Transcript Nursing of Adult Patients with Medical & Surgical Conditions

Nursing of Adult Patients
with
Medical & Surgical Conditions
Musculoskeletal
Disorders
Assessment
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Scoliosis
• Lateral curvature of the spine
Assessment
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Kyphosis
• A rounding of the thoracic spine
• Hump-backed appearance
Assessment
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Loradosis
• An increase in the curve at the lumbar region
Assessment
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Blanching Test
• Capillary nail refill
• Signals circulation status
• Compress each fingernail or toenail, release the
pressure, and note how quickly the pink color
returns to the nail bed.
• Should return to normal color within 2 seconds
Diagnostic Tests
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Myelogram
• Injection of a radiopaque dye into the subarachnoid
space at the lumbar spine to determine the presence of
herniated disk or tumors.
• Assess for allergies to iodine and seafood
• Oil-based dye
• Removed to prevent meningeal irritation
• Flat for 12 hours (keeps air space in lower spine)
• Water-soluble dye
• Not removed; absorbed by body
• Semi-fowler’s position for 8 hours (keeps dye in lower spine)
• Encourage fluids to assist with absorption of dye
Diagnostic Tests
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Nuclear Scanning
• Given a low dosage of radioactive isotopes
• Scanner or camera detector is used to record
images
• Nursing Measures
• Written consent
• Informing the patient about radioacive isotopes; will
not affect others
• Follow instrucitions by nuclear medicine dept.
Diagnostic Tests
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Magnetic Resonance Imaging
• Involves the use of magnetism and radio waves
to make images of cross sections of the body
• Gives detailed picture of fluid filled soft tissue
and blood vessels
• Patient must remove any metal objects
• patients with metal prosthesis (heart valves,
othopedic screws) cannot undergo and MRI
• Sedatives may be given for anxiety due to
claustrophobia
Diagnostic Tests
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Computer Axial Tomography (CAT scan)
• 3-D picture of the structure (Soft tissue &
bones)
• More sensitive than standard x-rays
• Iodine contrast may be used
• Nursing Measures
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Written consent
Ask about allergies to iodine and seafood
NPO 3-4 hours before test
Baseline vital signs
Remove jewelry, etc.
Teach pt. about procedure
Computer Axial Tomography
(CAT scan)
Diagnostic Tests
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Bone Scan
• Detects metastatic and inflammatory bone
disease
• Radioisotopes administered IV 2-3 hours before
test
• Encourage fluids
• A scanning camera is used to reveal the degree
of uptake
• Areas of uptake may indicate a tumor or other
abnormality
Diagnostic Tests
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Arthroscopy
• Direct visualization of a joint
• exploration of joint
• drainage of fluid from the joint
• removal of damaged tissue or foreign bodies
• Involves insertion of a large-bore needle into
the suprapatellar pouch.
