Nursing Care B: Complex Disorders of the Musculoskeletal System PDF 2020

25/08/2021 NSG2201 Nursing 4. Nursing Care B. Complex Disorders of...

25/08/2021 NSG2201 Nursing 4. Nursing Care B. Complex Disorders of the Musculoskeletal system Created by Cathy Stanguts. Adapted from Lewis's Medical –Surgical Nursing, 2020 This Photo by Unknown author is licensed under CC BY-SA. 1 Learning Outcomes On completion of this subject, learners will be able to; 1. demonstrate an in-depth understanding of the pathophysiology of alterations in oxygenation, perfusion, renal/urological function, regulation, digestion, absorption, elimination and metabolism and the problem of pain. 2. explain methods and techniques used to conduct a comprehensive nursing history and focused physical assessment, using a systematic primary and secondary survey approach; 3. identify and analyse diagnostic tests and investigations appropriate to diagnose health problems associated with the Musculoskeletal system (MSK). 4. explain the way in which pain assessment frameworks and tools can be used to assess pain in medical and surgical contexts, and across diverse population groups; 5. recognize the clinical cues for patient deterioration associated with complex disorders of the MSK. 6. apply a critical analysis of assessment findings and an in-depth understanding of clinical reasoning cycle to develop a therapeutic plan of care for patients experiencing complex MSK conditions. 7. outline the collaborative management strategies for patients in the acute care setting and the role of the registered nurse within the team. 8. examine a range of pharmacological agents used to treat complex MSK system and the impact of polypharmacy on nursing care. 2 1  25/08/2021 Lecture 2. Osteomyelitis Complex Bone tumours (benign & malignant) Disorders of Muscular dystrophy the MSK Lower back pain (acute & chronic) system 3 Osteomyelitis Severe infection of the bone, bone marrow and surrounding soft tissue. AEITIOLOGY Can be caused by a variety of microorganisms – most commonly Staphylococcus aureus. 4 2  25/08/2021 Osteomylitis - Pathophysiology Infecting microorganism can invade by indirect or direct entry; Indirect (haematogenous) - most frequently affects developing boys (less than 12 years old). Most common sites = distal femur, proximal tibia, humerus, radius. Direct entry - can occur at any age and where there is open wound (penetrating wounds, fractures or ulcers). After gaining entry to the bone via the blood, microorganisms lodge in area of bone where circulation slows, usually the metaphysis. Microorganisms then multiply, resulting in increased pressure, due to non- expanding nature of bone. Increasing pressure, eventually leads to ischaemia and vascular compromise of periosteum. Eventually infection spreads through bone cortex and marrow cavity, resulting in cortical devascularisation and necrosis. 5 Osteomylitis – Pathophysiology contin... 6 3  25/08/2021 Signs and symptoms (Acute & Chronic) Local Systemic Constant bone pain Fever Swelling Night sweats Tenderness Chills Warmth (at infection site) Restlessness Restricted movement Nausea Malaise 7 Bone or soft tissue biopsy Blood and wound cultures Elevated WBC count Diagnostic Elevated ESR studies Radionucleotide bone scans (gallium) MRI and CT scans 8 4  25/08/2021 PAUSE the lecture here and read Interprofessional p. 1723 (INTERPROFESSIONAL Care & Nursing CARE) & 1724 (Nursing Management) in Lewis' Medical- Management - Surgical Nursing textbook. Osteomylitis 9 Despite severity of infection, the widespread use of antibiotics in conjunction with Treatment surgical treatment has significantly reduced mortality rates and complications associated with this condition. 10 5  25/08/2021 PRIMARY BONE TUMOURS (benign & malignant) are relatively rare in adults. BONE METASTATIC BONE cancer is more common problem. TUMOURS 11 OSTEOCHONDROMA Most common primary benign tumour. Characterised by overgrowth of Benign bone cartilage and bone near end of the bone at growth plate. tumours Most commonly found in long bones of leg, pelvis or scapula. Occurs most often in people aged 10-25 years. 