Nursing Care 2: Musculoskeletal Problems PDF

NURS20009 Nursing Care 2 Unit 6 Nursing Care of Clients Experiencing Musculoskeletal Health Problems Unit 6 Topical Outline Definition—Low back pain, Upper extremity problems, foot problems, Arthritis, Overview of Soft Tissue & Sport Related Injuries, Fractures, Amputation & Rehabilitation Pathophys...

NURS20009 Nursing Care 2 Unit 6 Nursing Care of Clients Experiencing Musculoskeletal Health Problems Unit 6 Topical Outline Definition—Low back pain, Upper extremity problems, foot problems, Arthritis, Overview of Soft Tissue & Sport Related Injuries, Fractures, Amputation & Rehabilitation Pathophysiology/ Causes Risk Factors Manifestations Diagnostic Tests Treatment Nursing Interventions (discussion) Complications The Nursing Process (discussion) Case Study and Critical Thinking Low Back Pain Low Back Pain Pain in the lower back and spine. Leading cause of health problems and disability. Associated with low back pain: prolonged periods of seating, repetitive heavy lifting, vibration Types: – Acute – Chronic Causes: acute lumbosacral strain, instability of lumbosacral bony mechanism, osteoarthritis of lumbosacral vertebrae, degenerative disc disease and herniation of intervertebral disc Risk Factors: obesity, age, and disuse Acute Low Back Pain Lasts 6 weeks or less Associated with some type of activity that causes undue stress on tissues of lower back Symptoms often do not appear at the time of injury but develop later because of gradual increased pressure on the nerve by an intervertebral disc. Few definitive diagnostic abnormalities with nerve irritation or muscle strain MRI and CT not done unless trauma or systemic disease is suspected © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 6 Acute Low Back Pain Treated on an outpatient basis if acute muscle spasms and pain are not severe and debilitating - NSAID’s - Muscle relaxants - Opioid analgesics All clients should avoid activities that aggravate pain: lifting, bending, twisting , prolonged sitting © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 7 Acute Low Back Pain Nursing Management: Maintain appropriate body weight. Flat shoes Avoid prone for sleeping, firm mattress Assess client’s use of body mechanics, and offer advice when activities could produce strain.ba Do’s Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing. Maintain appropriate body weight. Use local heat and cold application. Use a lumbar roll or pillow for sitting. © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 8 Chronic Low Back Pain Lasts longer than 3 months or is a repeated incapacitating episode Spinal stenosis Narrowing of vertebral canal or nerve root canals caused by encroachment of bone on space May be congenital More often acquired through degenerative or traumatic changes to spine In lumbar area, common cause of chronic or recurrent low back pain © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 9 Chronic Low Back Pain Treatment regimens for chronic back pain Reduction in pain associated with daily activities Formal back pain program Ongoing medical care Rest and local heat application when cold, damp weather aggravates back pain Mild analgesics to decrease pain and stiffness Weight reduction Sufficient rest periods Local heat and cold application Exercise and activity throughout day Keep muscle and joints mobilized. © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 10 Common Upper Extremity Problems Upper Extremity Problems Bursitis and Tendinitis: Inflammatory conditions that commonly occur in the shoulder. Bursae are fluid-filled sacs that prevent friction between joint structures during joint activity. When inflamed, they are painful. The inflammation causes proliferation of synovial membrane and pannus formation, which restricts joint movement. Treatment: Conservative treatment(rest of extremity, intermittent ice, and heat to the joint); NSAIDs to control inflammation & pain. Upper Extremity Problems Carpal Tunnel Syndrome: An entrapment neuropathy that occurs when median nerve at the wrist is compromised by a thickened flexor tendon sheath, skeletal encroachment, edema, or soft tissue mass. Causes: repetitive hand and wrist movements, arthritis, diabetes, tumors, trauma. Clinical manifestations: Pain, numbness, paresthesia Diagnosis: Physical examination(tinel’s sign, phalen test). Treatment: Wrist splints; Medication(corticosteroids), Surgical open nerve release or endoscopic laser surgery Common Foot Problems Common Foot Problems Plantar Fasciitis: an inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with first steps in the morning. The pain is localized to the anterior medial aspect of the heel & diminishes with gentle stretching of the foot and Achilles tendon. Management includes stretching exercises, wearing shoes with support & cushioning to relieve pain, orthotic devices, corticosteroid injections. Common Foot Problems Flat Foot: a common disorder in which the longitudinal arch of the foot is diminished. Causes: congenital