requires ongoing observation Risser scale Scoliosis: treatment Observation Based on magnitude, location and type of curve Bracing: often the treatment of choice for mild curves Boston and Wilmington braces TLSO—thoracolumbosacral orthotic Surgery: anterior or posterior approach may be used Luque-rod Cotrel-Dubouset Dwyer or Zielke  Difficult time as adolescence is a time of identify formation Surgical pre-op: X-ray; pulmonary function tests, lab tests Scoliosis: Significant blood loss expected Post-op: Nursing PCA—significant pain, foley catheter, log-roll Interventions Possible brace Assessment: wound, neuro, circulation, VS Mobilization (depending on surgical approach) Personal items for comfort and distraction Cerebral Palsy Characterized by abnormal muscle tone and coordination Most common permanent motor disability in childhood Low birth weight infants at high risk (100x) Cause: believed to be from existing prenatal brain abnormalities Cerebral Palsy Therapy goals Typical Treatments To establish locomotion, communication and Ankle-foot orthoses/ Wheeled go-carts for self-help skills mobility To gain optimal appearance and integration of Orthopedic surgery: due to contractures and motor functions spastic deformities, spinal fusion; dorsal rhizotomy To correct associated defects Pain: spasms To provide educational opportunities adapted Medications: dantrolene sodium, for the child baclofen, diazepam, Botulinum toxin A To promote socialization experiences with other AEDs: children carbamazepine (Tegretol), divalproex (valproate sodium and valproic acid)  Cerebral Palsy: Nursing Interventions ADLs (majority of time and effort spent) Dental hygiene Frequent rest periods needed Toilet training Diet: gastrostomy feedings may be necessary Electronic devices: give biofeedback; may Jaw control an issue improve, eye-hand coordination and body mechanics Vocational training Participate as able Behavioral issues: ADHD and learning delays Additional Support Emotional support Vision difficulties Siblings Speech pathologist may help with speech and feeding issues Hospitalization Possible respite Physiotherapist: assist with mobility and stretching  Neural tube defects: largest group of congenital anomalies Decreased rates of NTD due to prenatal supplementation and termination of pregnancies have affected incidence rates (folic acid Neural tube supplements) Encephalocele and anencephaly are abnormalities defects from the anterior end of the neural tube not closing Encephalocele: herniation of brain and meninges through a skull defect; may be from hydrocephalus; shunting main intervention Anencephaly: most serious NTD; both hemispheres of brain are absent; incompatible with life  Diagnosis based on clinical manifestations CT, MRI, ultrasound, neuro evaluation Spina bifida cystica: Bowel and bladder dysfunction Motor dysfunction of lower extremities Hydrocephalus Orthopedic deformities Spina bifida Spina bifida occulta: Skin depression, port-wine angiomatous nevi or dark tufts of hair Gait disturbance with foot weakness Bowel and bladder sphincter disturbances  Closure within 24 hrs of birth ideal when CSF leaking Objective is skin coverage Shunt procedures may be required to deal with hydrocephalus Chiari II malformation only deal with if child is symptomatic Myelomeningocele Prenatal surgery more effective than postnatal surgery Postnatal surgery: prevent infection with broad spectrum antibiotics, skin closure of myelomeningocele within 12-72 hours Myelomeningocele  Long term issues: Hydrocephalus and shunt malfunctions Chiari II development Scoliosis Bowel and bladder management issues Latex allergy Spina bifida Epilepsy Prevention Rates dropped from 1997-2007: 0.86/1000 to 4.0/10,000 births Folic acid supplementation Early abortions  DMD: Duchenne muscular dystrophy; most common form of muscular dystrophy Genetic origin: gradual degeneration of muscle fibers Lifespan affected Supportive measures of physio and orthopedic Muscular procedures dystrophy High genetic component: 65% have family history Dystrophin is absent or reduced (a protein product in skeletal muscle) Muscular Dystrophy: DMD X-linked recessive trait; rarely a female will Isolation of pt and family requires have DMD support Normal development; muscle weakness Long term care options appears between 3-7 yrs End of life directives needed Ambulation impossible by 12 yrs of age Palliative care should be discussed Other symptoms: osteoporosis, fractures, constipation, skin breakdown, atrophy of facial oropharyngeal and respiratory muscles—leading to the requirement for long term respiratory support Cardiomyopathy seen in 50-80% of DMD pts Mild to moderate cognitive impairment commonly found