• Patient may be given a general or local
anesthetic
• Activities may be limited for several days
Diagnostic Tests
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Synovial Fluid Aspiration
• The puncture of a joint with a needle and the
withdrawal of synovial fluid
• Used for diagnosis of trauma, systemic lupus,
gout, osteoarthritis, and rheumatoid arthritis
• Normally straw colored, clear, or slightly
cloudy
• After procedure
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support extremity
joint rest for 12 hours
ice to joint for 24 - 48 hours
assess for s/s of infection
Diagnostic Tests
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Electromyogram (EMG)
• Insertion of needle electrodes into the skeletal
muscles to record the electrical activity
• Muscles do not produce electrical charge at rest
• Unusual patterns may be observed for
neuropathy and myopathy
Rheumatoid Arthritis
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Etiology/Pathophysiology
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Most serious form of arthritis
Chronic, systemic disease
Most common in women of childbearing age
Autoimmune disorder, but may also be genetic
Agents that should protect the body attack joint
tissues
• Can affect lungs, heart, blood vessels, muscles,
eyes and skin
• Chronic inflammation of the synovial
membrane of the diarthrodial joints (movable)
Rheumatoid Arthritis
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Signs & Symptoms
• Characterized by periods of remission and
exacerbation
• Malaise
• Muscle weakness
• Loss of appetite
• Generalized aching
• Edema & tenderness of joints
• Limited range of motion (morning stiffness)
Rheumatoid Arthritis
Rheumatoid Arthritis
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Diagnostic Tests
• Radiography studies show loss of articular
cartilage and change in bone structure
• Laboratory Tests
• Erythrocyte Sedimentation Rate (ESR)
– increase indicates inflammation
• Rheumatoid Factor (RF)
– elevation indicates abnormal serum protein concentration
• Latex agglutination test
– detects presence of IgM version of rheumatoid factor
(anti-IgG antibodies)
• Synovial fluid aspiration
– fluid is cloudy, yellow, less viscous and increased protein
Rheumatoid Arthritis
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Treatment
• Medications
• Salicylates (Aspirin)
• Nonsteroidal Anitinflammatory Drugs (NSAID’s)
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indomethacin (Indocin)
ibuprofen (Motrin)
naproxen (Naprosyn)
piroxicam (Feldene)
nabumetone (Relafen)
• Potent Antiinflammatory Agents
– adrenocorticosteroids (prdnisone)
– phenylbutazone (Butazolidin)
• Slow-Acting Antiinflammatory Agents (6-12 mo.)
– hydroxychloroquine (Plaquenil)
Rheumatoid Arthritis
• Rest
• 8-10 hours of sleep a night; 2 hour nap during day
• Exercise
• Range of motion 2-3 times per day
• prevents joints from “freezing” and muscles from
weakening
• Heat
• Hot packs, heat lamp, and/or hot paraffin
• Relaxes and soothes muscles
• Rehabilitation
• Help pt. to adapt to physical limitaions and
promoting normal daily activities
Rheumatoid Arthritis
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Prognosis
• Remissions and exacerbations are common
• Disease normally progresses to include joint
deformity, extensive muscle atrophy, soft tissue
lesions, bone and cartilage destruction, and
fibrous or bony ankylosis (fixed joints)
Ankylosing Spondylitis
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Etiology/Pathophysiology
• Chronic, progressive disorder of the sacroiliac
and hip joints, the synovial joints of the spine,
and the adjacent soft tissues.
• Most common in young men
• Strong hereditary tendency
Ankylosing Spondylitis
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Signs & Symptoms
• Low back pain and stiffness
• “sciatica pain” lasts for a few days then subsides
• worse when standing
• May also affect joints in the neck, jaw,
shoulders, knees, and hips
• Decreased ROM
• Elevated temperature
• Tachycardia
• Hyperpnea
Ankylosing Spondylitis
Ankylosing Spondylitis
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Diagnostic Tests
• Hemoglobin and Hematocrit
• Low due to anemia
• ESR
• elevated due to inflammation
• Serum alkaline phosphatase
• elevated due to immobilization
• Radiographic
• reveals sacroiliac joint and intervertebral disk
inflammation with bony erosion and joint space
fusion
Ankylosing Spondylitis
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Treatment
• Analgesics
• NSAID’s
• Exercise program
• swimming and walking
• Surgery
• replace fused joints
• Maintain spine alignment
• firm mattress
• bed board
• back brace
• Breathing exercises
• Turn and position every 2 hours
Ankylosing Spondylitis
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Prognosis
• Chronic disease
• Lasts about 20 years leaving permanent damage
Degenerative Joint Disease
(Osteoarthritis)
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Etiology/Pathophysiology
• Nonsystemic, noninflammatory disorder that
progressively causes bones and joints to
degenerate
• Primary
• Cause is unknown
• Secondary
• Caused by trauma, infections, previous fractures,
rheumatoid arthritis, stress on weight-bearing joints.
