Promoting Health in Patients with Musculoskeletal Disorders PDF

Promoting Health in Patients with: Musculoskeletal Disorders KAYL A GALL AGHER, MSN, RN, CNE FRANKLIN PIERCE UNIVERSITY Objectives 1. Explore the role of the nurse when caring for clients experiencing musculoskeletal injuries 2. Correlate clinical manifestations with pathophysiological process o...

Promoting Health in Patients with: Musculoskeletal Disorders KAYL A GALL AGHER, MSN, RN, CNE FRANKLIN PIERCE UNIVERSITY Objectives 1. Explore the role of the nurse when caring for clients experiencing musculoskeletal injuries 2. Correlate clinical manifestations with pathophysiological process of selected musculoskeletal conditions 3. Develop a comprehensive nursing plan of care for patients with musculoskeletal disorders. 4. Develop a teaching plan for a patient with musculoskeletal disorders. 5. Discuss potential diagnostic procedures for patients experiencing musculoskeletal disorders  A&P review: inflammation Cellular injury initiates an inflammatory process with the intention to promote healing Body tried to remove agents present that cause damage and heal the damaged tissue Blood vessel dilation => increased permeability => more blood, fluid, and WBC to reach injured area => swelling Acute inflammation = sudden onset, severe Chronic inflammation = slower onset, worsens over time Manifestations of acute inflammation o Redness o Heat o Swelling o Pain o Loss of function Tie it together: what will you include in your musculoskeletal assessment?  Tie it together: what will you include in your musculoskeletal assessment? Ask: o History of trauma, mobility problems, changes in gait Ambulation/gait PMH, PSH, medications Joints (appearance, mobility, pain, Pain swelling, etc) Swelling Mobility Stiffness Crepitus Inflammation Posture Warmth Alignment Chills Range of motion Weaknesses Strength Arthritis Acute or chronic inflammation in the joint Articular cartilage protects ends of bones and allows seamless movement between each other Typical manifestations: pain, stiffness, decreased ROM, and joint deformities Many different types Treatment and presentation is going to depend on type of arthritis Osteoarthritis Damage to the articular cartilage Risks o Older adult Can affect any joint o Genetic link Bone changes can occur o Previous injury Synovial membrane can be inflamed o Obesity o Muscle weakness Bone cysts can form o Joint malalignment Damage to joint = irreversible o Sedentary lifestyle Causes o Wear and tear o Trauma from injury, overuse Osteoarthritis: manifestations Joint pain Stiffness Swelling Friction from bone spurs Impaired ROM (progressive) Mobility impairment Fatigue Atrophy of the muscle Bone deformities Crepitus with movement Osteoarthritis: management Diagnosis: Interventions o H&P o Vital signs o Imaging: x-ray, MRI, US o Physical assessment o Labs to rule out other conditions o Encourage increased physical activity o Collaborate with PT, OT Treatment: o Maintain healthy weight o NSAIDs o Heat and cold compress o Acetaminophen o Massage o Opioids (severe) o Utilize mobility aids and comfortable o Cortisone injections (steroid) shoes o Arthroplasty o Fusions Tie it together: NSAIDs Tie it together: NSAIDs Example: aspirin, ibuprofen, naproxen, celecoxib Action: reduce inflammation and joint damage; some have antiplatelet effects, fever reduction Adverse: bleeding, GI irritation, ulcers, kidney damage, (ASA Reye's syndrome) Uses: arthritic pain, minor to moderate pains, headaches, colds/flus o Type specific (ASA can be used for cardiac, CVA prevention, etc) Tie it together: acetaminophen Tie it together: acetaminophen Action: inhibits synthesis of prostaglandins that may serve as mediators of pain and fevers (i.e. blocks pain/fever signals) Route: PO, PR, IV Uses: mild pain, fevers Adverse: Liver 3-4g limit in 24 hours Tie it together: corticosteroids  Tie it together: corticosteroids Example of injectables: betamethasone, dexamethasone, hydrocortisone, methylprednisolone, prednisolone Use (musculoskeletal specific): arthritis, bursitis, carpal tunnel, and other MS inflammatory conditions Adverse: HA, bruising, facial hair, lower extremity edema, fatigue, changes in appetite, lightheadedness, N&V, changes in menstruation, infection, fluid retention, mood changes, hypokalemia, hyperglycemia, hypertension, osteoporosis Client instruction: monitor for s/s infection/hyperglycemia, do not take in same timespan as live vaccine (w/in 2 weeks) Contraindications/precautions: osteoporosis, infections, uncontrolled hyperglycemia, diabetes Can be injected by a provider Topical analgesics Examples: capsaicin (Pain-X), diclofenac sodium gel (Voltaren), lidocaine patch (Lidoderm), Methyl