12 6  25/08/2021 Painless, hard, immobile mass; Lower than normal height for age Soreness of muscles in close proximity to tumour OSETOCHONDROMA Or one leg or arm longer than – Signs & Symptoms the other Pressure or irritation when exercising 13 OSTEOCHONDROMA DIAGNOSIS Confirmed using X-ray, CT scan & MRI TREATMENT & MANAGEMENT No treatment necessary if asymptomatic If tumour causing pain or neurological compression, surgical resection can be used. Regular screening to detect early malignant transformation. 14 7  25/08/2021 A sarcoma is a malignant tumour that can develop in bone, muscle, fat, nerve or cartilage. Characterised as being either a MALIGNANT soft- or a hard-tissue tumour. BONE Most common types = osteogenic sarcoma, TUMOURS chondrosarcoma and Ewing's sarcoma. 15 OSTEOGENIC SARCOMA (Osteosarcoma) Primary malignant bone tumour – extremely aggressive and rapidly metastasises to distant sites. Occurs in distal femur, proximal humerus, as well as pelvis. Most common malignant bone tumour in children and young adults. Highest incidence males 10-25 years. SECONDARY osteosarcoma more common in older adults (most often associated with Paget's disease). Metastisis is present in 10-20% of individuals 16 8  25/08/2021 Gradual onset of pain and swelling – especially around knee A minor injury may bring the pre- existing condition to medical OSTEOSARCOMA attention. – SIGNS & Joint movement may be SYMPTOMS restricted. 17 OSTEOSARCOMA - Diagnosis Confirmed by BIOPSY. Elevation of serum alkaline phosphatase and calcium levels. X-ray, CT scans and MRI 18 9  25/08/2021 Preoperative chemotherapy maybe used to decrease tumour size prior to surgery. Limb salvage is usually contraindicated if major neurovascular involvement, TREATMENT pathological fracture, infection or substantial muscle involvement. Chemotherapy can also be used after surgery (amputation or limb salvage) and has been shown to increase survival rates. 19 Metastatic BONE CANCER Most common form of malignant bone cancer. Due to metastasis from a primary tumour located at another site. Common primary sites (breast, prostate, lungs, kidney and thyroid) Metastatic cancer cells travel from primary tumour to bone via lymph and blood supply. SIGNS & SYMPTOMS Metastatic bone cancer should be suspected in any patient who has local bone pain and a past history of cancer. 20 10  25/08/2021 TREATMENT May be palliative (pain management & radiation) Metastatic Surgical stabilisation of bone may be indicated if fracture/OR if patient at high risk BONE of fracture CANCER PROGNOSIS Dependent on primary type of cancer and any other sites of metastasis. 21 PAIN MANAGEMENT (pain can be severe) MAINTAINING PHYSICAL MOBILITY AND QUALITY OF LIFE – preventing pathological NURSING fractures or reducing complications. MANAGEMENT – BONE TREATMENT OF HYPERECALCAEMIA (due to CANCER bone de-calcification) Management of other symptoms, such as weakness from ANAEMIA. 22 11  25/08/2021 MUSCULAR DYSTROPHY (MD) A group of genetic diseases characterised by progressive symmetrical wasting of skeletal muscles without evidence of neurological involvement. PAUSE the Lecture here and watch the 'Muscular dystrophy' video (located in the PREPARE section of Brightspace for Week 5), and answer the following questions; 1. Discuss the pathophysiology involved in development of MD? 2. Identify 4 clinical manifestations of MD? 3. What is the most common type of MD affecting adults? 23 Muscular dystrophy Diagnostic studies & Treatment Muscle serum enzymes (eg. creatinine kinase) Electromyogram testing Muscle fibre biopsy ECG – can be used to identify any signs of cardiomyopathy Currently no definitive treatment available to stop progression of MD. Corticosteroid therapy may be used to significantly halt disease progression (short term). Goals of treatment = preserve mobility and independence through exercise, physio and use of orthopaedic appliances. Prevent injuries due to falls 24 12  25/08/2021 LOWER BACK PAIN One of most common health care problems in Australia. Most frequent activity-limiting complaint in young and middle-aged adults. Disability from lower back pain places a significant economic burden on individual and community – among leading cause of disease burden in Australia (AIHW 2020). Most often due to a musculoskeletal problem. May be localised or diffuse (pain spread all over a larger area and comes from deep tissue layers. May also be classified as radicular or referred. 25 ACUTE lower back pain Lower back pain that last for 4 weeks or less. Usually caused by trauma or some type of activity that causes stress of the lower back (eg. Heavy lifting, overuse of back muscles, sports injury). Often symptoms do not occur at time of injury but develop later (usually within 24 hours). 