Transcript Musculoskeletal Disorders Part II Final
Musculoskeletal Disorders Part II
Osteoporosis Fractures Degenerative Joint Disease/Osteoarthritis Total Hip and Knee Prostheses Bone Infections / Osteomyelitis Gout
Concept Map: Selected Topics in Musculo-Skeletal Nursing ASSESSMENT
Physical Assessment
Inspection Palpation Percussion Auscultation
“Neuro / Circ Checks” - ”The 6 P’s” Lab Monitoring
PATHOPHYSIOLOGY Fracture Osteoporosis Degenerative Joint Disease Osteoarthritis Osteomyelitis Gout Amputation Total Joint Replacement PHARMACOLOGY Opioids NSAIDs Antibiotics Disease Specific Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more…based On Nursing Process: A_D_O_P_I_E
NURSING DIAGNOSES THAT APPLY….
Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary
Nursing Diagnoses That (Might) Apply
Pain, acute Comfort, impaired Mobility, altered Self-care deficit –feeding, grooming; bathing, hygeine; toileting Falls, risk for Skin breakdown, risk for Constipation, risk for Diversional activity, risk for Mobility, Physical, impaired Mobility, bed, risk for Walking, impaired, Tissue perfusion, impaired peripheral Peripheral neurovascular dysfunction, risk for Knowledge, deficient Body image, disturbed Grieving More……
Neurovascular Components:
“The 6 P’s”
Pain Early or Late Signs Assessment Parameters
Early
Paresthesia Pallor Polar Paralysis Pulses
Early Early Late Late Late
Client Teaching / Symptoms to Report Assess area involved using 0 to 10 rating scale: 0 = no pain 10 = worst pain imaginable Increasing pain not relieved with elevation or pain medication Assess for numbness/tingling, pins or needles sensation: Should be absent.
Assess capillary refill.
Brisk is < 3 seconds Numbness or tingling, pins or needles sensation Increased capillary refill time > 3 seconds, blue fingers or toes Assess skin temperature by touch: Warm
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Degenerative Joint Disease (DJD)
a degenerating arthritic condition that affects any joint in the body, including the spine (then it is called DDD – Degenerative Disc Disease) Risk Factors: Obesity (More in the weight – bearing joints) Poor nutrition, low in calcium or vitamin D Genetics – familial arthritis Overuse injuries or manual labor Sports injuries which affect the bursae or tendon - meniscal tissues that cushion the joint Smoking – as it dehydrates and constricts tissues
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Degenerative Joint Disease (DJD) Pathophysiology - the bone and supporting tissues start to degenerate, causing atrophy of tendons, and bone spurring, with degeneration of menisci and bursa which would normally protect the joint. Main symptoms are “stiffness in the morning” and pain. Eventually the bone spurring and breakdown will cause joint deformities.
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Degenerative Joint Disease (DJD) Also called OA – Osteoarthritis Diagnosis: Symptoms and history Arthroscopy X-rays MRI – for soft tissue visualization, i.e of menisci or bursae Bone scan if cancer has to be ruled out
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Degenerative Joint Disease (DJD) Note the loss of joint space with bone on bone
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Degenerative Joint Disease (DJD)
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Degenerative Joint Disease (DJD)
Treatments – heat and cold therapy Preventative exercises – to strengthen supporting muscles Joint Injections – Hydralan, cortisone, etc.
Analgesics/Anti-inflammatories – COX – 2 inhibitors i.e. Mobic, Celebrex Tylenol – contraindicated for liver patients Indocin - more risk for peptic ulcers Aspirin – more risk for peptic ulcers Partial or complete surgical repair Joint prosthesis
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Degenerative Joint Disease (DJD) –
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Hip Prosthesis
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knee prosthesis
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Care of Patients –
Pain control Ambulation with assistance - only Prevent falls Exercise; usually has physical therapy from 6 - 8 weeks Non-smoking Encourage adequate intakes of vitamin C Post-op anti-coagulants, whether Lovenox, coumadin, heparin, or aspirin
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Hip prosthesis – NEVER adduct the leg (letting the hip and leg cross the other one will pop the prosthetic ball out of the pelvis) Only allow hip flexion to 90 degrees Turn patients using an adductor pillow while aligning the spine
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Adductor pillow between knees
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Bone infections Causes: Immunological problems Diabetes, nutritional problems Injury which allows pathogens into the bone fractures coral cuts trauma post-operative surgery
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Bone infections Chronic Osteomylitis in a diabetic
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Bone infections Diagnosis: Bone scan X-rays MRI for soft tissue view Blood cultures – need to be done 15 minutes apart from two different sites Wound cultures – if drainage is apparent
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Bone infection symptoms: Foul smelling drainage Fever Lethargy Swelling Redness Increased WBC’s on CBC with differential With increased neutrophils on the CBC, sometimes called PMN’s or polymorphic neutrophils. These cells in particular replicate to fight infection. If the WBC is not elevated with these symptoms, the patient is immunosuppressed and at risk for sepsis.
