Musculoskeletal Disorders

OsteoporosisFracturesDegenerative Joint Disease/OsteoarthritisTotal Hip and Knee Prostheses Bone Infections / OsteomyelitisGoutMusculoskeletal DisordersPart II1Concept Map: Selected Topics in Musculo-Skeletal NursingPATHOPHYSIOLOGY

FractureOsteoporosisDegenerative Joint DiseaseOsteoarthritisOsteomyelitisGout

AmputationTotal Joint Replacement

PHARMACOLOGY

OpioidsNSAIDsAntibioticsDisease Specific

ASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation

Neuro / Circ Checks--The 6 Ps

Lab MonitoringCare PlanningPlan for client adls, Monitoring, med admin.,Patient education, morebasedOn Nursing Process: A_D_O_P_I_E

NURSING DIAGNOSES THAT APPLY.Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary2NeurovascularComponents:

The 6 PsEarly orLate SignsAssessment ParametersClient Teaching /Symptoms to ReportPainEarlyAssess area involved using 0 to 10 rating scale: 0 = no pain 10 = worst pain imaginableIncreasing pain not relieved with elevation or pain medicationParesthesiaEarlyAssess for numbness/tingling, pins or needlessensation: Should be absent.Numbness or tingling, pins or needles sensationPallorEarlyAssess capillary refill.

Brisk is < 3 secondsIncreased capillary refill time > 3 seconds, blue fingers or toesPolarLateAssess skin temperature bytouch:

Warm CoolCool/cold fingers or toesParalysisLateAssess mobility: Moves fingers or toes Able to plantar dorsiflex the ankle area not involved or restricted by castUnable to move fingers or toesPulsesLateAssess pulse(s) distal toinjury: Pulse is palpable and strongWeak palpable pulses, unable to palpate pulses, pulse detected only with DopplerDegenerativeJoint DiseaseMusculoskeletal DisordersDegenerative 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 DGenetics familial arthritisOveruse injuries or manual laborSports injuries which affect the bursae or tendon - meniscal tissues that cushion the jointSmoking as it dehydrates and constricts tissues

6Musculoskeletal DisordersDegenerative 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.7Musculoskeletal DisordersDegenerative Joint Disease (DJD)Also called OA OsteoarthritisDiagnosis:Symptoms and historyArthroscopyX-raysMRI for soft tissue visualization, i.e of menisci or bursaeBone scan if cancer has to be ruled out

8Musculoskeletal DisordersDegenerative Joint Disease (DJD)Note the loss of joint space with bone on bone

9Musculoskeletal DisordersDegenerative Joint Disease (DJD)

10Musculoskeletal DisordersDegenerative Joint Disease (DJD)Treatments heat and cold therapyPreventative exercises to strengthen supporting musclesJoint Injections Hydralan, cortisone, etc.Analgesics/Anti-inflammatories COX 2 inhibitors i.e. Mobic, CelebrexTylenol contraindicated for liver patientsIndocin - more risk for peptic ulcersAspirin more risk for peptic ulcersPartial or complete surgical repairJoint prosthesis

11Musculoskeletal DisordersDegenerative Joint Disease (DJD)

12Musculoskeletal DisordersHip Prosthesis

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Musculoskeletal Disordersknee prosthesis

15Musculoskeletal DisordersCare of Patients Pain controlAmbulation with assistance - onlyPrevent fallsExercise; usually has physical therapy from 6 - 8 weeksNon-smokingEncourage adequate intakes of vitamin CPost-op anti-coagulants, whether Lovenox, coumadin, heparin, or aspirin16Musculoskeletal DisordersHip 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 spine17Musculoskeletal DisordersAdductor pillow between knees

18Musculoskeletal DisordersBone infectionsCauses:Immunological problemsDiabetes, nutritional problemsInjury which allows pathogens into the bone fractures coral cuts trauma post-operative surgery19Musculoskeletal DisordersBone infectionsChronic Osteomylitis in a diabetic

20Musculoskeletal DisordersBone infectionsDiagnosis:Bone scanX-raysMRI for soft tissue viewBlood cultures need to be done 15 minutes apart from two different sitesWound cultures if drainage is apparent21Musculoskeletal DisordersBone infection symptoms:Foul smelling drainageFeverLethargySwellingRedness

Increased WBCs on CBC with differentialWith increased neutrophils on the CBC, sometimes called PMNs 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.

