15 - Musculoskeletal Lecture.pdf

Care of the Patient with Musculoskeletal Disorders 1 reminder to look at test plan 1  Objectives After completing this lesson...

Care of the Patient with Musculoskeletal Disorders 1 reminder to look at test plan 1  Objectives After completing this lesson related to musculoskeletal disorders, the learner will be able to: ∙ Identify pathophysiology ∙ Recognize clinical manifestations ∙ Identify diagnostic tests ∙ Develop and evaluate the plan of care ∙ Discuss pharmacological interventions ∙ Identify musculoskeletal complication 2 2  Musculoskeletal system Skeletal System Bones Joints Muscular System Involuntary Skeletal 3 bones, joints – storage for calcium, phosphorus protects our vital organs (heart, lungs, etc) red marrow – makes blood cells muscular system ○ won’t go too much into smooth muscles ○ issues with bones will often affect muscles too 3  Osteopenia & Osteoporosis 4 decrease in bone density osteopenia – less than normal density in the bone osteoporosis – severe osteopenia think about older patients – if they fall and break bone, can be start of huge decline identify people with this issue and start interventions 4  Osteoporosis Terminology Osteomalacia Bone Remodeling Bone softening Osteoblasts Osteoporosis Osteoclasts Decreased bone mass Bone Mineral Density 5 osteomalacia – aka rickets in kids, osteomalacia in adults ○ lack of calcification in bone ○ not typically seen in affluent countries but more so seen in poor, third world countries osteoporosis – decreased bone mass constant remodeling happening in bones thru life ○ osteoblast – building bone (b for building) ○ osteoclast – consuming bone (c for consuming) ○ peak bone mass – at 30 years of age more osteoblast activity for people born female – estrogen helps with bone density and menopause → lack of estrogen → can cause bone density to be affected and to go wrong there is a quantitative way to know risk of osteoporosis 5  Types of Osteoporosis Generalized Primary Secondary Regional 6 primary osteoporosis ○ no direct cause but many things that are risks age, post-menopausal – biggest risks secondary – secondary to something else ○ glucocorticoids, diuretics – can cause osteoporosis (systemic loss of bone density) regional – to one area ○ if you’ve ever broken your leg or broken ankle – that leg becomes less dense even though it repairs itself ○ astronauts tend to have regional osteoporosis in legs due to lack of gravity 6  Risk Factors Family Age Nutrition History Exercise & Smoking/ Hormone Immobility Alcohol Deficiency Weight Medication 7 age – older → more decrease in bones ○ after age 50 family hx – especially if your mom had osteoporosis, certain genes are passed down genetically nutrition – lack of enough calcium and vitamin D deficits ○ people who avoid dairy are at risk ○ make sure that people who avoid dairy have supplements exercise/mobility – not enough weight bearing activity (letting your body work against gravity) ○ walking – the best weight bearing activity smoking/alcohol ○ smoking cigs and drinking ○ drinking – alcoholics often have health deficits 2+ drinks for men per day = too much 1+ drinks for women per day = too much hormone deficit – menopause from radical hysterectomy weight – being very thin and having low weight will be more of risk factor 7  ○ weighing less = less weight on bones to strengthen them diuretics and steroids – very common for osteoporosis  Signs and Symptoms not much s/s until they have a fall and bone breaks bone pain, loss of height over time (from tiny fractures) that make spine shrink, neck or lower back pain, stooped posture ADLs are affected as well 8  Diagnostic Testing Labs: Calcium & Vitamin D Imaging: dual x-ray absorptiometry (DXA) 9 calcium and vitamin D levels – need to be checked for people over 50+ ○ not a diagnostic DEXA – like an x-ray ○ uses very little radiation ○ no need for meds, no NPO ○ no chunky jewelry or belt buckles ○ tells us bone mass and how it looks ○ can be diagnostic ○ depo provera patients – need DEXA scans to make sure osteoporosis doesn't happen 9  Prevention and Treatment 10 not a lot of foods have vitamin D, you get it from the sun exercise – weight bearing, 30 minutes 3-4 times a week osteoporosis – don’t tell them to jog!! it could cause a fracture limit alcohol and tobacco drug therapy – we’ll recommend it for postmenopausal women or men 50+ with low bone density ○ or anyone over 50+ with hip fracture 10  Calcium calcium carbonate (Oscal), calcium