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Bone Infections
Most common organisms
:
Staphlococci Aureus – MRSA in the hospital post operatively (a drug resistant organism) Enterococci from wounds/trauma Clostridium Perfringens – gangrene E-Coli – fecal contamination
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Osteomylitis Treatments/Interventions #1 Pain control Monitor Vital signs every 4 hours and prn (Observe for signs of sepsis or drug reaction) Monitor skin integrity and site
intravenous antibiotics to get rid of infection (need a physician’s order)
Surgical repair or debridement Removal of infected prostheses Sometimes it is necessary for amputation
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Ewing’s Sarcoma of the bone – usually malignant with mets, often treated with amputation
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Osteosarcoma –
most common type of malignant bone tumor, most often in males between 10 and 30 y.o. or in older patients with Paget’s Disease
osteosarcoma
Chondrosarcoma
This is a photograph of 70 year old woman who first presented like this with a massive chondrosarcoma of her right upper humerus of 8 months duration. She refused all treatment, and she died of a massive haemorrhage when the tumour burst the following week.
http://worldortho.com/dev/index.php?option=com_content& task=view&id=1814&Itemid=328
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Chondroma
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Types of amputations Simple Toe – uncomplicated, most often due to injury and diabetes
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Amputations – BKA Below the knee Treatments for amputations will be further covered in Adult Health Care II
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Types of Amputations AKA – above the knee – a surgical technique for saving a person’s life from an infected prosthesis or necrotic limb
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Amputations - facts and figures
: More than 100,000 amputations are performed in the USA every year.
The most common cause of amputations is diabetes & infection Of the 9,985 nonfatal workplace amputations in 1999, more than 1 in 3 cases required 31+ days away from work to recuperate (OSHA study) The third most common cause today is war-related.
http://www.peglegbiker.com/index.html
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Assessment must include: Pain as a no. 1priority Proper patient assessment must include pain intensity, radiation, relief, medication side effects, and reassessment on a regular basis.
Skin integrity Tissue Perfusion Prevention of infection Promotion of nutrition Exercise & ROM Body Image
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Gout –
Pathophysiology
Gout is a disease caused by the kidneys not clearing the uric acid out of the blood stream. Uric acid is the end product of purines in our diet (one of the amino acids in the body). This causes a hyperuricemia (high levels of uric acid in the blood) and initiates an inflammatory response in the joints. The urate crystals deposit into a joint and/or subcutaneous tissues.. This deposit and inflammation causes “gouty arthritis” and may appear the same as OA on X-ray. The deposits can also cause kidney stones, as deposits build up in the kidneys. Renal stones are `1000 times more common in people with gout.
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Gout Symptoms: Tophi - white crystalized deposits in the tissue, usually seen on the hands or toes.
Heat & Redness Pain – Severe & sudden onset Swelling Inflammation – usually on one side of the body first, a ankle joint, knee, or toe May become an acute inflammation after an injury, i.e. stubbing your toe on the sprinkler
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Gout – Diagnosis: - X-ray of limb to rule out regular arthritis, or osteomylitis/cellulitis - blood test for a uric acid level normal is 4.0-5.2 (lab values may differ based on the age of the patient) - Anything over 6.0 is consider high - An aspiration of the fluid in the joint will demonstrate crystalline deposits by microscope
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Treatments Anti-inflammatories STAT – drugs of choice are colchicine and indocin – Patients need to be educated to side effects and dosing .
Sometimes, doctors will give Toradol IM for immediate pain relief, as it acts like injectable aspirin and reacts quickly Pain control Maintenance on daily allopurinol – to allow the kidneys to secrete the acid Educate patient to avoid high purine foods
gout
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Gout tophi
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Gouty tophi (in red)
Pharmacology Associated with Musculoskeletal Patients--General Information
Assess/monitor the client’s need for pain medication, and plan and provide care to meet the client’s needs for pain intervention.
Assess/monitor the client for actual/potential specific food and medication interactions.
Assess/monitor the effectiveness of pain intervention, and advocate for the client’s needs as indicated.
Identify contraindications,
actual/potential incompatibilities, and
interactions between medications, and intervene appropriately.