26 13  25/08/2021 Muscle aches to shooting stabbing pain Spasms ACUTE Lower Limited flexibility or range of motion back pain Inability to stand up straight. Symptoms & Thorough physical examination Diagnostic (Musculoskeletal) tests MRI & CT scans generally not done unless trauma or systemic disease (eg. cancer) is suspected. 27 CHRONIC Lower back pain Lower back pain that lasts more than 3 months or is a repeated incapacitating episode. Causes can include; Degenerative conditions (arthritis or disc disease) Osteoporosis or other metabolic bone diseases Prior injury (scar tissue can weaken the back) Chronic strain on lower back muscles from obesity, pregnancy, job-related repetitive injury. Congenital abnormalities in spine. 28 14  25/08/2021 Past history, Medications, past surgery or other treatments Neurological and Musculoskeletal system assessments Lower back MRI or CT scans if underlying pathologic pain changes suspected. Assessment PAUSE the Lecture here and read pages 1730 –1732 for NURSING MANAGEMENT & TREATMENT of both Acute & Chronic lower back pain, in your prescribed text (Lewis' Medical- Surgical). 29 Thank you!! Please now move to Lecture 2. for further complex musculoskeletal conditions (Arthritis & Connective tissue disorders). 30 15  25/08/2021 Osteoarthritis Rheumatoid Arthritis Systemic Lupus Erythematsus LECTURE 3. Fibromyalgia Arthritis & Connective tissue diseases 31 OSTEOARTHRITIS (OA) A slowly progressive, non-inflammatory disorder of diarthrodial (synovial) joints. Most common form of arthritis in Australia This Photo by Unknown author is licensed under CC BY-SA. (AIHW 2017-2018) 32 16  25/08/2021 OSTEOARTHRITIS - AEITIOLOGY & PATHOPHYSIOLOGY Involves the formation of new joint tissue in response to cartilage destruction. Not considered a normal part of the ageing process (but ageing is one risk factor for disease development). Usually caused by a known event or condition that directly damages cartilage or causes joint instability. Increased incidence of OA in ageing woman (associated with oestrogen reduction at menopause). 33 Age (after 55 years or age, females more affected than males. Obesity History of joint trauma Mechanical stress – repetitive physical activities OA – Risk Joint instability Factors History of Neurological disorders Skeletal deformities Medications (indomethacin, colchicine and corticosteroids; can stimulate collagen-digesting enzymes in joint synovium). 34 17  25/08/2021 OA - Pathogenesis Complex - genetic, metabolic and local factors interact causing process of cartilage deterioration. Results from cartilage damage at the level of the chondrocytes. Progression causes normally smooth, white translucent articular cartilage to become dull, yellow and granular. Affected cartilage becomes softer, less elastic and less able to resist wear with heavy use. Body's attempt to repair cartilage cannot keep up with destruction. Continued changes in collagen structure of cartilage leads to fissuring and erosion of articular surfaces. 35 OA- Pathogenesis contins.... As central cartilage becomes thinner, cartilage and bony growth (osteophytes) increase at joint margins. Resulting incongruity in joint surfaces creates uneven distribution of stress across joint and contributes to reduction in motion. NB. Although inflammation not characteristic of OA, secondary synovitis may result – these inflammatory changes may contribute to early pain and stiffness. WHERE AS, pain of later disease results from contact between exposed bony joint surfaces after articular cartilage has deteriorated. 36 18  25/08/2021 No systemic symptoms in OA. JOINTS PAIN = predominant symptom, worsens with joint use (activity) and can contribute significantly to disability and loss of function. OA – SIGNS STIFFNESS - typically provoked by activity, occurs after periods of rest or rest or static position. Early morning & stiffness common, but generally resolves after 30mins. SYMPTOMS Crepitations (a grating sensation) caused by lose particles of joint cartilage in the joint cavity. Joints usually affects joints asymmetrically. Most common joints affected = distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints of fingers; weight- bearing joints (hips & knees), cervical and lower lumbar vertebrae. 