NURS 3510 Musculoskeletal PDF

Coordinating Care for Patients With Musculoskeletal Disorders Carlie Hunt, MSN, RN NURS 3510 Clinical Judgement in Nursing for Simple and Stable Conditions Auburn University College of Nursing  1. Recognize assessment findings for patients with neuromusculoskeletal...

Coordinating Care for Patients With Musculoskeletal Disorders Carlie Hunt, MSN, RN NURS 3510 Clinical Judgement in Nursing for Simple and Stable Conditions Auburn University College of Nursing  1. Recognize assessment findings for patients with neuromusculoskeletal illnesses. 2. Employ appropriate nursing interventions for simple or stable neuromusculoskeletal illnesses. 3. Evaluate the effectiveness of nursing interventions for simple or stable neuromusculoskeletal illnesses. Learning 4. Identify individual risk factors for neuromusculoskeletal illnesses and health promotion strategies to decrease Objectives incidence. 5. Collaboratively manage the care of patients experiencing neuromusculoskeletal alterations. 6. Identify appropriate health education for patients, families, and communities experiencing neuromusculoskeletal alterations. Osteoarthritis  Osteoarthritis What is it? A slowly progressive noninflammatory disorder of the synovial joints Disease that affects the joint as a whole because of biological, chemical, & viscoelastic changes within the joint Characterized by progressive deterioration of the articular cartilage Cartilage destruction outweighs production Also referred to as degenerative joint disease Osteoarthritis Pathophysiology  Osteoarthritis Pathophysiolog y Cartilage loss Unprotected bone Deterioration of joint function Synovial membrane thickens Joint surface becomes uneven --> restricted joint movement Muscle atrophy Epidemiology Most common form of arthritis in U.S. 27 million people in U.S. Leading cause of chronic disability Postmenopausal loss of estrogen Osteoarthritis Risk Factors Age 80% over age 55 affected Female sex Genetics Family history Other bone/joint disorders Obesity Occupation Metabolic disorders Common Joints Affected- Figure 20.1 Knees Hips Feet Lumbar spine Cervical spine Proximal interphalangeal joints Distal interphalangeal joints of the hands Osteoarthritis of the Hand  Osteoarthritis Clinical Manifestations Progressive pain over time ▪ Increased with activity & relieved with rest Decreased range of motion Tenderness to touch Swelling Crepitus https://www.youtube.com/watch?v=287N SXirWeA - crepitus sound example  Medical Management—Diagnosis History Laboratory testing ▪ ESR- elevated in RA, usually normal in OA ▪ CRP- elevated in RA, usually normal in OA Radiographs (X-ray)(decreased joint space, possible fractures from the grading, bone spurs) CT & MRI ▪ Not typically used for diagnosis but can help  Medical Management—Treatm ent No cure o Goal: Decrease pain, maintain mobility, increase joint strength Nonpharmacological therapy ▪ Weight loss ▪ Heat & cold ▪ Aerobic exercise ▪ PT/OT, orthopedic physician, rheumatologist, dietitian, ▪ Ambulatory assist devices ▪ Therapeutic footwear ▪ Joint protection- braces/splints ▪ Energy conservation Medical Management—Medications Acetaminophen- hepatotoxic ▪ Do not exceed 4 g/ day NSAIDs- nephrotoxic mainly (but can also be hepatotoxic esp. with long term use) Corticosteroid or hyaluronan injections- if Tylenol(is toxic to liver) or NSAIDs( toxic to kidneys) do not help Opioids Surgical Management Arthroscopic irrigation and/or debridement Arthroscopic synovectomy Surgical fusion Total joint replacement (total arthroplasty) Total or Partial Knee Arthroplasty Total Hip Arthroplasty Complication s Due to decreased mobility/exercise Exacerbate diabetes Exacerbate heart failure Nursing Management—Assess ment & Analysis Unsteady gait Swelling Fatigue Painful ROM Elevated serum creatinine ▪ secondary to NSAID use Elevated liver enzymes ▪ related to polypharmacy, &/or prolonged NSAID use Constipation Nursing Management—Nursing Diagnoses Pain Ineffective sleep patterns Self-care deficit Nursing Interventions—Assess ments Vital signs(increased HR/BP due to pain, BP due to kidneys bc of meds) look out for pressure ulcers check bony prominences Weight Skin integrity Monitor serum creatinine Monitor LFTs(liver function tests) Nursing Interventions—Actions Administer analgesic & anti-inflammatory medications, should be short term Cold packs Heat pad Nursing Interventions—Teaching Take medications as prescribed Report chest pain, abdominal pain, abnormal bleeding Participate in regular physical activity PT & OT Orthopedic surgery