citrate (Citracal) Why is patient taking this medication? Treat mild hypocalcemia Supplementation of dietary calcium Treat or prevent osteoporosis/osteopenia in combination with other therapies What are the nursing implications with Monitor calcium, vitamin D, & phosphorus levels med? Administer with vitamin D Take with water Take with or after a meal How would you know if medicine was ↑ calcium levels working? Stabilization of osteoporosis/osteopenia No new fractures What would the nurse look for if the Kidney stones patient was having an adverse response to Hypercalcemia the medication? Hypophosphatemia can be given to those at risk of osteoporosis usually given with vitamin D all in one tablet take with water, they’re HUGE pills they can take it with or without meal how to know its working → calcium levels go up, normal body system will have decrease in phosphorus with increase in calcium ○ inverse relationship adverse effects – kidney stones (most common is made of calcium) 11  Vitamin D cholecalciferol (Vitamin D3) Why is patient taking this medication? ↓ vitamin D levels Osteomalacia In combination with Ca++ for osteoporosis treatment/prevention What are the nursing implications? Administer with calcium Evaluate calcium, vitamin D, & phosphorus levels How would you know if this medication ↑ vitamin D levels is working? Improvement in osteomalacia Stabilization of osteoporosis/osteopenia No new fractures What would the nurse look for if the Hypercalcemia patient was having an adverse Hypophosphatemia response to the medication? can cause hypercalcemia, hypophosphatemia no fractures, increased labs = mean its working :) 12  Bisphosphonates alendronate (Fosamax) PO ibandronate (Boniva) PO & IV risendronate (Actonel) PO zoledronic acid (Reclast) IV Why is patient taking this med? Osteoporosis What are the nursing implications with this Report onset of dysphagia, dyspepsia med? Report pain or swelling in mouth How would a nurse know if medicine is Stabilization of osteoporosis working? No new fractures What would a nurse look for if the patient Osteonecrosis of jaw was having an adverse response to this Esophagitis medication? used when bones become TOO dense don’t memorize the IV vs PO med versions many serious adverse effects ○ can cause esophageal erosion s/s – dysphagia, difficulty swallowing ○ to prevent this take it on empty stomach AND full 8 oz glass of water no other liquids, just water need to sit upright after taking it!! avoid eating for 30 minutes ○ osteonecrosis of the jaw – more so with IV but can with PO bone gets necrotic and bone dies jaw pain, teeth issues with feeling loose ***before IV bisphosphonate – need to see dentist and have them on staff 13  Osteonecrosis of jaw D – necrotic tissue in jaw ○ lateral side of face showing jaw 14  Estrogen Agonist/Antagonists raloxifene (Evista) Why is patient taking this medication? prevention & treatment of postmenopausal osteoporosis What are the nursing implications? Monitor symptoms of venous thromboembolism How would you know if this medication Stabilization of osteoporosis/osteopenia is working? No new fractures What would the nurse look for if the Deep Vein Thrombosis patient was having an adverse response Pulmonary Embolism to the medication? Thrombotic stroke if we give estrogen it will help with bone density if taken for lack of estrogen, also positive effect in preventing osteoporosis adverse effects ○ stroke ○ clot that become DVT ○ PE not for trans patients, for patients that are postmenopausal stroke – typically patient will be prohibited from not having birth control ****just know clotting is huge for this med 15  Osteomyelitis Infection in bone tissue caused by bacteria, virus, parasites, or fungi Exogenous Endogenous Contiguous 16 osteomyelitis – infection in the bone can be bacterial, viral, fungal – typically fungal typically seen in diabetics – infection needs good blood flow, PAD is common with DM pts this condition is often influenced by neuropathy and PAD seen a lot with IV drug abusers – infection from dirty tools circulates in blood exogenous – something from outside going directly to bone ○ like trauma with bone sticking out, direct bacteria on bone difficult to treat this condition due to bone wanting to repair itself and growing more bone over itself, better to remove infected bone to prevent thins endogenous – inside the bone ○ patients with sepsis inside body, can settle in bone ○ happens with DM – skin infection → doesn’t heal → becomes skin infection