Provide appropriate client education, and reinforce client teaching regarding the purposes and possible effects of pain medications.
Identify symptoms/evidence of an allergic reaction, and respond appropriately.
Evaluate/monitor and document the therapeutic and adverse/side effects of medications.
Assess/monitor the client for expected effects of medications.
Assess/collect data regarding the client’s medication use over time.
Assess/monitor the client for side/adverse effects of medications.
Musculoskeletal Pharmacology :
Medications for Pain & Inflammation
NSAIDs—Non Steroidal Anti-Inflammatory Drugs Prototypes: 1 st Generation: Aspirin 2 nd Generation: celecoxib (Celebrex®)
Pharmacological Action Inhibition of cyclooxygenase: Inhibition of COX-2 results in ↓ inflammation, pain, and fever. Inhibition of COX-1 results in the ↓ of platelet aggregation Therapeutic Uses
Inflammation suppression Analgesia for mild to moderate pain
Fever reduction Dysmenorrhea Low level suppression of platelet aggregation
Aspirin contraindications include:
Peptic ulcer disease.
Bleeding disorders (e.g., hemophilia, vitamin K deficiency) Hypersensitivity to aspirin and other NSAIDs.
Pregnancy (Pregnancy Risk Category D).
Children with chickenpox or influenza.
Use NSAIDs cautiously in older adults,
clients who smoke cigarettes, and in clients with H. pylori infection, hypovolemia, hay fever, chronic urticaria, and/or a history of alcoholism.
Musculoskeletal Pharmacology :
Medications for Pain & Inflammation
NSAIDs—Non Steroidal Anti-Inflammatory Drugs Prototypes: 1 st Generation: Aspirin 2 nd Generation: celecoxib (Celebrex®) CONTINUED…
Therapeutic Nursing Interventions and Client Education
Advise the client to stop aspirin 1 week before an elective surgery or expected date of childbirth.
Advise the client to take aspirin with food, milk, or
a full glass of water to reduce gastric discomfort.
Instruct the client not to chew or crush enteric-coated or sustained-release aspirin tablets.
Advise the client to notify the primary care provider if signs and symptoms of gastric discomfort or ulceration occur.
Clients unable to tolerate aspirin due to GI ulceration, risk of bleeding, or renal impairment should be prescribed a 2nd generation NSAID, such as celecoxib (Celebrex).
One 1st generation NSAID, ketorolac (Toradol), is
used for short-term treatment of moderate to severe pain such as that associated with postoperative recovery.
Ketorolac provides analgesia without anti inflammatory effect.
When ketorolac is used concurrently with opioids, the analgesic effect of opioids is enhanced without the occurrence of adverse effects associated with opioids (e.g., respiratory depression, constipation).
When ketorolac is used with other NSAIDs serious adverse effects can occur; therefore, ketorolac should be used no more than 5 days. Usually started as parenteral administration and then progresses to oral doses.
Depending on therapeutic intent, effectiveness of NSAID USE may be evidenced by:
Reduction in inflammation.
Reduction of fever.
Relief from mild to moderate pain or dysmenorrhea.
Platelet aggregation suppression.
Musculoskeletal Pharmacology :
Medications for Pain & Inflammation
Acetaminophen Prototypes: acetaminophen (Tylenol® )
Pharmacological Action
Nursing Interventions and Client Education
Acetaminophen slows the production of prostaglandins in the central nervous system.
Therapeutic Uses
Analgesic (relief of pain) effect Antipyretic (reduction of fever) effects
Side/Adverse Effects:
Nursing Interventions and Client Education Acute toxicity that results in liver damage with early symptoms of nausea, vomiting, diarrhea, sweating, and abdominal discomfort progressing to hepatic failure, coma, and death Advise the client to take acetaminophen as prescribed and not to exceed 4 g per day. Administer the antidote,
Acetylcysteine (Mucomyst® ).
Acetaminophen is a component of multiple prescribed and over-the-counter medications. Keep a running total of daily acetaminophen intake and follow recommended dosages as prescribed by the primary care provider to prevent toxicity, not to
exceed 4 g per day.
In the event of an acetaminophen overdose, liver damage can be reduced by administering a weight based dosage of the antidote acetylcysteine (Mucomyst) in a diluted form via an oroduodenal tube (has an unpleasant odor that ↑ risk of emesis).
Nursing Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by: Relief of pain.
Use cautiously in clients who consume three or more alcoholic drinks/day and those taking warfarin (interferes with metabolism).
Reduction of fever.