abnormalities, excessive weight, poor fitting shoes, arthritis. Clinical manifestations: burning sensation, fatigue, clumsy gait, edema, pain. Management: exercises to strengthen the muscles and improve posture & walking; orthotics for additional foot support. Metabolic Bone Disorders Osteoporosis Characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength. Most prevalent bone disease in the world. Osteopenia is the precursor to osteoporosis. Pathophysiology: Normal homeostatic bone turnover is altered; the rate of bone reabsorption that is maintained by osteoclasts is greater than the rate of bone formation that is maintained by osteoblasts, resulting in a reduced total bone mass. The bone become progressively porous, bristle, and fragile; they fracture easily under stress Osteoporosis Risk Factors Genetics: Caucasian or Asian, female, family history, small frame Age: postmenopausal, advanced age Nutrition: Low ca+, low vit. D, and high phosphate intake, inadequate intake. Physical exercise: sedentary, lack of weight-bearing exercise, low weight & BMI Lifestyle: Caffeine, alcohol, smoking, lack of sunlight exposure Medication: corticosteroids, anti- seizures medications, thyroids hormones, heparin Medical conditions: anorexia nervosa, hyperthyroidism, malabsorption syndrome, renal failure Osteoporosis Diagnosis: BMD; labs( serum calcium, phosphate, alkaline phosphatase, Hct., ESR) Treatment: Medication: calcium and vitamin D supplement; bisphosphonates(Fosamax), or risedronate (Aactonel). Prevention: Physical activity Weight-bearing activity Exposure to sunlight for vitamin D. Consume adequate dietary calcium and vitamin D. Arthritis and Connective Tissue Diseases Arthritis Osteoarthritis (OA) – slowly progressive noninflammatory disorder of the diarthrodial joints. Rheumatoid Arthritis (RA) – Chronic, systemic, autoimmune disease The prevalence of arthritis in older adults is high Osteoarthritis (OA) ˜ ˜ ˜ ˜ ˜ Slowly progressive non-inflammatory disorder of the diarthrodial joints OA is not a normal part of the aging process Growing older is a risk factor. After age 55, women are more affected than men. Caused by a known event or condition that directly damages cartilage or causes joint instability. Number of factors have been linked: Ø Estrogen reduction Ø Genetic factors Ø Obesity © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 23 Etiology and Pathophysiology (Cont.) © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 24 Clinical Manifestations ˜ Systemic Ø ˜ Joints Ø ˜ Fatigue, fever, and organ involvement not characteristic of OA Range from mild discomfort to significant disability; localized pain and stiffness, crepitation Deformity Ø Ø Specific to joint involved Can appear as early as 40 years of age © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 25 Diagnostic Studies ˜ ˜ ˜ ˜ ˜ ˜ Bone scan Computed tomography (CT) Magnetic resonance imaging (MRI) Radiological studies Blood studies Synovial fluid analysis © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 26 Collaborative Care ˜ Focuses on: Ø Ø Ø ˜ ˜ Managing pain and inflammation Preventing disability Maintaining and improving joint function Foundation for OA management is nonpharmacological interventions. Drug therapy serves as an adjunct. Copyright © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 27 Collaborative Care (Cont.) ˜ ˜ ˜ ˜ ˜ ˜ Rest and joint protection Heat and cold applications Nutritional therapy and exercise Complementary and alternative therapies Drug therapy Health promotion Ø Prevention is possible in many cases. Ø Community education should focus on alteration of modifiable risk factors. Ø Athletic instruction and physical fitness programs should include safety measures. Copyright © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 28 Rheumatoid Arthritis (RA) ˜ Chronic, systemic autoimmune disease RA usually peaks between 30 and 50 years of age. Women are more likely to have RA than men. ˜ Cause is unknown ˜ ˜ Ø Ø Autoimmunity Genetic factors Copyright © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 29 Etiology and Pathophysiology (Cont.) © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 30 Clinical Manifestations ˜ ˜ Nonspecific manifestations such as fatigue, anorexia, weight loss, and generalized stiffness may precede the onset of arthritic complaints. Joints Ø Articular involvement manifested by pain, stiffness, limitation of movement, signs of inflammation Ø As disease progresses, it leads to deformity and disability. © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 31 Clinical Manifestations (Cont.) © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 32 Complications ˜ ˜ ˜ ˜ ˜ ˜ ˜ Joint destruction begins as early as first year of disease without treatment. Flexion contractures and hand deformities Nodular myositis and muscle fibre degeneration Cataracts cardiopulmonary effects Depression and loss of vision Later, 33 Copyright © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. Diagnostic Studies (Cont.) ˜ ˜ ˜ ˜ ˜ ˜ Positive RF