Home health referral Nursing Management—Evaluating Care Outcomes Maintain normal function Pain control Unrestricted movement Gout  Gout What is it? Systemic disease in which uric acid crystals are deposited in joints, bone, & soft tissues, accompanied by inflammation Also called "gouty arthritis" Primary & secondary classifications most commonly seen in the big toe joint very painful  Gout Patho Purines from certain foods are broken down into uric acid which can be eliminated by the kidneys Kidneys cannot excrete enough uric acid or there is too much being made for the kidneys to eliminate --> hyperurecemia Urate crystals deposit into soft tissues & joints Inflammatory process --> swelling, warmth, intense pain in affected joint Epidemiology 2% of people in the US Men aged 40 to 60 Women aged 55 to 70 Black individuals have higher incidence than white individuals Risk Factors Obesity Hypertension Diet high in meat & seafood Thiazide diuretics Aspirin Consuming large quantities of alcohol(beer) watch for food with high purine content  Clinical Manifestations Acute Acute onset of pain, redness, swelling Intercritical Asymptomatic period between gout attacks Chronic Repeated attacks of many years, leading to the production of tophi (uric acid deposits or nodules in the joint) & joint destruction  Medical Management—Diagnosis Diagnosis is often made based on symptoms alone Synovial fluid aspiration Gold standard Uric acid crystals present in synovial fluid Medical Management—Nonp harmacologic Treatment Weight management Limit alcohol Avoid foods high in purines (image) Avoid foods/beverages high in fructose Splinting affected joint  NSAIDs – for acute ▪ Anti-inflammatory Indomethacin (Indocin) Ibuprofen (Advil) Adrenocorticotropic hormones(ACTH)- for acute ▪ Anti-inflammatory Medical ▪ Option if NSAIDS or steroids are problematic Management— Antigout Agent- for acute & chronic Medications ▪ Anti-inflammatory ▪ NSAID is added to treat pain for acute Colchicine (Colcrys) can be used to prevent acute flares for patients with chronic gout  Glucocorticoids- for acute if unresponsive to NSAIDs or unable to take NSAIDs § Anti-inflammatory Medical Prednisone Management § Uric acid–lowering agents/Xanthine oxidase inhibitors- for chronic, never for acute —Medications § Decrease uric acid production Allopurinol (Zyloprim) Febuxostat (Uloric) Common Antigout Medications Complications Kidney stones ▪ May develop pyelonephritis (infection), kidney injury, or kidney disease Severity varies, may cause: ▪ Progressive disability ▪ Joint deformity ▪ Large crystals can cause a break in the skin- risk for infection ▪ Cartilage destruction causing secondary OA Nursing Management—Assessment & Analysis Intense joint pain Tenderness on palpation of affected joint Swelling of affected joint Erythema of affected joint Warmth over affected joint Decreased ROM Presence of tophi Nursing Management—Nursing Diagnoses Pain Knowledge deficit Nursing Interventions—Assessments Monitor uric acid level Assess for presence of tophi Assess for red, swollen, painful joints Assess pain levels Nursing Interventions—A ctions Administer medications as ordered Only use warm compress bc cold can help uric acid crystals grow Nursing Interventions—Teaching Avoid alcohol Take medications as directed Report flares promptly Proper nutrition Nursing Management—Evaluating Care Outcomes Eliminate gout flares Prevent joint destruction Osteoporosis  Osteoporosis What is it? A chronic condition that results in deterioration of bone tissue & density, increasing a patient’s risk for fractures Bone loss (osteopenia) occurs when bone resorption is greater than bone rebuilding --> decreased bone mineral density osteoblasts bud build bone, osteoclasts break down bone Bone Metabolism Quick Review  Epidemiology 10.2 million Americans have osteoporosis 54 million Americans have low bone density After menopause, 50% of women will sustain an osteoporotic fracture  Risk Factors: Primary Genetics: Age (older than 50 & postmenopausal) Sex (females greater than males) Ethnicity (European or Asian descent) Family history Smaller body frame ( 3 months Anticonvulsants Heparin therapy Thyroid hormones  Disease pathology Cushing’s disease Hypogonadism or premature menopause Malabsorptive issues (Crohn’s, celiac disease, gastric surgery, etc.) Chronic liver disease Risk Inflammatory bowel disease Factors: Rheumatoid arthritis Secondary Hyperthyroidism Hyperparathyroidism Previous fracture Other Parental history of hip fracture Recurrent falls Prolonged immobilization Clinical “Silent