Degenerative Joint Disease
(Osteoarthritis)
Degenerative Joint Disease
(Osteoarthritis)
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Signs & Symptoms
• Joint edema, tenderness,
instability, and deformity
• Heberden’s Nodes
• nodules on the sides of the distal
joints of fingers
• Bouchard’s Nodes
• nodules on the proximal joints of
fingers
Degenerative Joint Disease
(Osteoarthritis)
Degenerative Joint Disease
(Osteoarthritis)
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Diagnostic Tests
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Radiographic studies
Arthroscopy
Synovial fluid examination
Bone scans
Degenerative Joint Disease
(Osteoarthritis)
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Treatment
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Exercise balanced with rest
Heat applications
Gait enhancers (canes, walkers, etc.)
Medications
• Salicylates (aspirin)
• NSAID’s (Motrin)
• Steriods (cortisone)
• Surgery
• Osteotomy
• Joint replacement
Degenerative Joint Disease
(Osteoarthritis)
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Prognosis
• Chronic disease that ultimately causes
permanent destruction of affected cartilage and
underlying bone.
Gout (Gouty Arthritis)
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Etiology/Pathophysiology
• Metabolic disease resulting from an
accumulation of uric acid in the blood
• Caused by an ineffective metabolism of purines
• Primary
• hereditary factors
• Secondary
• use of certain drugs, complication of other diseases,
or idiopathic
• Affects men more frequently than women
• Does not occur before puberty in the male or
before menopause in the female
Gout (Gouty Arthritis)
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Signs & Symptoms
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Excruciating pain
Edema
Inflammation
Most common in the great toe
Tophi
• calculi deposits
Gout (Gouty Arthritis)
Gout (Gouty Arthritis)
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Diagnostic Tests
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Serum and uric acid levels
Complete blood count
ESR
Radiography studies
• reveal cysts
• Synovial fluid aspiration
• contain urate crystals
Gout (Gouty Arthritis)
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Treatment
• Medications
• colchicine
– decreases uric acid
• phenylbutazone (Butazolidin)
• indomethacin (Indocin)
– antiinflammatory
• corticosteroids
• allopurinol (Zyloprim)
– decreased the production of uric acid
• sulfinpyrazone (Anturane)
– increases secretion of uric acid by the kidneys
Gout (Gouty Arthritis)
• Encourage fluid intake
• at least 2000 cc/day
• Monitor intake and output
• Bed rest and joint immobilization
• Diet
• Avoid high purine foods
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organ meats
anchovies
yeast
herring
mackerel
scallops
Gout (Gouty Arthritis)
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Prognosis
• Signs and symptoms are usually recurrent
• Can progress to destructive joint changes
Osteoporosis
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Etiology/Pathophysiology
• Reduction of bone mass
• Most common in women ages 55-65
• possibly related to lack of estrogen
• Contributing Factors
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Immobilization
Use of steroids
High intake of caffeine
Diet low in calcium
Smoking
Excessive protein in diet
Sedentary lifestyle
Osteoporosis
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Magnification of:
Healthy Bone
Bone with Osteoporosis
Osteoporosis
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Signs & Symptoms
• Backache
• especially in the thoracic and lumbar regions
• worse with sitting, standing, coughing, sneezing,
and straining
• Bones porous and brittle
• pathological or spontaneous fractures
• Dowager’s hump
• spinal deformity and height loss that develop from
repeated spinal vertebral fractures
Osteoporosis
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Diagnostic Tests
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CBC
Serum calcium
Phosphorus
Alkaline phosphatase
Blood urea nitrogen
Creatinine level
Urinalysis
Liver and thyroid function tests
Radiography studies
Osteoporosis
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Treatment
• Calcium supplements
• 1000 mg for men
• 1500 mg for women
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Vitamin D
Weight-bearing exercises
Estrogen
alendronate (Fosamax)
• absorbs calcium phosphate crystal in bone
• Diet
• Milk and dairy products provide the most calcium
• Limit caffeine
Osteoporosis
