Musculoskeletal Disorders PDF

12/8/24 1 Promoting Health in Patients with: Musculoskeletal Disorders KAYLA GALLAGHER, MSN, RN, CNE FRANKLIN PIERCE UNIVERSITY 2 Objectives 1.Explore the role of the nurse when caring for clients experiencing musculoskeletal injuries 2...

12/8/24 1 Promoting Health in Patients with: Musculoskeletal Disorders KAYLA GALLAGHER, MSN, RN, CNE FRANKLIN PIERCE UNIVERSITY 2 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 6. 6. 3 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 oRedness oHeat oSwelling oPain oLoss of function 4 5 1 1  oLoss of function 4 Tie it together: what will you include in your musculoskeletal assessment? 5 Tie it together: what will you include in your musculoskeletal assessment? 1 Ask: oHistory of trauma, mobility problems, changes in gait PMH, PSH, medications Pain Swelling Stiffness Inflammation Warmth Chills Weaknesses 2 Ambulation/gait Joints (appearance, mobility, pain, swelling, etc) Mobility Crepitus Posture Alignment Range of motion Strength 6 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 7 1  7 Osteoarthritis 1 Damage to the articular cartilage Can affect any joint Bone changes can occur Synovial membrane can be inflamed Bone cysts can form Damage to joint = irreversible Causes oWear and tear oTrauma from injury, overuse 2 Risks oOlder adult oGenetic link oPrevious injury oObesity oMuscle weakness oJoint malalignment oSedentary lifestyle 8 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 9 Osteoarthritis: management 1 Diagnosis: oH&P oImaging: x-ray, MRI, US 9 1 oH&P oImaging: x-ray, MRI, US oLabs to rule out other conditions Treatment: oNSAIDs oAcetaminophen oOpioids (severe) oCortisone injections (steroid) oArthroplasty oFusions 2 Interventions oVital signs oPhysical assessment oEncourage increased physical activity oCollaborate with PT, OT oMaintain healthy weight oHeat and cold compress oMassage oUtilize mobility aids and comfortable shoes 10 Tie it together: NSAIDs 11 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 oType specific (ASA can be used for cardiac, CVA prevention, etc) 12 Tie it together: acetaminophen 13 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 14 15 12 13 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 14 Tie it together: corticosteroids 15 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 16 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) 17 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 18  addiction risk, educate on temporary use 18 Rheumatoid arthritis (RA) Chronic inflammation that affects a joint surrounding tissue Chronic autoimmune disease oPeriods 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 19 RA: manifestations 1 Chronic pain Deformity of affected joints Difficulty with ADLs Difficulty with movement Balance impaired Severe cases: presence of rheumatoid nodules 2 If organs are affected: oEyes: dry eye, disruptions/loss of vision, inflammation, redness, floaters, blurred vision, pain oMouth: gum disease, dry mouth, high tooth decay rate oLimbs: deformities, swelling, locking, weakening, ruptured tendons, bunions oSkin: rashes, ulcers, rheumatoid nodules oHeart: heart attacks, stroke, anemia oLungs: inflammation and scarring (interstitial lung disease), COPD, pleurisy, nodules, chronic coughing oKidneys: impaired function due to protein build ups 20 RA: complications Lower quality of life Impaired mobility Heart disease and diabetes risk increases 21 1 20 Impaired mobility Heart disease and diabetes risk increases Glaucoma 21 RA: management 1 Diagnosis: oLabs: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), CBC, rheumatoid factor assay, antinuclear antibody (ANA) assay oImaging: x-ray affected joints, MRI, US oSynovial fluid aspiration Treatment: oDisease-modifying antirheumatic drugs (DMARDs) (examples: methotrexate, sulfasalazine, hydroxychloroquine) oCorticosteroids oNSAIDs oTopical capsaicin oPlasmapheresis oSurgical: synovectomy, tenosynovectomy, arthroplasty o 2 Interventions oVS, physical assessment oPromote moderate physical activity oFall risk oAssist with ADLs PRN oShoes with Velcro oMobility aids oAssistive devices oMedication/treatment implementation and education oPromote healthy weight oCold or heat for pain oPsychological/emotional support o 22 Joint replacements 23 Let's review: surgical prep 24 1 22 23 Let's review: surgical prep 24 Let's review: surgical prep 1 H&P prior to surgery Medication assessment Prehabilitation Imaging needs Smoking cessation Education Antibiotic ECG, urine specimen, labs Consent 2 Time out Vital signs Physical assessment IV placement Go the bathroom/catheter Surgical site cleansing before Take appropriate meds with a small sip of water 25 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 oLikely contraindicated: morbid obesity, ETOH or drug abuse, severe PVD 26 TKA complications 1 Surgical site infection (SSI) Wound dehiscence Thromboembolism 26 1 Wound dehiscence Thromboembolism Blood loss Fracture Dislocation Pain Vascular injury Nerve injury Stiffness Pressure injuries 2 27 TKA post operative care 1 Additional assessments: oVS oPhysical assessment §Wound/incision §Respiratory §Cardiac §Pain §GI §Neurovascular §Mental health §s/s infection 2 Discharge home or to rehab PT consult a must Incentive spirometer Drain management PRN Incision care/surgical site assessment No pillow behind knee Monitor labs Administer medications (and educate!) Early ambulation Possibly continuous passive motion (CPM) Pain management 28  Possibly continuous passive motion (CPM) Pain management 28 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 oLikely contraindicated: morbid obesity, ETOH or drug abuse, severe PVD 29 THA: complications Dislocation Fracture Surgical site infection Thromboembolism Sciatic nerve palsy Leg length