disease” Manifestatio not diagnosed until fracture ns occurs after a fall or strain Pathologic fracture (due to fragility) Medical Management—Diagn osis H&P Bone mineral density (BMD) tests ▪ Dual-energy x-ray absorptiometry (DEXA) scan Quantitative computed tomography (QCT Scan) Fracture Risk Assessment Tool (FRAX) Lab tests to rule out secondary osteoporosis and/or other metabolic bone disorders (i.e. Paget’s disease, osteomalacia) Medical Management—Treatment Prevention & early screening Weight loss & muscle-strengthening exercises reduce the incidence of falls & fractures Healthy lifestyle choices avoid smoking & excess ETOH  Medical Management—Medications Table 53.5 Med Surg text pg 1281 Calcium & vitamin D supplement Bisphosphonate(blocking action of osteoclasts= no breakdown of bone)( can cause hypocalcemia)( if calcium is low it can cramping and cardiac dysrhythmias) Alendronate (Fosamax) Calcitonin Estrogen/hormone therapy Only need 15 minutes of sunlight everyday for adequate vitamin D Medical Management—Medications Selective estrogen receptor modulators (SERMs) (agonist/antagonist)(promotes calcium reabsorption)(can cause blood clots, DVT, and could possibly lead to a stroke) Raloxifene (Evista) Parathyroid hormone Parathyroid hormone analog Monoclonal antibody not firstline only for high-risk patients not benefitting from other therapies Complications Falls Prolonged hospitalization Death  Nursing Management—Assessment & Analysis Clinical manifestations associated with decreased bone density- common findings include: “Dowager’s hump” (kyphosis of dorsal spine) Loss of height (loss as great as 2 to 3 in.) Back pain (sharp or acute)  Nursing Management—Assessment & Analysis Pain increased with activity and relieved with rest Restriction of movement, especially thoracic & lumbar Fear of falling, and/or history of previous falls Previous fractures Nursing Management—Nursing Diagnoses Risk for trauma Impaired physical mobility Risk for falls Nursing Interventions—Assessments Fall risk Pain Nutrition Activity and exercise Body image disturbance Nursing interventions—Actions Administer medications as ordered Exercise program Training for safe activities of daily living Home health referral Nursing Interventions—Teaching Take medication as prescribed Weight reduction Calcium and vitamin D supplementation  Nursing Management—Evaluatin g Care Outcomes Early identification of risk for osteoporosis & fracture Compliance with medication Maintain healthy lifestyle Paget's Disease of the Bone (PDB)  Paget’s Disease of the Bone (PDB) What is it? Bone metabolism disorder associated with accelerated bone remodeling --> structurally abnormal bone Increased osteoclast size & number causes accelerated bone resorption Osteoblasts then form new bone at an accelerated rate Larger bone does not mean stronger bone in PDB (disorganized & brittle)  Epidemiology 1% to 2% of white adult male population older than 55 years of age most affected It is most commonly associated with men of European, Dutch, and/or British descent For reasons not completely understood, the disease is most common in the United Kingdom Risk Factors Genetics Age Measles as a child Gene from measles virus has been linked Thought to be an environmental trigger Clinical Manifestations Most common: Pain Deformity at affected bony site Fracture  Clinical Manifestations If advanced disease: Can cause cardiac & neurologic complications Heart Failure Loss of bladder/bowel control Hearing &/or vision loss  Medical Management—Diagnosis H&P Radiographical examination Routine laboratory chemistry Increased serum alkaline phosphatase (ALP) with no evidence of hepatobiliary disease Medical Management—Medications Treatment goals: Pain management Improved functional outcomes Analgesia- Aspirin, NSAIDs, opioids (if severe) Calcitonin Many side effects & resistance seen over time Bisphosphonates Zoledronic acid, IVPB Preferred medication Surgical Management Joint replacement Spinal decompression (adding more joint space for the nerves that are coming out of the spine) Spinal Decompression info: https://www.youtube.com/watch?v=3_PIRi_tNlQ - https://www.youtube.com/watch?v=KmIHkW4WqNc Complications Skeletal changes Impingement on auditory nerve Weakened bones --> increased risk fractures Osteosarcoma  Nursing Management—Assess ment & Analysis Generalized pain, especially in the lower back, & bone pain Deformity of long bones &/or cranial bones Deafness and/or paralysis of other cranial nerves Fissures of the cortex  Nursing Management—Assessment & Analysis Spinal