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Prognosis
• Chronic disorder
• Prevention should begin before bone loss
occurs
Osteomyelitis
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Etiology/Pathophysiology
• Local or generalized infection of the bone and
bone marrow
• Staphylococci most common cause
• Introduced through trauma (injury or surgery)
or by the bloodstream from another site in the
body to the bone
• Bacteria invade the bone and degeneration of
bone occurs
Osteomyelitis
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Signs & Symptoms
• Persistent, severe, and increasing bone pain
• Wound draining purulent fluid
• S/S of infection
• temperature, tachycardia, and tachypnea
• Edema of affected area
Osteomyelitis
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Diagnostic Tests
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Radiography studies
Bone scan
CBC (esp WBC)
ESR
Cultures of blood and drainage
Osteomyelitis
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Treatment
• Antibiotic therapy
• broad-spectrum antibiotic
– Keflin (cephalothin)
• IV for several weeks
• Surgery
• removal of necrotic bone
• Absolute rest of affected extremity
• Wound Care
• irrigate with hydrogen peroxide or antibiotic solution
• cover with sterile dressing
• Drainage and secretion precautions
• Diet
• high in calories, protein, and vitamins
Osteomyelitis
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Prognosis
• Acute
• usually responds to treatment after several weeks
• Chronic
• may persist for years with exacerbations and
remissions
Herniation of Intervertebral Disk
(Herniated Nucleus Pulposus)
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Etiology/Pathophysiology
• Rupture of the fibrocatrilage surrounding an
intervertebral disk, releasing the nucleus
pulposus that cushions the vertebrae above and
below
• Lumbar and cervical herniations are most
common
• May occur from lifting, twisting, trauma, or
degenerative changes.
Herniation of Intervertebral Disk
(Herniated Nucleus Pulposus)
Herniation of Intervertebral Disk
(Herniated Nucleus Pulposus)
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Signs & Symptoms
• Lumbar
• low back pain that radiates over the buttock and
down the leg
• numbness and tingling in affected leg
• Cervical
• neck pain, headache, and neck rigidity
Herniation of Intervertebral Disk
(Herniated Nucleus Pulposus)
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Diagnostic Tests
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Radiography studies
CT
Myelogram
Electromyelography (EMG)
Herniation of Intervertebral Disk
(Herniated Nucleus Pulposus)
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Treatment
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Bed rest
Pain medication
Muscle relaxants
Physical therapy
• muscle strengthening
• ultasound
• heat - cold application
• Traction
• pelvic or cervical
Herniation of Intervertebral Disk
(Herniated Nucleus Pulposus)
• Surgery
• Laminectomy
– Removal of the bony arches or vertebrae
– Removal of displaced vertebral disk
• Spinal Fusion
– Immobilization of joint
– Remove disk and fuse vertebrae; may use bone from iliac
crest
• Diskectomy
– Removal of extruded disk material
• Chemonucleolysis
– Injection of chymopapain to dissolve the nucleus pulposus
Tumors of the Bone
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Etiology/Pathophysiology
• May be primary or secondary
• Benign or Malignant
• Osteogenic sarcoma
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primary malignant bone tumor
seen most often in male ages 10-25
can metastasize via bloodstream
fast-growing and aggressive
• Osteochondroma
• benign tumor
• seen most often in males ages 10-30
• may be a single tumor or muliple tumors
Tumors of the Bone
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Signs & Symptoms
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Spontaneous fractures
Anemia
Pain esp. with weight bearing
Edema and discoloration of skin at site
Tumors of the Bone
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Diagnostic Tests
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Radiography studies
Bone Scan
Bone biopsy
CBC
Platelet count
Serum protein levels
serum alkaline phosphatase level
Tumors of the Bone
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Treatment
• Surgery
• Depends on tumor size, location and extent of tissue
involvement
• Wide excision or resection
• Bone curettage
• Leg or arm amputation
• Chemotherapy and Radiation
• Decrease size or tissue involvement before surgery
• Limb-salvage procedure
Tumors of the Bone