discrepancy Vascular injury Pain Bleeding Wound dehiscence Pressure injuries 30 THA post operative care 1 Additional assessments: oVS oPhysical assessment §Wound/incision §Respiratory §Cardiac §Pain §GI §Neurovascular 2  §GI §Neurovascular §Mental health §s/s infection o o 2 Discharge home or to rehab PT consult a must Incentive spirometer Drain management PRN Incision care (surgical site assessment) Hip precautions Monitor labs Administer medications (and educate!) Early ambulation Use raised toilet seat, shoehorn, etc o o 31 Hip arthroplasty: hip precautions 1 Do not bend hip more than 90 degrees Do not cross legs or feet Do not roll or lie on unoperated side for first 6 weeks (sleep on back for 6 weeks) Do not twist the upper body when standing Pillow or abduction device between legs when turning A "POP" is bad! 2 Early ambulation oTransfer client out of bed from their unaffected side into chair or wheelchair oEnsure to utilize prescribed weight-bearing status (usually toe touch – partial for first few weeks) oUtilize assistive devices oIce following ambulation o 32  oIce following ambulation o 32 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 33 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,  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 34 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 35 Let's review: NSAIDs 36 Let's review: acetaminophen 37 Let's review: opioids 38 Herniated disk Herniation = leaking out of the interior disk contents into the vertebral areas Risk Age Male > female Obesity Smoking Occupation Genetics 39  Occupation Genetics Repetitive lifting, pulling, pushing, bending sideways, twisting 39 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 40 Herniated disk: interventions and complications 1 Interventions Vital signs Physical assessment Pain management Corticosteroids administrations Positioning ROM Increase fluid and fiber 2 Complications Numbness and weakness Loss of bowel and bladder control Increased pain (back, arm, leg, neck) Saddle anesthesia Chronic pain 41  2 Chronic pain 41 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 42 Osteoporosis 1 Low bone mineral density caused by altered bone microstructure which increases risk of fractures Related to aging process, decreasing sex hormones Medication that cause: corticosteroids, anti epileptic, chemo, PPI Diseases that cause: hyperparathyroidism, anorexia, malabsorption, hyperthyroidism, CKD, Cushings, disease that cause long term immobilization Long term immobilization leads to osteoporosis 2 Risks oAge oLow body weight oSmoking oFamily history of osteoporosis oWhite or Asian oEarly menopause oLow levels of physical activity oHistory of fractures after age 40 oImmobility 43 Osteoporosis: manifestations Chronic pain Fractures Height loss Spinal malformations Posture changes 44 1 43 Posture changes 44 Osteoporosis: management 1 Diagnosis oH&P oScreening: women at age 65 and men at age 70 oBone mineral density test (AKA dual-energy absorptiometry (DEXA) scan) Treatment oCalcium and Vitamin D3 oBisphosphonate derivatives (alendronate (Fosamax), zoledronate (Reclast)) oTeriparatide oDenosumab (Prolia) 2 Interventions oWeight-bearing exercises oSmoking cessation oAlcohol cessation oCalcium rich diet oVitamin D3 oTreatment administration and education oHealthy body weight Complications oFractures 45 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 oMost people asymptomatic oPain from lesions in bone or due to bone overgrowth and deformities oBone deformities oFracture oGait can be impacted 46 1  oFracture oGait can be impacted 46 Paget's: management 1 Diagnosis oLabs: elevated alkaline phosphate of bone origin oImaging: Paget's changes in bone (deformities – thickened and/or tunneling) §Bone scan, bone x-ray Treatment oBisphosphonates oCalcitonin oDenosumab oCalcium and vitamin D oPain management – NSAIDs, acetaminophen oSurgery to treat fractures and malalignments 2 Interventions VS, physical assessment ADLs – assess and assist PRN stay active Administer/educate about treatment PT/OT collaboration Calcium rich diet Vitamin D3 Healthy body weight 47 Paget's complications Nerve impingement Fractures Osteoarthritis Bone tumors Neurologic disease Calcium and phosphate abnormalities Excessive bleeding during orthopedic surgery 48 Gout 1 Inflammatory arthritis Disease in which defective metabolism of uric acid causes arthritis 2 48 1 Inflammatory arthritis Disease in which defective metabolism of uric acid causes arthritis Monosodium urate (MSU) monohydrate crystals deposition in the tissues Hyperuricemia Commonly occurs in smaller bones of the feet 2 Risks oGenetic oDietary §High purine foods Organ meats, seafood, alcohol, high fructose corn syrup, sweetened soft drinks oMedication: aspirin, diuretics oMen > women oOlder age oWeight loss PRN oPromote adequate hydration Complications oTophi, joint deformity, osteoarthritis, bone loss, urate nephropathy, renal calculi, ocular complications from crystals 49 Gout: manifestations Pain in a joint Erythema in a joint Warm joint Swollen joint Systemic symptoms oFever oGeneral malaise oFatigue 50 Gout management: 1 Diagnosis oSerum urate levels oSynovial fluid analysis oWBC, ESR, CRP oUltrasound, CT 50 1 oWBC, ESR, CRP oUltrasound, CT Treatment oFlares §NSAIDs Not aspirin (salicylates) §Colchicine §Corticosteroid oPrevention of flares §Allopurinol §Febuxostat §Probenecid o o 2 Interventions oVital signs oPhysical assessment oDiet modification §Avoid purine rich food §Consume: dairy, DASH diet, vitamin C rich foods, cherries oFlares: rest and ice packs oEducation and administer prescribed treatments o 51 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) 6.Clinical manifestations and diagnosis of gout (Angelo L. Gaffo) 7.Total knee arthroplasty (Martin & Harris)