occurs in ~80% of clients. Titres rise during active disease. Antinuclear antibody (ANA) titres Anti-citrullinated protein antibody (ACPA) Synovial fluid analysis Bone scan © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 34 Nursing Management: Rheumatoid Arthritis Nursing implementation ˜ Health promotion Ø ˜ Acute intervention Ø ˜ Education focuses on symptom recognition. Primary focus is reduction of inflammation, pain, maintenance of joint function. Ambulatory and home care Ø Rest, joint protection, heat and cold therapy, exercise, psychological support Copyright © 2023 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 35 Soft Tissue & Sport Related Injuries Overview Soft Tissue Injuries Sprains—injury to ligaments and tendons that surround a joint Strains—pulled muscle or tendon. Contusions—soft tissue injury resulting in ecchymosis or bruise (bleeding within tissue) Sprain Strain Contusion Overview Sports Related Injuries Bruises Muscle strains Fractures Head injuries First Aid Remedy RICER—First 72 hours Rest—splint, non weight bearing Ice—minimize pain and swelling Compression—bandage, elastic wrap Elevation—above body Refer—to see MD or NP: If pain and swelling persist after 2 days or if injury hampers normal movement Quick Check 1 1. What are the causes of soft tissue and sports related injuries? 2. What signs are present during the inflammation phase of these injuries? 3. When should someone with soft tissue injury seek professional help? Fractures Fractures Break in the continuity of bone that may be accompanied by injury of surrounding soft tissue Types – Complete – Incomplete – Comminuted – Closed (simple) – Open (compound) Fractures Manifestations – Subjective: pain, tenderness, loss of function, muscle spasms – Objective: deformity, edema, bruising, shortening of extremity, crepitus Diagnostic tests—x-ray exam, CT-Scan or MRI Treatment of Fractures Pain Management: Medications Reduction – Closed reduction - manual manipulation to bring ends into contact – Open reduction - surgical intervention to cleanse and attach devices to hold fractured fragments together(aligned). Cast – Immobilize, support and protect during healing process Traction – Realign the bones through pulling force Treatment of Fractures Closed Reduction – Nonsurgical realignment – GA or LA – Use of traction and/or manual pressure – The immobilizing device maintain the reduction & stabilize the extremity for bone healing. – X-ray done and cast is applied Treatment of Fractures Open reduction – Surgical procedure with incision – Clean area of fragments and debris – Attach devices to hold the bones in position Fixation: rods, pins, nails, screws, metal plates – Cast and traction – Internal fixation devices ensure firm approximation & fixation of the bony fragments. Treatment of Fractures Treatment of Fractures Nursing Interventions—Cast Pain Management Observe—neurovascular impairment of limb Elevate—reduce edema Promote drying of cast—expose to air Inspect skin for irritation under edges of cast— apply lotion, pad edges, apply tape to edge Measure and note—presence of drainage Observe for possible infection Apply ice—first 24 hours to reduce edema Observe for complications: neurovascular impairment Nursing Interventions—Cast Signs of Neurovascular Impairment: Cyanosis Slow capillary refill times (more than 3 sec) Poor pulse Lack of sensation Complaints of numbness and tingling Quick Check 2 1. What are the signs of neurovascular impairment? 2. What would you include in your health teaching for a patient discharged with a cast? Tractions Nursing Interventions—Traction Inspect and maintain ropes, knots, pulleys, weights Care of skin traction—skin breakdown, neurovascular status Care of skeletal traction—infection, provide dressing change and cleanse pin sites Examine and give skin care to all pressure points Encourage diet high in protein and vitamins Encourage 2 to 3L fluid intake daily Encourage ROM Educate patient—proper position and alignment Effects of Fracture Acute pain R/T bone fracture, edema Ineffective tissue perfusion R/T tissue trauma Risk for infection R/T break in skin, bone trauma Impaired physical mobility R/T pain and immobilization Risk for impaired skin integrity R/T injury, immobility Activity intolerance R/T prolonged immobilization Complications Immediate Complications: Hypovolemic shock; Injury to major vessels, muscles & tendons, joints, and viscera Early Complications: Infection, Hypovolemic shock, Aseptic traumatic fever, adult respiratory distress syndrome(ARDS) DVT, fat embolism, pulmonary syndrome, Septicemia, Crush syndrome, compartment syndrome. Late Complications: Imperfect union of the fracture Other: Osteoarthritis, shortening, joint stiffness, avascular necrosis Complications Acute Compartment Syndrome – Decreased perfusion and hypoxia of tissues Internal pressure: bleeding or edema External pressure: cast or tight dressing – Pain not relieved by analgesics, edema, pallor, weak or unequal pulses, cyanosis, tingling numbness – Goal: relieve