salicylate (wintergreen, menthal (Bengay), trolamine salicylate (Aspercreme) Action: absorbed into skin and then block the pain signals Adverse: skin irritation, (dependent on which med) Opioid: tramadol (Ultram) Use: moderate to moderately severe pain Action: binds to opioid receptors Adverse: habit-forming, sedation, impairs balance, seizures, dizziness, HA, somnolence, constipation, nausea, euphoria, dependence, tolerance Promote bowel regularity, monitor for seizures, assess opioid addiction risk, educate on temporary use Rheumatoid arthritis (RA) Chronic inflammation that affects a joint surrounding tissue Chronic autoimmune disease o Periods of flare ups and remission Synovium becomes inflamed, immune system attacks tissue surrounding joint -> damage Usually affects joints, can affect: eyes, mouth, heart, and lungs Most common location: hands, wrists, knees Risk: ages 60s, genetics, female, obesity, another autoimmune disease, smoking, stress, infection, trauma RA: manifestations If organs are affected: Chronic pain o Eyes: dry eye, disruptions/loss of Deformity of affected joints vision, inflammation, redness, floaters, blurred vision, pain Difficulty with ADLs o Mouth: gum disease, dry Difficulty with movement mouth, high tooth decay rate Balance impaired o Limbs: deformities, swelling, locking, Severe cases: presence of weakening, ruptured tendons, rheumatoid nodules bunions o Skin: rashes, ulcers, rheumatoid nodules o Heart: heart attacks, stroke, anemia o Lungs: inflammation and scarring (interstitial lung disease), COPD, pleurisy, nodules, chronic coughing RA: complications Lower quality of life Impaired mobility Heart disease and diabetes risk increases Glaucoma  RA: management Diagnosis: Interventions o Labs: erythrocyte sedimentation rate (ESR), C- o VS, physical assessment reactive protein (CRP), CBC, rheumatoid factor assay, antinuclear antibody (ANA) assay o Promote moderate physical activity o Imaging: x-ray affected joints, MRI, US o Fall risk o Synovial fluid aspiration o Assist with ADLs PRN Treatment: o Shoes with Velcro o Disease-modifying antirheumatic drugs (DMARDs) o Mobility aids (examples: methotrexate, sulfasalazine, hydroxychloroquine) o Assistive devices o Corticosteroids o Medication/treatment implementation o NSAIDs and education o Topical capsaicin o Promote healthy weight o Plasmapheresis o Cold or heat for pain o Surgical: synovectomy, tenosynovectomy, o Psychological/emotional support arthroplasty  Total knee replacements Joint replacement s Total hip replacements Let's review: surgical prep Let's review: surgical prep H&P prior to surgery Time out Medication assessment Vital signs Prehabilitation Physical assessment Imaging needs IV placement Smoking cessation Go the bathroom/catheter Education Surgical site cleansing before Antibiotic Take appropriate meds with a small sip of water ECG, urine specimen, labs Consent Total knee arthroplasty (TKA) A surgical procedure in which parts of the knee joint are replaced with prosthetic parts Elective procedure Indications: destruction of joint cartilage (i.e. from: osteoarthritis, RA, degenerative joint disease, osteonecrosis Goal is to relieve pain, improve function, and quality of life Contraindications: active infections, septic knee within past year, chronic lower extremity ischemia, medically unstable, arterial impairment to affected knee, unable to follow post operative regimen o Likely contraindicated: morbid obesity, ETOH or drug abuse, severe PVD  TKA complications Surgical site infection (SSI) Wound dehiscence Thromboembolism Blood loss Fracture Dislocation Pain Vascular injury Nerve injury Stiffness Pressure injuries TKA post operative care Additional assessments: Discharge home or to rehab o VS PT consult a must o Physical assessment Incentive spirometer  Wound/incision Drain management PRN  Respiratory Incision care/surgical site assessment  Cardiac  Pain No pillow behind knee  GI Monitor labs  Neurovascular Administer medications (and educate!)  Mental health Early ambulation  s/s infection Possibly continuous passive motion (CPM) Pain management Total hip arthroplasty (THA) Surgical replacement of the hip joint Indications: osteoarthritis, hip osteonecrosis, congenital hip disorders, other arthritic conditions Goal: pain relief, functional restoration, improved quality of life Contraindications: hip infection/sepsis within past year, ongoing infection, medically unstable, arterial impairment to affected joint, unable to follow post operative regimen o Likely contraindicated: morbid obesity, ETOH or drug abuse, severe PVD THA: complications Dislocation Fracture Surgical site infection Thromboembolism Sciatic nerve palsy Leg length discrepancy Vascular