gangrene can BECOME osteomyelitis, due to skin infection leading to deeper infection 16  Osteomyelitis Clinical Manifestation Acute Chronic Fever, chills Foot Ulcer Swelling Bone surgery Tenderness Pain Erythema & heat Drainage Pain 17 acute phase – inflammation markers, swelling, erythema, chronic – a lot of times they may not feel pain ○ could still have drainage ○ could have pain depending on circulation ○ could have this from bone surgery 17  Risk factors: Osteomyelitis Immunosuppressed Malnourishment Chronic illnesses Medications Bloodstream infection Wounds Artificial joints immunosuppressed – HIV, elderly, people with immunosuppressive meds malnourished – not enough nutrients to help healing with simple cuts chronic illnesses – DM (biggest one and most common cause), can be other conditions medications – steroids, diuretics bloodstream infection – if patient has bloodstream infection, more at risk for osteomyelitis wounds – could lead to infection in bone artificial joints – mecca for infections bc they love getting in places they shouldn’t be ○ proper sterile technique during surgery is CRUCIAL 18  Osteomyelitis Diagnosis Labs Cultures X-ray MRI Biopsy labs – nonspecific leukocytosis (high WBC), we may not know why its high cultures of blood, wound, areas near wound x ray – osteomyelitis has change in bone structure (almost looks more dense MRI – detailed way to diagnose this bone biopsy – most optimal, biopsy of bone with infection will confirm the diagnosis 19  Treatment Nonsurgical Antibiotic Therapy Pain control Hyperbaric Oxygen Therapy (HBO) Surgical Debridement or bone excision Amputation 21 antibiotic therapy – used often for bacterial cases IV therapy – 4-6 weeks of this bc it works better than PO meds as long as 3 months for IV therapy for resistant bacteria ○ PICC line will be given sometimes for patients to do at home and administer to themselves ○ they’re taught how to do medicine admin by nurse so they can do it at home (1st and 2nd dose given by nurse then they do the rest by themselves ) ○ for patients abusing IV drugs – we wouldn't send them home with long term skilled facility used to treat patient instead pain control – extremely painful, some IV users may need higher dose hyperbaric oxygen therapy – more so like 2nd picture ○ increased pressure like being underwater and patients giving oxygen ○ bone thus becomes more perfused, more healing is promoted ○ HBO therapy – used for wounds, bone issues ○ 40 sessions, up to 2 hours Surgical debridement – may remove part of bone that is damaged (bone excision) 21  amputation – doc will determine how bad osteomyelitis is and will take some toes, a certain portion of bones, etc but TYPICALLY for treatment of osteomyelitis – you will always have antibiotics, always have pain control sometimes HBO, sometimes surgery  Fractures Complete Incomplete Closed Open 21 complete – complete break in bone incomplete – does not completely severe bone, more common in kids due to softer bone in development closed – skin is still intact with fracture open – skin is open, exposing bone ○ aka compound fracture ***need to know these 21  Types of Fractures Pathologic Fracture Stress Fracture (Spontaneous fracture) (Fatigue fracture) (Fragility fracture) Results from excessive stress or strain on the bone Occurs after minimal trauma Recreational or professional athletes Underlying disease causes bone to be weak Osteoporosis Osteomalacia Bone cancer 22 pathological fracture – little trauma, moreso from ○ spontaneous fracture – break in bone without any trauma or obvious cause; from weakened bones ○ fragility fracture – fracture caused by osteoporosis ○ osteomalacia – can cause breaks ○ bone cancer – can cause breaks stress fracture – bone is under a lot of stress, then breaks ○ fatigue fracture – from excessive strain and stress on bone caused by activities like jumping, running, repetitive motions  Fractures Clinical Diagnosis Manifestations X-ray Pain CT scan MRI Loss of function Deformity Crepitus Ecchymosis Edema 23 common ones – pain loss of function – may notice pain there, but person avoids using area deformity – looks off, arm is bent where it shouldn't be, at an odd angle crepitus – subcutaneous air, crunching, grinding, grating sound that happens from moving a joint ○ rib fractures, facial fractures ○ feels like rice krispies – from subcutaneous air edema – happens anytime bone is broken → edema occurs → blood flow compromised from swelling CT scan – complex breaks MRI – looking