22Musculoskeletal DisordersBone InfectionsMost common organisms:

Staphlococci Aureus MRSA in the hospital post- operatively (a drug resistant organism)

Enterococci from wounds/trauma

Clostridium Perfringens gangrene

E-Coli fecal contamination23Musculoskeletal DisordersOsteomylitis Treatments/Interventions#1 Pain controlMonitor 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 physicians order)Surgical repair or debridementRemoval of infected prosthesesSometimes it is necessary for amputation

24Musculoskeletal DisordersEwings Sarcoma of the bone usually malignant with mets, often treated with amputation

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Musculoskeletal DisordersOsteosarcoma most common type of malignant bone tumor, most often in males between 10 and 30 y.o. or in older patients with Pagets Disease

27osteosarcoma

ChondrosarcomaThis 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=328Musculoskeletal Disorders

Chondroma

30AmputationMusculoskeletal DisordersTypes of amputations Simple Toe uncomplicated, most often due to injury and diabetes

32Musculoskeletal DisordersAmputations BKABelow the knee

Treatments for amputations will be further covered in Adult Health Care II

33Musculoskeletal DisordersTypes of Amputations AKA above the knee a surgical technique for saving a persons life from an infected prosthesis or necrotic limb

34Musculoskeletal DisordersAmputations - facts and figures:More than 100,000 amputations are performed in the USA every year.The most common cause of amputations is diabetes & infectionOf 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.35

http://www.peglegbiker.com/index.htmlMusculoskeletal DisordersAssessment must include:Pain as a no. 1priorityProper patient assessment must include pain intensity, radiation, relief, medication side effects, and reassessment on a regular basis.Skin integrityTissue PerfusionPrevention of infectionPromotion of nutritionExercise & ROM Body Image

42GoutMusculoskeletal DisordersGout 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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Musculoskeletal Disorders Gout Symptoms:Tophi - white crystalized deposits in the tissue, usually seen on the hands or toes.Heat & RednessPain Severe & sudden onsetSwellingInflammation usually on one side of the body first, a ankle joint, knee, or toeMay become an acute inflammation after an injury, i.e. stubbing your toe on the sprinkler46Musculoskeletal DisordersGout 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

47Musculoskeletal DisordersTreatmentsAnti-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 quicklyPain controlMaintenance on daily allopurinol to allow the kidneys to secrete the acidEducate patient to avoid high purine foods48Musculoskeletal Disordersgout

49Musculoskeletal DisordersGout tophi

50Musculoskeletal DisordersGouty tophi (in red)

51MusculoskeletalSystemPharmacologyPharmacology Associated with Musculoskeletal Patients--General Information

Assess/monitor the clients need for pain medication, and plan and provide care to meet the clients needs for pain intervention.

Assess/monitor the effectiveness of pain intervention, and advocate for the clients 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.

Assess/monitor the client for actual/potential specific food and medication interactions.

Identify contraindications, 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 clients medication use over time.

Musculoskeletal Pharmacology : Medications for Pain & InflammationNSAIDsNon Steroidal Anti-Inflammatory DrugsPrototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex)Pharmacological ActionInhibition of cyclooxygenase: Inhibition of COX-2 results in inflammation, pain, and fever. Inhibition of COX-1 results in the of platelet aggregation

Therapeutic UsesInflammation suppressionAnalgesia for mild to moderate painFever reductionDysmenorrheaLow level suppression of platelet aggregationAspirin 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 & InflammationNSAIDsNon Steroidal Anti-Inflammatory DrugsPrototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex) CONTINUEDTherapeutic 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 & InflammationAcetaminophenPrototypes: acetaminophen (Tylenol )Pharmacological ActionAcetaminophen slows the production of prostaglandins in the central nervous system.Therapeutic UsesAnalgesic (relief of pain) effectAntipyretic (reduction of fever) effectsSide/Adverse Effects: Nursing Interventions and Client EducationAcute toxicity that results in liver damage with early symptoms of nausea, vomiting, diarrhea, sweating, and abdominal discomfort progressing to hepatic failure, coma, and deathAdvise the client to take acetaminophen as prescribed and not to exceed 4 g per day.Administer the antidote, Acetylcysteine (Mucomyst ).