injury Pain Bleeding Wound dehiscence Pressure injuries THA post operative care Additional assessments: Discharge home or to rehab o VS PT consult a must o Physical assessment Incentive spirometer  Wound/incision  Respiratory Drain management PRN  Cardiac  Pain Incision care (surgical site assessment)  GI Hip precautions  Neurovascular  Mental health Monitor labs  s/s infection Administer medications (and educate!) Early ambulation Use raised toilet seat, shoehorn, etc Hip arthroplasty: hip precautions Do not bend hip more than 90 Early ambulation degrees o Transfer client out of bed from their unaffected side into chair or wheelchair Do not cross legs or feet o Ensure to utilize prescribed weight- Do not roll or lie on unoperated side bearing status (usually toe touch – for first 6 weeks (sleep on back for 6 partial for first few weeks) weeks) o Utilize assistive devices o Ice following ambulation Do not twist the upper body when standing Pillow or abduction device between legs when turning A "POP" is bad!  Back pain Risks Obesity Cigarette smoking Poor posture Stress Poor physical condition Poor sleeping position Physical labor occupations Depression Causes: Injury, trauma, mechanical injury  Herniated disc, compression fractures, muscle or tendon strain Arthritis Osteoporosis Infections/inflammation/cancer Bone diseases Congenital abnormalities Spinal stenosis Cancer Back pain: manifestations & management Manifestations Pain along the spinal column Muscle spasms Numbness or tinging or weakness in legs/feet Impaired strength Impaired reflexes Management Physical assessment, symptom review, PMH Imaging studies Treatment Pharmacological: acetaminophen, NSAIDS, muscle relaxants, opioids, systemic corticosteroids, tricyclic antidepressants, and benzodiazepines Nonpharmacological: exercise therapy, heat, ice, acupuncture, massage, meditation/yoga, TENS, PT Surgical management: nerve block, TENS, back surgery  Back pain: interventions Vital signs Physical assessment Administer pain medication and anti- inflammatories Teach and implement complement pain therapies ROM Stool softeners PRN Fluid intake Exercise to strengthen core Posture Body mechanics Let's review: NSAIDs Drug example: Ibuprofen, ketorolac Action: Inhibits prostaglandin synthesis Use: Mild to moderate pain, fevers Adverse reac GI bleed/peptic ulcers, dyspepsia, vomiting, renal failure, tions: rashes (hypersensitivity), hypertension Interventions Monitor for s/s GI bleed, assess for skin rash, monitor pain, : monitor fever, monitor kidney function and s/s AKI Administratio PO, IV n: Client instruc Do not double dose, do not take more than 10 days, do not tions: take with alcohol Contraindicat GI bleed, PUD ions/ CV disease, renal or hepatic, with other nephrotoxic meds, precautions: Let's review: acetaminophen Drug example: Acetaminophen Action: Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS Use: Mild pain, fever Adverse reac Hepatotoxicity, elevated liver enzymes tions: Interventions Assess alcohol status, assess pain/fever, assess other : hepatotoxic medications, 3-4g max Administratio PO, IV, PR n: Client instruc Teach max doses and how to read labels, avoid alcohol tions: Contraindicat With alcohol use, severe hepatic impairment/active liver ions/ disease Let's review: opioids Drug example: Morphine Action: Binds to opiate receptors in the CNS, alters perception and response to painful stimuli while producing generalized CNS depression Use: Severe pain Adverse reac Confusion, sedation, dizziness, euphoria, hallucinations, tions: hypotension, bradycardia, vision changes, constipation, nausea and vomiting, urinary retention, respiratory depression, dependence, tolerance Interventions Assess pain, respirations, BP, O2, HR prior to administering : and after; assess for dependence, tolerance, addiction; assess bowel and urinary function, administer stool softeners/laxatives Administratio PR, IV, SQ, PR, IM, epidural n: Client instruc Fiber and water consumption, when to ask for pain med, do tions: not drive/operate machinery, abuse potential, change positions slowly, TCDB Herniated disk Herniation = leaking out of the interior disk contents into the vertebral areas Risk Age Male > female Obesity Smoking Occupation Genetics Repetitive lifting, pulling, pushing, bending sideways, twisting Herniated disk: manifestations and management Manifestations Pain Numbness Weakness Inability to control affected area Management Diagnosis: H&P, imaging (x-rays, CTs, MRIs) Treatment: Nonpharmacological: exercises, complementary therapies, weight loss, heat, ice, traction, electrical stimulation Pharmacological: NSAIDs, muscle relaxants, nerve pain medications, corticosteroids Surgical: laminotomy, microdiscectomy, spinal fusion, laminectomy/partial Herniated disk: interventions and complications Interventions Complications Vital signs Numbness and weakness Physical assessment Loss of bowel and bladder control Pain management Increased pain (back, arm, leg, neck) Corticosteroids administrations Saddle anesthesia Positioning Chronic pain ROM Increase fluid and fiber NCLEX question In completing the history and physical assessment of a client with back pain, which finding is most suggestive of a herniated nucleus pulposus? A. Constipation B. Numbness in left lower extremity C. Hyperactive reflexes D. Hematuria Osteoporosis Low bone mineral density caused by Risks altered bone microstructure which o Age increases risk of fractures Related to aging process, decreasing o Low body weight sex hormones o Smoking Medication that cause: o Family history of osteoporosis corticosteroids, anti epileptic, o White or Asian chemo, PPI o Early menopause Diseases that cause: hyperparathyroidism, anorexia, o Low levels of physical activity malabsorption, o History of fractures after age 40 hyperthyroidism, CKD, Cushings, disease that cause long term o Immobility immobilization Long term immobilization leads to osteoporosis Osteoporosis: manifestations Chronic pain Fractures Height loss Spinal malformations Posture changes Osteoporosis: management Diagnosis Interventions o H&P o Weight-bearing exercises o Screening: women at age 65 and men o Smoking cessation at age 70 o Alcohol cessation o Bone mineral density test (AKA dual- o Calcium rich diet energy absorptiometry (DEXA) scan) o Vitamin D3 Treatment o Treatment administration and o Calcium and Vitamin D3 education o Bisphosphonate derivatives o Healthy body weight (alendronate (Fosamax), zoledronate (Reclast)) Complications o Teriparatide o Fractures o Denosumab (Prolia) Paget's disease of the bone (PDB) Disorder of bone metabolism that occurs in aging skeleton Accelerated rate of bone remodeling -> overgrowth of bone at single or multiple sites and impaired integrity of affected bone Common affected areas: skull, spine, pelvis, long bones Manifestations o Most people asymptomatic o Pain from lesions in bone or due to bone overgrowth and deformities o Bone deformities o Fracture o Gait can be impacted Paget's: management Diagnosis Interventions o Labs: elevated alkaline phosphate of bone VS, physical assessment origin o Imaging: Paget's changes in bone ADLs – assess and assist PRN (deformities – thickened and/or tunneling) stay active  Bone scan, bone x-ray Administer/educate about treatment Treatment o PT/OT collaboration Bisphosphonates o Calcitonin Calcium rich diet o Denosumab Vitamin D3 o Calcium and vitamin D Healthy body weight o Pain management – NSAIDs, acetaminophen o Surgery to treat fractures and malalignments Paget's complications Nerve impingement Fractures Osteoarthritis Bone tumors Neurologic disease Calcium and phosphate abnormalities Excessive bleeding during orthopedic surgery Gout Inflammatory arthritis Risks o Genetic Disease in which defective o Dietary metabolism of uric acid causes  High purine foods arthritis Organ meats, seafood, alcohol, high fructose corn syrup, sweetened soft drinks Monosodium urate (MSU) o Medication: aspirin, diuretics monohydrate crystals deposition in o Men > women the tissues o Older age o Weight loss PRN Hyperuricemia o Promote adequate hydration Commonly occurs in smaller bones of Complications the feet o Tophi, joint deformity, osteoarthritis, bone loss, urate nephropathy, renal calculi, ocular complications from crystals Gout: manifestations Pain in a joint Erythema in a joint Warm joint Swollen joint Systemic symptoms o Fever o General malaise o Fatigue Gout management: Diagnosis Interventions o Serum urate levels o Vital signs o Synovial fluid analysis o Physical assessment o WBC, ESR, CRP o Diet modification o Ultrasound, CT  Avoid purine rich food Treatment  Consume: dairy, DASH diet, vitamin C rich o Flares foods, cherries  NSAIDs o Flares: rest and ice packs Not aspirin (salicylates) o Education and administer prescribed  Colchicine  Corticosteroid treatments o Prevention of flares  Allopurinol  Febuxostat  Probenecid References 1. Assessment Technologies Institute. (2023). Engage Medical- Surgical Nursing 2. Assessment Technologies Institute. (2019). RN adult medical- surgical nursing (11th ed,) 3. Hoffman & Sullivan (2020). Davis Advantage for Medical Surgical Nursing, (2nd Ed.). 4. Overview of treatment approaches to osteoporosis (Bente L. Langdahl) 5. Clinical manifestations and diagnosis of Paget disease of bone (Julia F. Charlse) 6. Clinical manifestations and diagnosis of gout (Angelo L. Gaffo) 7. Total knee arthroplasty (Martin & Harris)