at soft tissue and broken bone 23  Fracture Complications Acute Venous Thromboembolism Infection Acute Compartment Syndrome (ACS) Fat Embolism Syndrome (FES) Chronic Delayed bone healing Chronic pain 24 VTE – broken bone → less mobile → clot risk increases infection – compound fractures easily get infected due to open skin and open bone delayed bone healing chronic pain – sometimes more achy than others 24  Acute Compartment Syndrome (ACS) 25 airway-breathing-circulation problem, circulatory concern this usually happens in legs or arms → swelling → arteries and nerves become compressed → paresthesia under pressed nerve area compression on artery – blood flow to leg is ALSO compromised MEDICAL emergency – patients could lose their leg if not cared for could be interior pressure that gets intense if cast is on with swelling without expansion – compartment syndrome can occur due to swelling not having anywhere to go and pressing on nerves and vessels 25  6 P’s of ACS Pain Paresthesia Pulse Pallor Pressure Paralysis 26 need to recognize this syndrome EARLY pain is huge paresthesia – numbness and tingling, issue with perfusion (and possibly nerves) pulse – essential, you NEED TO check this since pulses tell us if arterial perfusion is occurring ○ may have weaker pulse on one side or absent pulse http://legsonfire.files.wordpress.com/2010/05/fsm7_compartmenttesting. jpg pallor in darker person – ashen or gray look ○ brown skin – yellowish at times pressure from skin being taught paralysis – wiggling toes may not be able to move due to NERVE COMPRESSION ***GOTTA KNOW 6 P’s 26  Medical Management ACS Contact surgeon immediately Keep extremity at heart level Remove dressing or cast Prepare for surgery (fasciotomy) 27 compartment syndrome needs relief of pressure; solved by opening skin nurse will probably recognize pressure building first → call physician and tell them what’s wrong with patient keep extremity where it’ll get most perfusion = at heart level ○ just a fracture and no ACS? – just elevate it if possible and allowed, remove dressing or cast 27  Fat Embolism Syndrome (FES) Fat enters bloodstream 12-48 hrs post injury Clinical manifestations Respiratory changes Neuro changes Skin: petechial rash 28 another complication that can occur with fracture, esp with long femur fatty bone marrow comes out and enters blood stream ○ does not always happens but can occur ○ goes throughout body (like thrombus) ○ s/s – breathlessness, hypoxia, neuro changes fat – can enter arterial circulation and enter brain – agitation, seizures, confusion ○ skin – petechial rash can occur (pinpoint spots) can happen after 48-hour mark due to increased pressure in capillary bed that causes pinpoint bleeding 28  Management of care: FES Treatment Prevention Respiratory support Cardiovascular support Corticosteroids 29 prevention ○ prevent them from getting fat embolism by: ○ early fracture immobilization ○ careful repositioning patient ○ special surgical techniques for surgeon to use to decrease chance of fat embolism, but is risk factor for fat embolism ○ as nurses – recognize → report it right away ○ give supportive care – if patient has RR distress, give oxygen, maybe ventilator ○ cardiac support – fluids, DVT prophylaxis, vital signs monitoring meds to regulate heart rhythm ○ corticosteroids for inflammation not shown to reduce mortality but we may see it in practice to prevent systemic response 29  Management of Fractures ABC’s Neurovascular check Pain management Reduction and Immobilization Elevation 30 always make sure patient has airway with circulation after ABCs checked → neurovascular check ○ 6 P’s = neurovascular check good paint mgmt due to severe pain reduction – realigning the bones ○ immobilizing – not moving it around elevate – to prevent inflammation we elevate the area to reduce edema and ACS 30  Immobilization of Fractures External Internal Casts Screws Splints Plates Boot Rods 31 casts, splints, boots ○ external ways to immobilize fractures screws, plates, rods – internal and more invasive ○ surgical mgmt is typically internal immobilization 31  Spica Cast Halo Cast 32 http://www.hmanstrong.com/resources/H%20halo%20vest.jpg http://1.bp.blogspot.com/_NURyBgG--RE/SO1mDSTwD5I/AAAAAAAAAbY/z5N3RXvk648/s400/Akira-asleep-cast_edited.jp g spica cast – for kids with hip dysplasia ○ not because of fracture ○ when hip joint does not develop normally, cast is used to gently reposition hip joint and hold it in correct position halo cast – keeps neck