Transcript Musculoskeletal Disorders Part I Final

Musculoskeletal Disorders
Part I
Osteoporosis
Fractures
Degenerative Joint Disease/Osteoarthritis
Total Hip and Knee Prostheses
Bone Infections / Osteomyelitis
Gout
Emergency & Ortho Nursing
……..is Not for the Faint of Heart !
Fractured femur 2* Gun Shot Wound
Transverse fracture
Oblique fracture / spiral fracture /
torsion fracture
Green stick fracture
Concept Map: Selected Topics in Musculo-Skeletal Nursing
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
“Neuro / Circ Checks”
--”The 6 P’s”
PATHOPHYSIOLOGY
PHARMACOLOGY
Fracture
Osteoporosis
Degenerative Joint Disease
Osteoarthritis
Osteomyelitis
Gout
Opioids
NSAIDs
Antibiotics
Disease Specific
Amputation
Total Joint Replacement
Lab Monitoring
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……
Musculoskeletal Disorders
 Objectives
 See the Study Guide for Complete List of Objectives
 Compare and contrast different types of fractures
 Discuss the usual healing processes for bone
 Identify complications of fractures
 Describe the nursing care of the client with casts or
traction, including client education
 Prioritize nursing care for patients who are at risk for
osteopenia
 Describe the role of drug therapy, diet, and exercise in
management of osteoporosis.
Musculoskeletal Disorders
 Objectives—
 See the Study Guide for Complete List of Objectives
 Describe the pain management of client with bone
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disorders
Prioritize nursing care for a patient who has had a hip
ORIF or knee replacement
Identify common types of amputations
Identify appropriate nursing care for patients with
degenerative joint disease (DJD)
Prioritize nursing care for patients who are at risk for
osteomylitis (bone infection)
Describe the role of drug therapy in prevention and
management of degenerative joint disease
Describe the causes of gout and appropriate treatments.
Musculoskeletal Disorders
 Review of Bone physiology – this is a picture of normal
bone, with osteoblasts rebuilding injured or old bone,
faster than osteoclasts can break it down
o
o
o
Healthy bone
Musculoskeletal Disorders
 This is one osteoclast dissolving bone
As part of the normal healing process
MusculoSkeletal Disorders
Healthy bone provides
structure and
support for the
human body.
The marrow makes
stem cells which
produce our red
and white cells
when they
mature.
Musculoskeletal Disorders
----Osteoporosis
 Osteoporosis– number one cause of fractures in the elderly,
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>1.5 million per year
Primary Osteoporosis is caused by osteopenia or thinning
of the bone. This occurs when osteoclastic bone loss is
faster than osteoblastic (bone building) activity.
This is measured by BMD (bone mineral density)
Osteopenia = T-score of less than- 1.0
Treatment starts here, new guidelines 2008
Osteoporosis = T-score of > -2.5
Musculoskeletal Disorders-----Osteoporosis
 Secondary Osteoporosis
 Caused by other disease mechanisms, or
treatments, i.e. long term corticosteroids,
methamphetamine or alcohol abuse, or
prolonged immobility – can occur within 12
weeks
 Treatments are the same for both types and
osteoclastic activity is the same
Low-power scanning electron microscope image of normal bone
architecture in the 3rd lumbar vertebra of a 30 year old woman
marrow and other cells have been removed to reveal thick, interconnected plates of bone
Slides courtesy of the Bone Research Society BRS, UK
Low-power scanning electron microscope image of osteoporotic
bone architecture in the 3rd lumbar vertebra of a 71 year old woman
marrow and other cells have been removed to reveal eroded, fragile
rods of bone
Detail of a trabicular bone element perforated by osteoclast
action-- note pitting of the bone ‘stalagmite’
Musculoskeletal diseases
 Osteoporosis Risk Factors
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Age
Post-menopause (lack of estrogen stimulation)
Thin lean body build
Asian or thin Caucasian race
Calcium and Vitamin D deficiency
Lack of weight bearing exercise
Alcohol abuse
Tobacco use
Excessive caffeine use (> 3 cups per day)
Eating disorders
Malabsorption disorders
Musculoskeletal diseases
 Osteoporosis
 Diagnostics:
DEXA Scan Screening annually of post-menopausal women
DEXA Screening for hypothyroid and hyperthyroid patients
Qualitative US – not used much
Bone Scan is used for differential diagnostics, i.e. to rule out
bone cancer
 Labs for Calcium, Magnesium, Phosphorus levels
 Urine for pyridinium levels
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DXA Scan
 This is a typical bone
densitometry study. A low dose
x-ray is performed of the
lumbar spine, hip (shown here)
or wrist.
 From the resulting image
/measurement, calculations
can be made to determine the
density of the patient's bone
(T-score) and compare it to the
reference standard of a healthy
thirty-year-old of the same sex
and ethnicity to determine
future risk of fracture.
http://www.radiologyinfo.org/en/info.cfm?pg=dexa
Musculoskeletal diseases
 Osteoporosis Treatments and Nursing Interventions
 Educate – Side effects of meds
 Calcium supplementation – new evidence is 1700 mg of
calcium per day, or more for post-menopausal women not on
hormone therapy. May use TUMS if stomach is upset with