37 OA- SIGNS & SYMPTOMS contin... DEFORMITY Specific to the involved joint. Heberden's nodes (DIP joints as indication of osteophyte formation and loss of joint space). Bouchard's nodes – occur in PIP joints and indicate similar disease involvement. OA of knee leads to joint malalignment as a result of cartilage loss 38 19  25/08/2021 Bone scan , CT scan, MRI (all can detect early joint changes) DIAGNOSTIC X-rays (helpful in confirming disease and staging progression of joint damage). tests Synovial fluid analysis allows differentiation between OA and other forms of inflammatory arthritis. 39 Rest & joint protection Heat & cold applications Nutritional therapy & exercise Interprofessional Complementary and alternative therapies Care & Medication therapy Treatment Paracetamol NSAIDs (Ibuprofen, Diclofenac) COX-2 inhibitor (Celecoxib) Corticosteroid (intra-articular injection) Surgical Therapy 40 20  25/08/2021 RHEUMATOID ARTHRITIS (RA) A chronic, systemic autoimmune disease characterised by inflammation of connective tissue in diarthrodial (synovial) joints. Characterised by periods of remission and exacerbation, and frequently accompanied by extra-articular symptoms. Can occur at any age, incidence increases with age – peaking between 30-50 years. 41 Exact CAUSE is unknown, a combination of genetics and environmental triggers may play a role. RA – AEITIOLOGY AUTOIMMUNE 42 21  25/08/2021 RA - Pathophysiology AUTOIMMUNE Antigen triggers formation of an abnormal Immunoglobulin G (IgG). RA characterised by autoantibodies (rheumatoid factor – RF) against this abnormal IgG. Autoantibodies combine with IgG to form immune complexes that initially deposit in synovial membranes or superficial articular cartilage in joints. Immune-complex formation > to activation of complement, and inflammatory response results. Neutrophils attracted to site of inflammation > release proteolytic enzyme > damage articular cartilage, causing synovial linings to thicken. 43 RA – Pathophysiology contin... OTHER Inflammatory cells involved = T-helper (CD4) cells CD4 cells stimulate monocytes, macrophages and synovial fibroblasts which secrete proinflammatory cytokines (IL-1, IL-6 & TNF). These cytokines drive the inflammatory response in RA. 44 22  25/08/2021 Onset insidious Non-specific signs – fatigue, anorexia & weight loss. JOINTS Generalised stiffness that becomes more localised as disease progresses. SIGNS & Pain SYMPTOMS Limitation of motion Signs of inflammation (heat, tenderness, swelling) Joint symptoms occur symmetrically – and frequently affect small joints of hands (PIP & MCP) and feet (MTP). Larger peripheral joints may also be involved (wrists, elbows, shoulders), as well as the cervical spine. 45 SIGNS & SYMPTOMS contin.... EXTRA-ARTICULAR More likely to occur in the person with high levels of biomarkers (RF). Rheumatoid nodules – subcutaneous, firm, non-tender granuloma- type masses - usually located over the extensor surfaces of joints (fingers and elbows). Cardiopulmonary effects (pleurisy, pleural effusion, pericarditis and cardiomyopathy. Sjogren's syndrome - can occur in conjunction with RA. Flexion contractures and hand deformities > diminished grasp strength and affect the individual's ability to perform self-care. Depression – often due to chronic pain. 46 23  25/08/2021 ACCURATE diagnosis is essential to initiation of appropriate treatment and prevention of unnecessary disability. Early diagnosis crucial. History and physical examination DIAGNOSTIC Positive RF (80% of adult RA patients) ESR & CRP (general indicators of active STUDIES inflammation) Increased Antinuclear antibodies (ANA) Anti-citrullinated protein (ACPA) - more specific than RF Synovial fluid analysis – synovial WBC may also be measured. 47 INTERPROFESSIONAL CARE & TREATMENT PAUSE the Lecture here and work through p. 1762-1765 (Lewis' Medical-Surgical) and answer the following question; Identyify and discuss medication therapy used in the treatment/management of RA (including DMARDs, NSAIDs, COX-2 inhibitors, biological and targeted therapies)? 