pressure Management: extremity at heart level Opening the cast Complications Fat Embolism – Fat globules from marrow of fractured bone released into bloodstream – Respiratory distress, tachycardia, tachypnea, fever, confusion – Treatment: bed rest, oxygen, fluid restriction, diuretics, accurate fluid & output records. Complications Non-union and Delayed – Never healing or failure of a fracture to heal in the expected time – Inadequate immobilization/excess movement, poor alignment/ nutrition, infection – Treatment: implantation of bone graft (synthetic)—non-union Rehabilitation—Sling & Braces Sling—prevent unnecessary movements and avoid further injury Braces—immobilize unstable joint or fracture, diminish pain Rehabilitation—Crutches To increase mobility and assist with ambulation Motivation, age, interests and ability Length is two fingerbreadths of axilla, weight is distributed on the handgrips Physical therapist teaches and nurses reinforce Rehabilitation- Nutrition Calcium in the diet and calcium supplements Protein Vitamins B, C, D Milkshakes (high in calorie, protein and calcium) Daily fluid intake 2 to 3 L Quick Check 3 1. What type of nutrition is recommended for patients with fractures? 2. What is the health teaching for a patient with traction and external fixation devices? Amputation & Rehabilitation Amputation Surgical removal of all or part of an extremity Causes—progressive peripheral vascular disease, fulminating gas gangrene, severe trauma, congenital deformities, chronic osteomyelitis, malignant tumors, septic wounds, Amputation: Purpose To relieve symptoms, To improve functions, Prevent Sepsis Most important to save, or improve the patient’s quality of life. Treatment Psychological preparation Rehabilitation preparation Nutritional status buildup Prosthetic device Nursing Interventions—Pre-op Expression of feelings Phantom limb pain Program of exercises to be independent – Strengthening of upper extremities – Transferring from bed to chair – Ambulating with a walker or crutches Nursing Interventions—Post-op Routine post-op care Monitor hemorrhage and apply pressure Apply elastic bandages in a crisscross or figure-8 Elevate residual limb 8 to 12 hours on pillow Place in prone position 1 hour out of every 4 hours to prevent contracture Massage residual limb to soften scar and improve circulation Use of TENS for relief of phantom limb pain Encourage progressive ambulation and physical therapy Complications Hemorrhage Infection Skin breakdown Joint contracture Phantom pain Nursing Interventions—Post-op Phantom pain – Transcutaneous Electrical Nerve Stimulator (TENS) – Medications—narcotics (morphine) Rehabilitation for Amputees Preoperative—functional level expectations Amputation surgery Post surgical—wound healing, pain control Preprosthetic—residual limb shaping Prosthetic training—increase wearing time and functional use Community integration—resumption of roles, recreational activities, coping strategies Vocational rehabilitation—job modification Follow-up—lifelong prosthetic, emotional support Quick Check 4 A 32-year-old, senior machinist, sustained an injury in an industrial accident that required amputation of his right (dominant) forearm just below the elbow. He is married and is the father of three children. His wife is a homemaker who has never worked outside the home. 1. List 3 activities that are likely to require modification after loss of the dominant hand. 2. List 3 nursing diagnoses based on the scenario. Case Study Case Study Mrs. Jacobson, age 80, was admitted for a fracture in the right wrist 2 days ago. Before the injury, she lived alone and cared for herself. She was active, alert and independent. Since the fracture repair, she has complained of pain over the area of the break but has had no signs of infection. Her physician is ready to discharge her to her home. Information Subjective Data Complains that she needs assistance with ADL, particularly bathing, dressing and toileting Objective Data B/P 165/95 mm Hg; pulse 98 b/min with slight irregularity; resp 20 b/min; oral temp 97.4°F (36.3°C) Weight 132 lb Alert and oriented to time, place and person Cast on right arm from above her elbow to her fingers Critical Thinking 1. What activities can the patient perform that will promote bone and tissue healing? 2. What signs and symptoms require physician/Nurse practitioner’s intervention? 3. Group activity: List 3 nursing diagnoses and appropriate interventions based on the case study. References Day, R.A., Paul, P., Williams, B., Smeltzer, S.C., Bare, B.. Brunner and Suddarth's Textbook of Canadian Medical-Surgical Nursing (Current Edition). Philadelphia: Lippincott Williams & Wilkins Kwong, J., Reinisch, C., Tyerman, J., Cobbett, S., Hagler, D., Harding, M., & Dott (2023). Lewis's Medical-Surgical Nursing in Canada (5th Edition). Elsevier Health Sciences (US). Lewis, S.L., Bucher, L., Heitkemper, M.M., Harding, M.M., Barry, M.A., Lok, J., Tyerman, J., Goldsworthy, S. (2019). Medical-Surgical Nursing in Canada (4th ed.). CA: Elsevier