supplements
 Exercises
 Fall prevention and safety
 Biphosphonates i.e. Fosamax, Actonel, Boniva– have to be taken
1 hour before any other foods or vitamins, with only water to
be absorbed.
 Vitamin D therapy – not usually needed in the sunny desert,
found in dairy and green leefy vegetables
Musculoskeletal Disorders
 Fracture treatment
 Nursing primary concern is to assess and prevent neuro-vascular
dysfunction.
 Neuro / circulation checks should be done of the affected limb every
15 minutes x 4, then every 30 minutes x2, then every hour. ( The
book says every hour, but that is really too long, and your patient
could go into shock)
 Immobilize the limb
 Control the pain
 Assess for shock
Risk for Peripheral Neurovascular deficit
Other fracture interventions (with casting or
immobilization/traction).
 Monitor for numbness, tingling, hyperesthesia, hypoesthesia
 Monitor for DVT’s – check pulses and color
 Instruct the client to examine the skin daily for any breakdown or
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alterations, call MD if oozing or redness occur
Instruct client to avoid crossing their legs
Instruct patient to completely abstain from tobacco
Remove home safety hazards in the home
Instruct patient not to scratch underneath the cast or around the
pins/traction
Give patient anticoagulants and analgesics if ordered
Instruct patient to take vitamins, adequate amoaunts of magnesium, vitamin
C, etc…for healing.
Neurovascular
Components:
Early or
Late Signs
Assessment Parameters
Client Teaching /
Symptoms to Report
Early
Assess area involved using 0 to 10 rating scale:
Increasing pain not
relieved with elevation or
pain medication
“The 6 P’s”
Pain
0 = no pain
10 = worst pain imaginable
Paresthesia
Early
Assess for numbness/tingling, pins or needles
sensation:
Should be absent.
Numbness or tingling, pins
or needles sensation
Pallor
Early
Assess capillary refill.
Increased capillary refill
time > 3 seconds, blue
fingers or toes
Brisk is < 3 seconds
Polar
Late
Assess skin temperature by
touch:
Cool/cold fingers or toes
Warm <or> Cool
Paralysis
Late
Assess mobility:
Moves fingers or toes
Able to plantar dorsiflex the ankle area
not involved or restricted by cast
Unable to move fingers or
toes
Pulses
Late
Assess pulse(s) distal to
injury:
Pulse is palpable and strong
Weak palpable pulses,
unable to palpate pulses,
pulse detected only with
Musculoskeletal Disorders
 Fractures- Pathological fractures
 occur when abnormal force is applied, or the bone is already
weakened (osteoporosis, cancers, sarcomas, benign bone
cysts, etc.).
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The type of fracture depends on the type of loading force and stress applied to the bone. See below.
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Closed - Greenstick -Spiral - Open (compound)
 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
Musculoskeletal Disorders
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Fractures-
 Complications of fractures include:
 Fat emboli syndrome/CVA/Stroke
 Hematoma (leakage from the bone marrow usually),
which can also be a hemmorhage
 Callus formation
 DVT - thromboembolism
 Infection – to Osteomyelitis
 Ischemic necrosis
 Fracture blisters
 Delayed union, nonunion, and malunion
 Osteoblastic proliferation…..
 i.e. Osgood’s Schlatter’s
 Osteoblastic proliferation:
Osgood Schlatter’s is a common
disorder among athletes and runners
stemming from small fractures of the
tibial plateau from impact which heals
builds up bone callous.
Immobilizing Interventions:
Casts, Splints, & Traction
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Perform/assist with relevant
laboratory, diagnostic, and
therapeutic procedures within the
nursing role, including:
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Preparation of the client for the
procedure.
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Client teaching (before and following
the procedure).
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Accurate collection of specimens.
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Accurate interpretation of procedure
results (compare to norms) and
appropriate notification of the
primary care provider.
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Assessment and evaluation of the
client’s response (expected,
unexpected adverse response,
comparison to baseline) to the
procedure.
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Planning and implementing body
system specific interventions as
appropriate.
Monitoring and taking actions,
including client education, to prevent
or minimize the risk of complications.
Recognizing signs of potential
complications and reporting to the
primary care provider.
Recommending changes in the
test/procedure as needed based on
client findings.
Protect the client from injury.
Monitor therapeutic devices
(drainage/irrigating devices, chest
tubes), if inserted, for proper
functioning.
Identify the client’s prognosis based
on knowledge of pathophysiology
and understanding of the client’s
pathology report.
 Casts
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Casts are more effective than splints or
immobilizers because they cannot be
removed by the client.
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Types of casts include:
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Short and long arm casts.
 Splints and Immobilizers
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Short and long leg casts.
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Splints are removable and allow for monitoring of
skin swelling or integrity.
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Splints can be used to support fractured/injured
areas or used for postparalysis injuries to avoid joint
contracture.
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Immobilizers are prefabricated and are fastened with
Velcro straps.
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Spica cast, which refers to a portion of
the trunk and one or two extremities.
Body cast, which encircles the trunk of
the body.
 Traction
 Traction uses a pulling force to
promote and maintain alignment to
the injured area. In straight or
running traction, the
countertraction is provided by the
client’s body. In balance suspension
traction, the countertraction is
produced by devices such as slings
or splints.
 Goals of traction include:
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Realignment of bone fragments.
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Decreasing muscle spasms and pain.
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Correcting or preventing further
deformities
 Types of Traction
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Manual
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Skin
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Skeletal
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Halo Traction
Pin Site Care
* Pin care is done frequently throughout immobilization (skeletal traction and
external fixation methods) to prevent and to monitor for signs of infection
including:
--Drainage (color, amount, odor).
--Loosening of pins.
--Tenting of skin at pin site
(skin rising up pin).
Pin care protocols (use of hydrogen peroxide, povidone iodine) are based
on provider preference and institution policy.
A primary concept of pin care is that one cotton-tip swab is used per pin to avoid
cross-contamination.
Every 8 hr is a common parameter for pin care schedule.
Immobilization: (Casts, Splints, & Traction)
Casts plaster & fiberglass
Bi-Valved (bivalve) Plaster Cast
Posterior Splints
Crutchfield Tongs
Halo Traction
Stryker Frame
External Fixation
 External fixation involves
fracture immobilization using
percutaneous pins and wires that are
attached to a rigid external frame.
 Used to treat:
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Comminuted fracture with
extensive soft tissue.
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Leg length discrepancies from
congenital defects.
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Bone loss related to tumors or
osteomyelitis.
 Advantages include:
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Immediate fracture stabilization.
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Allows three plane correction of the
injury.
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Minimal blood loss occurs in
comparison with internal fixation.
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Allows for early mobilization and
ambulation.
 Disadvantages include:
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Risk of pin tract infection.
Potential overwhelming appearance
to client.
Musculoskeletal Disorders
 Fractures- complications
 Acute Compartment Syndrome (ACS)
 A serious condition which can lead to a loss of life and limb, usually an arm
or a leg. The swelling of an injury or trauma causes lack of innervation and
compromised circulation to the affected part of the body, causing tissue
death and necrosis. Edema causes this.
 Treatment is mandated by alleviating the pressure.
 The most common type of acute compartment syndrome in the hospital is
infiltration of IV fluids, and in trauma victims.
Musculoskeletal Disorders
 --Acute Compartment Syndrome (ACS)
Musculoskeletal Disorders
 Signs and Symptoms of ACS:
 Greater pain with passive movement than with active
movement
 Swelling
 Pain not relieved with analgesics
 These are early signs and the physician needs to notified
at once.
 ACS can lead to renal failure, shock, and loss of the limb or life.
Musculoskeletal Disorders
 Acute Compartment Syndrome (ACS)
Musculoskeletal Disorders
 Acute Compartment Syndrome (ACS)
 Treatment
 Determine the cause of swelling,
 If the cast is too tight then it needs to be cut off.
 If the dressing is too tight, loosening the bandage will release the
pressure
 Surgical release of tissue pressure is often required. (Fasciotomy)
Musculoskeletal Disorders
 Assessing fractures and trauma:
 Color or pallor of patient
 Color of the limb distal to the injury
 Movement
 Sensation
 Distal pulses
 Pain
 Skin temperature
 Capillary refil
Musculoskeletal Nursing
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.
 Identify contraindications,
 Assess/monitor the effectiveness of
pain intervention, and advocate
for the client’s needs as indicated.
 Provide appropriate client
education, and reinforce client
teaching regarding the purposes
and possible effects of pain
medications.
 Assess/monitor the client for