immobilized (external cast) 32  Cast Care 33 nothing UNDER the cast – even if it gets itchy make sure it doesn't get soggy keep it clean and dry make sure they don’t pull padding out cast care – educate patient about 6 P’s ○ if toes turn blue, feel tingling, toes are cold, anything unusual – could indicate neurovascular issues 33  Traction Assess traction Inspect rope, knot, & pulley Check Weight Pain Neurovascular Status 34 not seen as often anymore but seen in orthopedic or trauma way to reduce the bones Prof Jones – “used often for patients that aren’t stable enough to go to surgery” weight keeps traction (or pull) check for pressure points where patient is laying and where setup is attached to patient assess for pain check weight and make sure its what was ordered check 6 P’s 34  External Fixation Advantages Alignment Early mobilization Wound care Disadvantages ↑ infection ↑ osteomyelitis Altered body image http://3.bp.blogspot.com/-VyZjN 35 way to realign bones and provide wound care simultaneously secures bones with external device used for areas where skin needs to heal patients are able to mobilize early, get wound care pins go into skin then bone do careful pin care ○ even with careful pin care, an infection is still possible altered body image is common for patients with this 35  Open Reduction Internal Fixation (ORIF) 36 open (open procedure) + reduction (patient realign the bones) + internal (inside) the bones we (fix) them 36  Amputations Types Below knee (BKA) Above knee (AKA) Upper extremity 37 one major advantage of BKA – still have knee joint, allows better mobility for walking around and prosthetics suture sites of middle picture are a bit taught, concerning lower extremity amputation – most common cause is PAD ○ 2nd most common – trauma upper extremity amputation – typically from trauma 37  Complications of Amputations Hemorrhage Infection Phantom limb pain Flexion contractures 16 hemorrhage – from initial trauma if it was a traumatic injury, but can happen during surgery due to large vessels being cut osteomyelitis – can occur due to bone being open phantom limb pain – limb isn't there but still feel neuropathy ○ can be stimulated by touch, pressure, flexion contracture – make sure patients get good range of motion 38  Health Promotion Education Assistive devices Exercises Community resources 39 how to care for excision ○ dressing changes risk of DVT – move around, ankle pumps, may go home with lovenox lower amputation could have nager drvt ouno chat assistive devices = prosthetics risk factor modification ○ make sure that BG need to continue ○ quitting smoking ○ keep weight at a healthy balance make sure they support groups big mental component to amputations 39  Rheumatoid Arthritis (RA) Cause Cure Goal 40 chronic progressive, inflammatory, autoimmune disease process no cure for RA progressive over time s/s – tired, fever, underlying disease process for MS not sure what causes, sever goal – to prevent damage 40  Pathophysiology of RA Autoimmune reaction Inflammation Pannus formation Joint changes Systemic disease 41 RA stages just understand the pathophysiology is chronic joint inflammation cartilage begins to erode fiber between bones decreases and thins dramatically sometimes the bones can fuse together 41  Clinical Manifestations of RA Early disease Late disease Joint inflammation Pain and morning Fever stiffness Weakness Deformed joints Anorexia and weight loss Osteoporosis Severe fatigue Weight loss Vasculitis Kidney disease Pericarditis Fibrotic lung disease Sjogren syndrome 42 RA symptoms anorexia weaknessd osteoarthritis – deals about th sikc==== RA – secondary cause of osteoporosis pericarditis – lunch disease inflammation and damage over time sjogren syndrome – vaginal dryness, dry cough, fatigue, joint pain early in disease – weakness, sometimes because it’s an autoimmune process, a fever is considered a sign of a flare up 42  Diagnosis of RA History & physical exam Rheumatoid Factor Anti-cyclic citrullinated peptide (anti-CCP) Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) X-rays Arthrocentesis 43 pericarditis – lunch disease inflammation and damage sjogren syndrome – vaginal gets super dry take a good hx good physical exam tiredness, fever, joint pain? tell me your diet, how’re you eating?” check blood for anti CCP) all 4 is the fors ESR/CRP – just specially for genetic markers CP – detects rheumatoid factor arthrocentesis – checks for WBCs, inflammatory cells, is it cloudy, RA factor? all these