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Prognosis
• Survival rates with aggressive treatment are
approximately 50% at 5 years
Traumatic Injuries
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Contusions
• An injury from a blow or blunt force which
causes local bleeding under the skin
• Treatment
• Cold compresses for 15-20 minutes intermittently
for 12 to 36 hours
• Elevate involved extremity
Traumatic Injuries
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Sprains
• Results from a wrenching or hyperextension of
a joint, tearing the capsule and ligaments
• May involve bleeding into the joint
(hemarthrosis)
• Treatment
• Cold compresses for 15-20 minutes intermittently
for 12 to 36 hours
• Elevate involved extremity
Traumatic Injuries
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Whiplash
• Injury at cervical spine caused by
hyperextension
• Usually caused by violent back-and-forth
movements of the head and neck
• Symptoms
• Pain in the cervical area; may radiate down the arm
• Headache, blurred vision, weakened hand grip
• Treatment
• Analgesics
• Muscle relaxants
• Cervical traction (neck brace)
Traumatic Injuries
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Ankle Sprains
• Caused by a wrenching or twisting of the foot and ankle
• Signs & Symptoms
• Edema of the ankle
• Pain with movement of ankle
• Treatment
• Elevate injured area
• Cold compresses for 15-20 minutes intermittently for 12-36
hours
• Warm compresses for 15-30 minutes four times a day after 24
hours
• Compressive dressings and splint
• Surgery
– may be necessary for torn ligaments
Traumatic Injuries
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Strains
• Microscopic muscle tears as a result of overstretching
muscles and tendons
• Signs & Symptoms
• Sudden & severe pain in affected muscle
• Ecchymosis and edema over area
• Treatment
• Analgesics
• Exercise legs
• Cold compresses 15-20 minutes for 12-36 hours then warm
compresses 15-30 minutes after 24 hours
• Surgery
– may be required if muscle is completely ruptured
Traumatic Injuries
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Dislocations
• Etiology/Pathophysiology
• Temporary displacement of bones from their normal
position
• May be caused by:
– congenital
– disease process
– trauma
Traumatic Injuries
• Signs & Symptoms
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Erythema
Discoloration
Edema
Pain
Limitation of movement
Deformity or shortening of the extremity
Traumatic Injuries
• Treatment
• Closed reduction
• Open reduction
• Cold compresses first 24 hours and warm
compresses after 24 hours
• Elevate injured extremity
• Elastic bandage
• Immobilze
– splint
– sling
• Analgesics
– Demerol, Morphine
– Motrin, Tylenol
Carpal Tunnel Syndrome
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Etiology/Pathophysiology
• Compression of the median nerve between the
carpal ligament and other structures in the
carpal tunnel
Carpal Tunnel Syndrome
• Predisposing Factors
• Obese, middle aged women
• Employment in occupations involving repetitious
motions of the fingers and hands
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computer usage
basket weaving
meat carving
typing
Carpal Tunnel Syndrome
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Signs & Symptoms
• Paresthesia
• sensation of pricks of pins and needles
• Hypoesthisia
• decrease in sensation in response to stimulation
• Burning pain or tingling in the hands
• may be intermittent or constant
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Inability to grasp or hold small objects
Edema of the hand, wrist, or fingers
Muscle atrophy
Depressed appearance at the base of the thumb on the
palmer side
Carpal Tunnel Syndrome
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Diagnostic Tests
• Physical exam
• Tinel’s sign
– increased tingling with gentle tap over tendon sheath on
ventral surface of central wrist
• Electromyogram
• MRI
Carpal Tunnel Syndrome
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Treatment
• Immobilizer
• cock-up splint
• Elevate extremity
• ROM exercises
• Surgery
• Release carpal ligament
• Post-op Interventions
– Elevate the hand and arm for 24 hours
• Needs to be elevated as high as possible
– ROM to thumb and fingers
– Analgesics
– Monitor vital signs
– Assess fingers for circulation, sensation, and movement every 12 hours for 24 hours
Carpal Tunnel Syndrome
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Prognosis
• Mild symptoms may be relieved by nonsurgical
treatment
• Severe symptoms may be relieved by surgical
treatment
• Pregnancy induced usually subside after
delivery