expected effects of medications.
 Assess/monitor the client for
side/adverse effects of medications.
actual/potential incompatibilities, and
interactions between medications,
and intervene appropriately.
 Identify symptoms/evidence of an
allergic reaction, and respond
appropriately.
 Evaluate/monitor and document
the therapeutic and adverse/side
effects of medications.
 Assess/collect data regarding the
client’s medication use over time.
Musculoskeletal Pharmacology : Medications for Pain & Inflammation
NSAIDs—Non Steroidal Anti-Inflammatory Drugs
Prototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®)
Pharmacological Action
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Aspirin contraindications include:
Inhibition of cyclooxygenase: Inhibition of
COX-2 results in ↓ inflammation, pain, and
fever. Inhibition of COX-1 results in the ↓ of
platelet aggregation
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Peptic ulcer disease.
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Bleeding disorders (e.g., hemophilia, vitamin K
deficiency)
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Hypersensitivity to aspirin and other NSAIDs.
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Pregnancy (Pregnancy Risk Category D).
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Children with chickenpox or influenza.
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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.
Therapeutic Uses
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Inflammation suppression
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Analgesia for mild to moderate pain
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Fever reduction
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Dysmenorrhea
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Low level suppression of platelet
aggregation
Musculoskeletal Pharmacology : Medications for Pain & Inflammation
NSAIDs—Non Steroidal Anti-Inflammatory Drugs
Prototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®)
Therapeutic Nursing Interventions and
Client Education
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Advise the client to stop aspirin 1 week before an
elective surgery or expected date of childbirth.
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Advise the client to take aspirin with food, milk, or
a full glass of water to reduce gastric
discomfort.
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Instruct the client not to chew or crush enteric-coated
or sustained-release aspirin tablets.
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Advise the client to notify the primary care provider if
signs and symptoms of gastric discomfort or
ulceration occur.
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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).
CONTINUED…
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One 1st generation NSAID, ketorolac (Toradol), is
used for short-term treatment of moderate to
severe pain such as that associated with
postoperative recovery.
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Ketorolac provides analgesia without antiinflammatory effect.
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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).
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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.
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Depending on therapeutic intent, effectiveness
of NSAID USE may be evidenced by:
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Reduction in inflammation.
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Reduction of fever.
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Relief from mild to moderate pain or dysmenorrhea.
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Platelet aggregation suppression.
Musculoskeletal Pharmacology : Medications for Pain & Inflammation
Acetaminophen
Prototypes: acetaminophen (Tylenol® )
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Pharmacological Action
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Acetaminophen slows the production of
prostaglandins in the central nervous system.
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Therapeutic Uses
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Analgesic (relief of pain) effect
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Antipyretic (reduction of fever) effects
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Side/Adverse Effects:
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Nursing Interventions and Client
Education
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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.
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In the event of an acetaminophen overdose, liver
damage can be reduced by administering a weightbased dosage of the antidote acetylcysteine
(Mucomyst) in a diluted form via an
oroduodenal tube (has an unpleasant odor that ↑
risk of emesis).
Nursing Interventions and Client Education
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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
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Advise the client to take acetaminophen as
prescribed and not to exceed 4 g per day.