things together lead to dx of RA 43  Medications for RA **Review analgesics from surgical lecture Anti-inflammatory or analgesic actions 44 **** review analgesic from the surgical center NSAIDS – decrease inflammation number one treatment for RA – fidrsadd ○ suppressed immune system steroids – when pt is having flair up for RA, joints are attacked 44  Disease Modifying Anti-Rheumatic Drugs (DMARDs) methotrexate (Rheumatrex) etanercept (Enbrel) infliximab (Remicade) Why is patient taking this med? Rheumatoid Arthritis What are the nursing implications with this Establish LMP med? Monitor liver enzymes, & creatinine. Decrease ability to fight off infection Discuss contraception (teratogenic) How would a nurse know if medicine is Decrease pain working? Increase ability to perform ADLs What would a nurse look for if the patient GI ulcer was having an adverse response to this bone marrow suppression medication? altered hepatic & kidney function always check and see when last menstrual period was check creatinine, urine output decreases people's ability to find out about an infection not the best time to start meds if someone is recovering bone marrow suppression – anemia, low RBC 45  Teaching for RA patients Rest Mobility Promotion Energy conservation Heat/cold treatment Complementary & Integrative Health Follow up Support groups 46 rest but be mobile have periods where they’re exercising then resting make sure there’s mobility energy conservation – make sure there’s rest in mobility spurts complementary, integrative health – acupuncture, meditation, hypnosis ○ important to treat the whole patient with this need to know when to follow up with their provide support groups – recurring with anything that is a chronic or traumatic condition, emotional support is very important 46  Osteoarthritis (OA): Degenerative Joint Disease Pathophysiology Etiology Primary Secondary Goals 47 where and tear on cartilage, where bones might start to grind against each other types ○ primary – risk factors genetic age – older – higher risk, more joint wear and tear high use joints – athletes, workers with repetitive jobs that cause break down of cartilage ○ secondary – from a trauma or injury goals ○ reduce pain ○ make sure patient is able to stay as mobile as possible 47  Osteoarthritis Risk Factors Signs & Symptoms Gender Pain Age Crepitus Genetic factor Joint Stiffness Obesity Enlarged joint Trauma Joint effusion Occupation Skeletal muscle atrophy Decrease function & mobility Depression/anxiety 48 gender – if under 55, more likely to be a male patient that could have OA ○ over 55 – more likely to be female due to body aging and changes ages – the older you are, the likely you’ll have breakdown family hx – if there are people in family with this, you’re more likely to have it obesity – the heavier you are, the more likely you’ll be to have this occupation – athletes, s/s – localized ○ localized pain ○ crepitus – grinding sensation in the legs ○ stiffness in the joints, esp after sitting for a while ○ joint effusion – fluid buildup in joint space ○ skeletal atrophy – if there’s a lot of pain, you won’t exercise and muscles atrophy ○ decrease function – pain caused decreased functioning ○ depression/anxiety – being limited in your daily functioning can lead to depression and anxiety 48  OA Diagnostic Test Laboratory Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) Diagnostics X-ray MRI CT studies 49 CRP, ESR – to RULE OUT RA, to see if there’s systemic inflammation XR – not the best way, but some things can be seen like bone on bone MRI – best picture, often times CT will be skipped and go straight to MRI ○ insurance can make barriers before you can get MRI 49  Medications to treat OA acetaminophen rest Topical meds ❖ lidocaine weight loss ❖ salicylates ambulatory devices/braces/splints ❖ NSAIDs physical therapy Other PO options NSAIDs Opioid analgesics Steroids injections 50 acetaminophen – no antiinflammatory effect due to OA not really being inflammatory ○ later in process – it often is inflammatory topical meds – not as absorbed systemically, may be better for patients who we’re worried about adverse effects ○ salicylates – like aspirin ○ topical NSAIDs ○ lidocaine patch ○ many orthopedists will have XRs in =office if all other things don’t work: ○ opioid analgesics – ****go back and review surgical medications we want them to avoid getting up and moving ○ steroid injections – for people with a lot of pain and to avoid surgery 50  Nonpharmacologic