Use cautiously in clients who consume three or more alcoholic drinks/day and those taking warfarin (interferes with metabolism).Nursing Interventions and Client EducationAcetaminophen 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 EffectivenessDepending on therapeutic intent, effectiveness may be evidenced by: Relief of pain. Reduction of fever.Musculoskeletal Pharmacology : Medications for Pain & InflammationOpioid AgonistsPrototypes: Morphine sulfatePharmacological ActionOpioid 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 UsesRelief of moderate to severe pain (e.g., postoperative pain, myocardial infarction pain, cancer pain)SedationReduction of bowel motilityCodeine: cough suppressionContraindications/PrecautionsContraindicated: 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 prostateDemerol -- meperidineRepeated use of meperidine (Demerol) can result in the accumulation of normeperidine, which can result in seizures and neurotoxicity.

Do not administer meperidine more than600 mg/24 hr, and limit its use to less than 48 hr.Morphine SulfateSide Effects / Adverse EffectsNursing Interventions / Client EducationRespiratory depression--Monitor the clients vital signs.--Stop opioids if the clients 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 clients bladder for distention by palpating the lower abdomen area every4 to 6 hr.Cough suppression--Advise the client to cough at regular intervalsto prevent accumulation of secretions in theairway.--Auscultate the clients lungs for crackles, andinstruct the client to intake of fluid to liquefysecretions.Sedation--Advise the client to avoid hazardous activitiessuch as driving or operating heavy machinery.Biliary colic--Avoid giving morphine to clients who have ahistory of biliary colic. Use meperidine as analternative.Emesis--Administer an antiemetic such aspromethazine (Phenergan).Opioid overdose triad of coma, respiratory depression, and pinpoint pupils--Monitor the clients vital signs.--Place the client on a ventilator.--Administer opioid antagonists, such as naloxone (Narcan) or nalmefene (Revex).Musculoskeletal Pharmacology Medications for Pain & InflammationAgonist Antagonist OpioidsPrototypes: pentazocine (Talwin )Pharmacological ActionCompared 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).--Less respiratory depression. Kappa receptors will cause a certain degree of respiratory depression and then no more (have a ceiling).

Therapeutic UsesAgonists-antagonists opioids relieve mild to moderate pain; not used for treatment of severe pain.Contraindications/PrecautionsUse cautiously in clients with a history of myocardial infarction ( cardiac workload) and clients who are physically dependent on opioids.

Nursing Interventions and Client EducationTake the clients baseline vital signs. If the clients respiratory rate is less than 12/min, withhold the medication and notify the primary care provider.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 & InflammationOpioid AntagonistsPrototypes: naloxone (Narcan )Pharmacological ActionOpioid antagonists interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no effect in the absence of opioids.

Therapeutic UsesTreatment of opioid overdoseReversal of effects of opioids, such as respiratory depressionReversal of respiratory depression in an infant

Contraindications/PrecautionsHypersensitivityOpioid dependencyPregnancy Risk Category BTherapeutic Nursing Interventions and Client EducationNaloxone 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 clients need for analgesia (e.g., if given for postoperative opioid-related respiratory depression).

Nursing Evaluation of Medication EffectivenessReversal 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 & InflammationAdjuvant Pain MedicationsPrototypes:Tricyclic anti-depressants; anticonvulsants; CNS Stimulants; antihistamines; glucocorticoids; & biphosphonatesTricyclic antidepressants: amitriptyline (Elavil)Anticonvulsants: carbamazepine (Tegretol), gabapentin (Neurontin), phenytoin (DilantinCNS stimulants: methylphenidate (Ritalin), dextroamphetamine (Dexedrine)Antihistamines: hydroxyzine (Vistaril)Glucocorticoids: dexamethasone (Decadron), prednisone (Deltasone)Bisphosphonates: etidronate (Didronel), pamidronate (Aredia)Pharmacological ActionsAdjuvant medications for pain enhance the effects of opioids.Therapeutic UsesUsed in combination with opioids cannot be used as a substitute for opioidsTreating 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 & InflammationAntigout MedicationPrototypes: colchicinePharmacological ActionColchicine 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.Therapeutic UsesColchicine 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.Contraindications/PrecautionsAvoid 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 EducationInstruct 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 EffectivenessDepending 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.Musculoskeletal DisordersCase Study Exercise Group IJohn 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.

64Musculoskeletal DisordersCase Study Exercise Group IIMaria 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.

65Musculoskeletal DisordersCase Study Exercise Group IIIFranklin 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.

66Musculoskeletal DisordersCase Study Exercise Group IVJohnna 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.

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