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Administer the antidote,
Nursing Evaluation of Medication
Effectiveness
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Depending on therapeutic intent, effectiveness may
be evidenced by:
Acetylcysteine (Mucomyst® ).
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Use cautiously in clients who consume
three or more alcoholic drinks/day and
those taking warfarin (interferes with
metabolism).
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Relief of pain.
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Reduction of fever.
Musculoskeletal Pharmacology : Medications for Pain & Inflammation
Opioid Agonists
Prototypes: Morphine sulfate
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Pharmacological Action
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Contraindications/Precautions
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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.
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Contraindicated:
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Therapeutic Uses
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asthma, emphysema, and/or head injuries
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Relief of moderate to severe pain (e.g.,
postoperative pain, myocardial infarction pain,
cancer pain)
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Infants and older adult clients
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Pregnant clients
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Sedation
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Clients in labor
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Reduction of bowel motility
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Clients with inflammatory bowel disease
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Codeine: cough suppression
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Clients with an enlarged prostate
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after biliary tract surgery.
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for premature infants (during and after
deliverydue to respiratory depressant effects).
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Used Cautiously: because of respiratory
depression
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
Nursing Interventions /
Client Education
Respiratory depression
--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).
Constipation
--↑ 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.
Orthostatic hypotension
--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.
Urinary retention
--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.
Cough suppression
--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.
Sedation
--Advise the client to avoid hazardous activities
such as driving or operating heavy machinery.
Biliary colic
--Avoid giving morphine to clients who have a
history of biliary colic. Use meperidine as an
alternative.
Emesis
--Administer an antiemetic such as
promethazine (Phenergan).
Opioid overdose triad
of coma, respiratory depression, and
pinpoint pupils
--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
 Compared to pure opioid agonists, agonistantagonists have:
 --A low potential for abuse causing little
euphoria. In fact, high doses can cause adverse
effects (e.g., anxiety, restlessness, mental
confusion).
 --Less respiratory depression. Kappa receptors
will cause a certain degree of
respiratory depression and then no more (have a
“ceiling”).

Therapeutic Uses
 Agonists-antagonists opioids relieve mild to
moderate pain; not used for treatment of severe
pain.
Contraindications/Precautions
 Use cautiously in clients with a history of
myocardial infarction (↑ cardiac workload) and
clients who are physically dependent on
opioids.
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Nursing Interventions and Client
Education
 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.

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Warn the client not to ↑ dosage without
consulting the primary care provider.

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

Contraindications/Precautions

Hypersensitivity
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Opioid dependency

Pregnancy Risk Category B
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).

 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
 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.
 Probenecid inhibits uric acid reabsorption by the renal
tubules.
 Contraindications/Precautions

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.

Therapeutic Nursing Interventions and
Client Education

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).

 Therapeutic Uses
Colchicine and indomethacin:

--Treatment of acute gout attacks.

--If given in response to precursor symptoms of an acute
gout attack, can abort the attack.






--↓ in the incidence of acute attacks for clients with chronic
gout.
Allopurinol and probenecid:
--Hyperuricemia (chronic gout secondary to cancer
chemotherapy).
Probenecid:
--Prolongs the effects of penicillins and cephalosporins by
delaying their elimination.

--↓ in number of gout attacks.

--↓ in uric acid levels.