curvature changes § scoliosis or kyphosis § Spinal cord compression § neurological impairment Complete or incomplete fractures Increased heat in the skin overlying the affected bone Osteosarcoma Nursing Management—Nursing Diagnoses Risk for trauma Acute/chronic pain Impaired physical mobility Nursing Interventions—Assessments Pain Weight Serum calcium levels Fall risk Body image disturbance Nursing Interventions—Actions Administer medications as ordered Apply thermal therapy as ordered Support exercise program Provide training and supportive measures Home health referral Nursing Interventions—Teachin g Take medication as prescribed Adequate ingestion of calcium & vitamin D Nursing Management—Evaluating Care Outcomes Management of pain Absence of fractures Absence of falls Foot Disorders Plantar Fasciitis Plantar Fasciitis Morton's Neuroma Flat Foot Orthotics Carpal Tunnel Syndrome (CTS) Carpal Tunnel Syndrome What is it? Compression of the median nerve in the wrist from swollen or thickened synovium, causing pain & numbness Associated with hobbies or work that require continuous wrist movement  Epidemiology Most frequent compression neuropathy of the hands Women are 3x more likely to be afflicted by CTS than males Peak incidence between ages 45 and 54 In the US: incidence of 1-3 per 1,000 people  Risk Factors Some metabolic & connective tissue diseases Rheumatoid arthritis (synovitis) & diabetes (reduced circulation) Occupational injury from repetitive stress of hand activities pinching or grasping during wrist flexion- i.e. computer users Repetitive sports injury (tennis) Children due to use of computers & handheld devices; however more commonly seen in adults Growth of a space occupying lesion- ganglia or lipoma Clinical Manifestatio ns Sharp pain, numbness, tingling of the hand Grip strength decreased Muscle atrophy Medical management—Diagnosis Patient history Phalen’s test Tinel's sign Nerve conduction studies (EMG) https://www.youtube.com/watch?v =SJTR8A1x8jA https://www.youtube.com/watch?v =AzLYAW_OeME EMG Test Medical Management—Treatment Modification of work environment Ultrasound therapy NSAIDs Steroid injections Night splinting  Surgical Management Carpal tunnel release surgery- Transverse ligament is transected to relieve nerve pressure Endoscopic or Open https://www.youtube.com/wa tch?v=BRyaEJf6SYk&t=2s Complication s If untreated: Chronic pain Immobility Loss of sensory & motor functions Surgical Complications: Infection Nerve injury Hematoma Nursing Management—Asses sment and Analysis Clinical manifestations related to nerve compression Nursing Management—N ursing Diagnoses Alteration in rest: Sleep pattern disturbance Acute/chronic pain Impaired physical mobility Nursing Interventions—Assessments Patient work or activity history Physical assessment of injured extremity Pain, paresthesia  Nursing Interventions—Actions Splinting at night or with symptoms Exercise/ROM therapy Administer medications as ordered Collaborate with occupational therapist Nursing Interventions—Teaching Immediately report worsening symptoms Exercise/physical therapy Pain management Work/activity modifications Nursing Management—Evaluating Care Outcomes Compliance with treatment protocol Symptomatic relief Return to normal functioning Questions ? Helpful Resources https://www.youtube.com/watch?v=sUOlmI-naFs - Osmosis Osteoarthritis https://www.youtube.com/watch?v=o1vjUC-volI - Tylenol vs NSAIDs https://www.youtube.com/watch?v=WtqIdLyHWvo- Dr. Mike NSAIDs https://www.youtube.com/watch?v=I1uHkbocRCw - NSAID Pharm and prostaglandin analogs https://www.youtube.com/watch?v=bznoU5bke4U - Gout Osmosis https://www.youtube.com/watch?v=detaDAwZLvQ- Medicosis on gout vs pseudogout (TMI, but helpful) https://www.youtube.com/watch?v=6fMkX1J9gWw- osmosis on osteoporosis https://www.youtube.com/watch?v=47cwM6sAWKs - osteoporosis diagnosis Helpful Resources https://youtube.com/watch?v=6jRs74NZCVw - Dexa Scan information https://www.cdc.gov/radiation-health/data-research/facts-stats/dexa-scan.html#:~:t ext=Your%20healthcare%20provider%20may%20recommend,who%20has%20bro ken%20a%20hip. - CDC on DEXA Scan https://www.who.int/news-room/fact-sheets/detail/measles#:~:text=Overview,500% 20in%202022%20(1). - WHO on Measles https://www.osmosis.org/learn/Paget_disease_of_bone:_Nursing - Paget's Disease https://www.youtube.com/watch?v=RdDkOklhrzA - Living with Paget's Disease- Linda's story https://www.youtube.com/watch?v=UhCKnTmFgtc - living with Paget's – Mickey's Story https://www.youtube.com/watch?v=BRyaEJf6SYk&t=2s - carpal tunnel syndrome