48 24  25/08/2021 Systemic Lupus Erythematous (SLE) Multi-system inflammatory disease Multifactorial origin – interaction between genetic, hormonal, environmental and immunological factors. Typically affects skin, joints and serous membranes (pleura, pericardium), along with the renal, haematological and neurological systems. Characterised by chronic unpredictable course marked by alternating periods of exacerbation and remission. Most cases occur in women in child-bearing years 49 Unknown... genetic influence suspected (associated with HLA complex). Hormones also know to play role (symptoms sometimes occur after AEITIOLOGY onset of menarche, with use of OCP and before and after pregnancy). Environmental triggers (sun exposure, infectious agents and some medications) 50 25  25/08/2021 Characterised by production of large variety of autoantibodies against nucleic acids, erythrocytes, coagulation proteins, lymphocytes, platelets. PATHOPHYSIOLOGY Circulating immune complexes containi ng antibody against DNA are deposited in basement membranes of capillaries in kidneys, heart, skin, brain and joints. Complement activated > inflammation. 51 SIGNS & SYMPTOMS Variable in severity, ranging from mild disorder to rapidly progressing one affecting multiple body systems. Specific symptoms of SLE depend on tissue/organ involved. Any organ can be affected. Maler rash, discoid rash, photosensitivity, oral ulcers, arthritis, Serositis( pleuritis or pericarditis), haemolytic anaemia 52 26  25/08/2021 SIGNS & SYMPTOMS FOR more detailed discussion of system specific signs and symptoms associated with SLE please see p. 1772 – 1774 (Lewis' Medical- Surgical). 53 Patient history & Physical Examination ANA (antinuclear antibodies), Anti-DNA, antineuronal, antiplatelet antibodies may also DIAGNOSTIC be present STUDIES URINALYSIS, ECG, X-ray of affected joints, FBC Elevated CRP and ESR – not diagnostic disease but may assist in monitoring disease activity. 54 27  25/08/2021 INTERPROFESSIONAL CARE Medications NSAIDs – joint pain Antimalarial agents – fatigue and moderate skin and joint problems Corticosteroids – use should be limited (may help control exacerbations). Immunosuppressive medications (azathioprine) 55 NURSING MANAGEMENT Health promotion Acute Intervention – recording severity of symptoms and documenting response to therapy Monitor patient's weight and fluid intake and output. Collection of 24 hour urine collection (protein and creatinine clearance) Observe for signs or bleeding Assessing neurological status 56 28  25/08/2021 FIBROMYALGIA Chronic disorder characterised by widespread, non-articular musculoskeletal pain and fatigue with multiple tender points. Commonly diagnosed musculoskeletal disorder and major cause of disability (associated with other causes of chronic pain) (AIHW 2020). https://www.aihw.gov.au/reports/chronic-disease/chronic-pain-in- australia/contents/summary 57 AEITIOLGY & PATHOPHYSIOLOGY Please watch the video provided in the PREPARE section of Brightspace 'Fibromyalgia', as well as reading the article 'Understanding Fibromyalgia' for information on the aetiology and pathophysiology (as well as common signs and symptoms) of this MSK condition. 58 29  25/08/2021 Tender points in Fibromyalgia 59 DIAGNOSTIC STUDIES Definitive diagnosis often difficult to establish. Lack of knowledge about this condition delays diagnosis and treatment. Lab tests are often used to rule out other MSK conditions. Muscle biopsy may show a non-specific moth-eaten appearance, or fibre atrophy. In Australia and New Zealand, The American College of Rheumatology classification is used for diagnosis. Patients are classified as having Fibromyalgia if two criteria are met - 1. Pain is experienced in 11 OF THE 18 tender points on palpation 2. A history of widespread pain is noted for at least 3 months. 60 30  25/08/2021 INTERPROFESSIONAL CARE Treatment is symptomatic and requires a high level of patient motivation. Rest can help, pain, tenderness and aching. Medications; Pregabalin Low-dose tricyclic antidepressants (amitriptyline) Selective serotonin reuptake inhibitors (sertraline), or benzodiazipines (diazepam) Long-acting opioids generally not recommended – paracetamol, ibuprofen used instead; Non-opiods eg. Tramadol also can be used. 61 NURSING MANAGEMENT Massage Application of alternating heat and cold packs Gentle stretching Dieticians – reduction of sugar, caffeine and alcohol (as they may cause muscle irritation). Relaxation strategies (mindful meditation) 62 31  25/08/2021 THANK YOU Please ensure you have completed all PREPARE material, as well as activities in the EXPLORE section for this week prior to attending your Tutorial session. 63 32