Musculoskeletal Pharmacology :
Medications for Pain & Inflammation
Opioid Agonists Prototypes: Morphine sulfate
Pharmacological Action
Opioid agonists, such as morphine, codeine,
meperidine, and other morphine-like
medications (fentanyl), act on the mu receptors, and to a lesser degree on kappa receptors. Activation of mu receptors produces analgesia, respiratory depression, euphoria, and sedation, whereas kappa receptor activation produces analgesia, sedation, and ↓ GI motility.
Therapeutic Uses
Relief of moderate to severe pain (e.g., postoperative pain, myocardial infarction pain, cancer pain) Sedation Reduction of bowel motility Codeine: cough suppression
Contraindications/Precautions Contraindicated:
after biliary tract surgery.
for premature infants (during and after deliverydue to respiratory depressant effects).
Used Cautiously: because of respiratory depression
asthma, emphysema, and/or head injuries Infants and older adult clients Pregnant clients Clients in labor Clients with inflammatory bowel disease Clients with an enlarged prostate
Demerol ® -- meperidine
Repeated use of meperidine (Demerol) can result in the accumulation of normeperidine,
which can result in
seizures and neurotoxicity. Do not administer meperidine more than
600 mg/24 hr, and
limit its use to less than 48 hr.
Morphine Sulfate Side Effects / Adverse Effects Respiratory depression Constipation Orthostatic hypotension Urinary retention Cough suppression Sedation Biliary colic Emesis Opioid overdose triad of coma, respiratory depression, and pinpoint pupils Nursing Interventions / Client Education --Monitor the client’s vital signs.
--Stop opioids if the client’s respiratory rate is less than 12/min, and then notify the primary care provider.
--Avoid the use of opioids with CNS depressant medications (e.g., barbiturates, benzodiazepines, and consumption of alcohol).
- ↑ fluid intake and physical activity.
--Administer a stimulant laxative, such as bisacodyl (Dulcolax), to counteract ↓ bowel motility, or a stool softener, such as docusate sodium (Colace), to prevent constipation.
--Advise the client to sit or lie down if symptoms of lightheadedness or dizziness occur.
--Avoid sudden changes in position by slowly moving the client from a lying to a sitting or standing position.
--Provide assistance with ambulation as needed.
--Advise the client to void every 4 hr.
--Monitor I&O.
--Assess the client’s bladder for distention by palpating the lower abdomen area every4 to 6 hr.
--Advise the client to cough at regular intervals to prevent accumulation of secretions in the airway.
--Auscultate the client’s lungs for crackles, and instruct the client to ↑ intake of fluid to liquefy secretions.
--Advise the client to avoid hazardous activities such as driving or operating heavy machinery.
--Avoid giving morphine to clients who have a history of biliary colic. Use meperidine as an alternative.
--Administer an antiemetic such as promethazine (Phenergan).
--Monitor the client’s vital signs.
--Place the client on a ventilator.
--Administer opioid antagonists, such as naloxone (Narcan) or nalmefene (Revex).
Musculoskeletal Pharmacology
Medications for Pain & Inflammation
Agonist – Antagonist Opioids Prototypes: pentazocine (Talwin ®)
Pharmacological Action
Contraindications/Precautions
Compared to pure opioid agonists, agonist antagonists have: --A low potential for abuse causing little euphoria. In fact, high doses can cause adverse effects (e.g., anxiety, restlessness, mental confusion).
Use cautiously in clients with a history of myocardial infarction ( opioids.
↑ cardiac workload) and clients who are physically dependent on
Nursing Interventions and Client Education
--Less respiratory depression. Kappa receptors will cause a certain degree of respiratory depression and then no more (have a “ceiling”).
Take the client’s baseline vital signs. If the client’s respiratory rate is less than 12/min, withhold the medication and notify the primary care provider.
Therapeutic Uses
Warn the client not to ↑ dosage without consulting the primary care provider.
Agonists-antagonists opioids relieve mild to moderate pain; not used for treatment of severe pain.
Nursing Evaluation of Medication Effectiveness
--Monitor for improvement of symptoms, such as relief of pain.
Musculoskeletal Pharmacology
Medications for Pain & Inflammation
Opioid Antagonists Prototypes: naloxone (Narcan ®)
Pharmacological Action Opioid antagonists interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no effect in the absence of opioids.
Therapeutic Uses
Treatment of opioid overdose Reversal of effects of opioids, such as respiratory depression Reversal of respiratory depression in an infant
Therapeutic Nursing Interventions and Client Education
Naloxone has rapid first-pass inactivation and should be administered IV, IM, or SC. Do not administer orally.
Observe the client for withdrawal symptoms and/or abrupt onset of pain. Be prepared to address the client’s need for analgesia (e.g., if given for postoperative opioid-related respiratory depression).