Interventions Rest & Exercise Physical Therapy Joint positioning Assistive Devices Heat & cold application Supplements Platelet rich plasma Glucosamine Weight Loss Chondroitin Medical Marijuana (cannabis) 51 rest and exercise – no continuous exercise, some periods of rest is optimal ○ keep them moving!! joint positioning – how are they positioning their joints, what's their body posture like ○ make sure there’s some movement happening as well heat and cold application – can help with pain PRP – injection of patient's own platelets increased growth factor, helps body repair area it’s injected into obesity – helping people to find ways to lose weight physical therapy – strengthen muscles to support bones, optimal assistive devices – walker and cane can be offered supplements – glucosamine and chondroitin are OTC that can be taken to help marijuana – can help with pain 51  Joint Replacement Total Knee Arthroplasty (TKA) Total Hip Arthroplasty (THA) 52 when conservative mgmt methods havent been effective – this will be contemplated bread and butter of orthopedics very common joints replaced on ortho floors 52  Total Knee Replacement (TKA) 53 breakdown in cartilage causes the pain placement of cartilage relieves the pain 53 Total Knee Replacement Surgery 54 54 55  Nursing management of care: TKA Infection prevention Pain control Mobility and ambulation Drains Continuous Passive Motion Machine (CPM) DVT prevention Patient education Rehabilitation 58 infection prevent is HUGE ○ not only during but after ○ needs to be cleaned and monitored for infection pain – give good pain control, catheter device has on queue bulb that infuses in pain area ○ turn up dial for more pain help mobility – need to get up the SAME day of surgery, needs to get up and get moving ○ extremely high risk for DVT due to lower ext. surgery and being immobilized for a while self control dials – not like PTA drains – may have JP drain but not always CPM – nurse will get orders from doctor for how often to use and moves the patient’s leg back and forth ○ helps with range of motion DVT – push for mobility for these patients ○ SCDs when in bed ○ anticoags like lovenox or subq heparin for these patients 58  if patient has surgery – they need incentive spirometer, turn cough, deep breath mobility limitations – kneeling can cause pressure to be on knee incision and making it break open avoid hyperflexion and hyperextension – could cause new joint to dislocate rehab – sometimes they’ll go to rehab before going home to get stronger before d/c ○ some patients will go home, it really depends  Total Hip Replacement (THA) 57 ball and socket joint replace ball of femur and socket of pelvis very extensive 57  Nursing Management of Care: THA Routine postop care Prevent dislocation Abduction pillow NO adduction of hip NO severe flexion at hip NO crossing of legs Elevated toilet seat Dressing at hip Physical therapy SCDs/TED hose Pain management Neurovascular checks 58 prevent dislocation ○ with surgery, muscles that keep ball and socket in place are weak, need time to heal and get stronger ○ first couple of months ○ abduction pillow – keep legs apart ○ NO moving leg past midline ○ NO lifting the leg – needs to be 90 degrees ○ NO crossing the legs – causing dislocation ○ NO knees above the hip dressing – often left on for like a week physical therapy – really important to build back hip strength SCDs – important for any surgery patient neurovascular checks ○ any patient with lower extremity surgery – 6 P’s are super important 58  Prevention of hip dislocation after THR 59 have legs down straight, NO internally rolling hip don’t bend hip past 90 degrees don’t move knee past the belly button need to have something supporting in between the legs to support the hips and prevent dislocations 59  S/S of hip dislocation Increased pain at surgical site Swelling Acute groin pain at affected hip Report of hearing a “popping" sensation in the hip Internal/external rotation of affected extremity Shortening of affected extremity Restricted ability to move extremity 60 extremely painful, intense swelling pain in groin area foot could have abnormal rotation leg may appear shorter 60  Discharge planning: TKA/THA Physical therapy Prevention of complications Infection DVT Dislocation Follow up HCP When to call the doctor Acute chest pain or shortness of breath call 911! 61 physical therapist will give exercises, helps joint heal and prevents dislocation prevent DVT, infection, dislocation chest pain – call 911 61