Contraindications/Precautions
Hypersensitivity Opioid dependency Pregnancy Risk Category B
Nursing Evaluation of Medication Effectiveness
Reversal of respiratory depression (e.g., respirations are regular, client is without shortness of breath, respiratory rate is 16 to 20/min in adults and 40 to 60/min in newborns)
Musculoskeletal Pharmacology
Medications for Pain & Inflammation
Adjuvant Pain Medications Prototypes:Tricyclic anti-depressants; anticonvulsants; CNS Stimulants; antihistamines; glucocorticoids; & biphosphonates
Tricyclic antidepressants:
amitriptyline (Elavil)
Anticonvulsants: carbamazepine
(Tegretol), gabapentin (Neurontin), phenytoin (Dilantin
CNS stimulants: methylphenidate (Ritalin),
dextroamphetamine (Dexedrine)
Antihistamines: hydroxyzine (Vistaril) Glucocorticoids: dexamethasone
(Decadron), prednisone (Deltasone)
Bisphosphonates: etidronate
(Didronel), pamidronate (Aredia)
Pharmacological Actions
Adjuvant medications for pain enhance the effects of opioids.
Therapeutic Uses
Used in combination with opioids – cannot be used as a substitute for opioids Treating pain with an adjuvant medication allows for lower dosages of opioids, and thereby ↓ the adverse effects experienced with opioids (e.g., sedation and constipation).
Help alleviate other symptoms that aggravate pain (e.g., depression, seizures, dysrhythmias) Used in the treatment of neuropathic pain (e.g., cramping, aching, burning, darting and lancinating pain).
Used in cancer-related conditions (e.g., ↑ intracranial pressure, spinal cord compression, bone pain).
Musculoskeletal Pharmacology Medications for Pain & Inflammation
Antigout Medication Prototypes: colchicine Contraindications/Precautions
Pharmacological Action
Colchicine and indomethacin ↓ inflammation in clients with gout by possibly preventing infiltration of leukocytes. These medications do not effect uric acid production or excretion.
Allopurinol inhibits uric acid production.
Avoid use of colchicine during pregnancy (FDA Pregnancy Risk Category C, if used orally; Category D, if used intravenously).
Use colchicine cautiously in older adults, debilitated clients, and clients with renal, cardiac, and gastrointestinal dysfunction.
Probenecid inhibits uric acid reabsorption by the renal tubules.
Therapeutic Uses
Therapeutic Nursing Interventions and Client Education
Colchicine and indomethacin: --Treatment of acute gout attacks.
--If given in response to precursor symptoms of an acute gout attack, can abort the attack.
- ↓ gout.
in the incidence of acute attacks for clients with chronic Allopurinol and probenecid: --Hyperuricemia (chronic gout secondary to cancer chemotherapy).
Probenecid: --Prolongs the effects of penicillins and cephalosporins by delaying their elimination.
Instruct the client to concurrently take preventive measures such as avoiding alcohol and foods high in purine (e.g., red meat, scallops, cream sauces). The client should ensure an adequate intake of water, exercise regularly, and maintain an appropriate body weight.
Nursing Evaluation of Medication Effectiveness
Depending on the therapeutic intent, effectiveness may be evidenced by: --Improvement of pain caused by a gout attack (e.g., ↓ in joint swelling, redness, and uric acid levels).
- ↓ in number of gout attacks.
- ↓ in uric acid levels.
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Case Study Exercise Group I John is a 34 y.o. skier with a spiral fracture of the right tibia. He has pins set to traction below his knee to continue with 5 pounds of pressure to hold the ones in place.
Create a nursing care plan, that you will present to the class.
Complete with two references: Research articles on Traction, pins, and spiral fractures.
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Case Study Exercise Group II Maria is a 48 y.o. with osteomyelitis and MRSA of the (R) tibia. Medical history includes Diabetes Mellitus, Type 2. She is returning from the operating room, S/P Right BKA
Create a nursing care plan, that you will present to the class.
Complete with two references: Research articles on amputation.
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Case Study Exercise Group III Franklin is a 64 y.o. male who is returning from the operating room, S/P (R) Total knee replacement. He is otherwise “healthy,” on no home medications other than NSAIDs.
Create a nursing care plan, that you will present to the class.
Complete with two references: Research articles on TJR.
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Case Study Exercise Group IV Johnna is a 48 y.o. with severe pain to her right ankle. Has just been diagnosed with gout.
Create a nursing care plan, that you will present to the class.
Complete with two references: Research articles on Gout and its treatment.