Neuro/Neuro/musculoskeletal musculoskeletal

By Diana Blum RN BSNMetropolitan Community College

Selective AnatomySelective Anatomy12 cranial nerves 31 spinal nervesNeuron transmits impulses to facilitate

movement or sensationMeninges serve as protection of the

brain and spinal cordBronca’s area in frontal lobe forms

speechHypothalamus regulates water,

appetite, tempCSF: surrounds and cushions brain and

cord

Mental statusMental statusDoes not decline with ageCaused by drugs or lack of o2 to

the brainAs we age LTM is better then

STM

functional Assessment functional Assessment Appearance SpeechMotor functionFamily historyEthnicity Diet ADLsRight handed or left handed

◦Brain injury is more pronounced in dominant hemisphere

Physical assessmentPhysical assessmentOrientationLOCMemory

◦ LTM (DOB)◦ STM (mode of transportation to hospital)◦ Immediate memory (repeat 3 words after 5

minutes)Attention

◦ Serial 7 testLanguage/copying

◦ Follows simple commandsCognition

◦ Current events

Sensory assessmentSensory assessmentPain and temp

◦Cotton ball vs paper clip◦Cold vs warm

Touch◦Pt closes eyes and you touch hand

etc and then have them touch where you touched

ABNORMAL FINDINGS Propioception-position sense below injury Contralateral- loss of sensation in

opposite side of body affected

Motor assessmentMotor assessmentHand graspsFoot strengthArm driftCoordinationGaitBalanceReflexesABNORMAL FINDINGS

tremors, weakness, paralysis, jerking muscles

Rapid assessmentRapid assessmentGlascow coma scale: eye opening,

motor response, and verbal response◦painful stimuli

Supraorbital pressure Sternal rub Mandibular pressure Trapezius squeeze

◦LOC Decortication-hands/arms turned in Decerebration- hands/ arms turned out

◦Pupil assess Response to light

The GCS is scored between 3 and 15, 3 being the worst

score, and 15 the best. It is composed of three parts:

Best Eye Response, Best Verbal Response, Best Motor Response

When doing a neuro assessment it is important to watch for trends indicating a decreasing LOC.

Keep in mind that when patients have ingested alcohol,

mind altering drugs, have hypoglycemia or shock with a systolic BP <80, the GCS may be invalid.

9 to 12 is a moderate injury 8 or less is a severe brain injury.   7 or less = Coma

A client has a 5 on the Glasgow Coma Scale. When assessing this client, the nurse would expect what level of consciousness?

Sleepy or drowsy

Stuporous

Fully alert and oriented

Comatose

Comatose

A score of 7 or less indicates a comatose client. Above that are varying degrees of consciousness.

Coma: No eye opening, no ability to follow commands, no word verbalizations (3-8)

Diagnostics Diagnostics Blood cultures to find

infection Xray for fx, erosion, etcPET

◦ Evaluates drug metabolism

◦ Detects alzheimer’s, epilepsy, etc

◦ No caffeine, alcohol, or tobacco 24 hrs before test

◦ NPO 6-12 hours prior◦ No insulin prior◦ Takes 2-3 hrs◦ No special follow-up

Angiography for circulation check◦ NPO for 4-6 hrs prior◦ Preop checklist◦ Remove jewelry and

hairpins◦ Neuro check and vs◦ Empty bladder before◦ After- monitor pulses, cap

refill, color, and vs

MRI◦ Signed consent◦ No food or fluid

restrictions◦ Inform of noise and offer

ear plugs◦ Check for hx of pins,

pacemaker, metal objects Lumbar puncture

◦ Needle in subarachnoid space to obtain CSF for analysis

◦ Signed consent◦ Empty bladder◦ Explain procedure◦ Lie in fetal position for

test◦ Bedrest 4-8 hours post◦ Increase fluid for 24 hours

to prevent spinal headache (3000ml)

Diagnostics continuedDiagnostics continuedCT

◦ No food 4-6 hrs prior

◦ Fluids okay◦ Remove jewelry

and hairpins◦ Monitor for rx to

dye◦ Monitor I/O

EEG◦ Determines brain activity◦ Determines origin of

seizures◦ Dx of sleep disorders◦ Determines brain death◦ Explain procedure◦ No coffee , tea, or

stimulants◦ May be ordered as speep

deprived◦ Hair should not have

product on it◦ Takes about 1 hour◦ When done remove gel

with acetone

Diagnostics continuedDiagnostics continuedEMG

◦ Looks at muscle activity

BRAIN SCAN◦ Locates tumors and

aneurysms◦ Explain the test◦ May need consent◦ 2 hour delay so brain

absorbs isotope◦ Must be still for

duration of test◦ 1-2 hour exam◦ f/u is to increase

fluids to promote elimination of isotope

Traumatic Brain InjuryTraumatic Brain Injury(TBI)(TBI)

Head Injury Head Injury Classification:Classification:

Severe Head Injury----GCS score of 8 or less

Moderate Head Injury----GCS score of 9 to 12

Mild Head Injury----GCS score of 13 to 15

(Adapted from: Advanced Trauma Life Support: Course for Physicians, American College of Surgeons, 1993).

Superficial InjuriesSuperficial InjuriesCommonAbrasions“Goose Eggs”Lacerations

◦Scalp is very vascularXray if suspect skull fracture

Skull FracturesSkull FracturesCategorized according to type

and severityFrequently seen in conjunction

with brain injuriesLinear skull fractures Comminuted skull fracturesBasal skull fracturesPossible associated cranial nerve

deficits

Open Skull FracturesOpen Skull Fractures

Linear- simple clean break

Depressed - bone pressed in towards tissue

Open -lacerated scalp that creates opening to brain tissue

Comminuted - bone fragments and depresses into brain tissue

Basilar- unique fx at base of skull with CSF leaking though the ear or nose◦ Racoon eyes/Battles sign

Closed Skull FracturesClosed Skull FracturesClosed- blunt trauma

◦Mild concussion-brief LOC◦Diffuse axonal injury- usually from MVA

May go into coma◦Contusion-bruising of brain

Site of impact (coupe) Opposite side of impact (contrecoupe)

Intracranial HematomasIntracranial Hematomas

Epidural- bleed b/w skull and dura◦Laceration of artery or vien

Subdural-bleed below dura and arachoid layers ◦Acute, subacute, chronic

Intracerebral-accumulation of blood in brain tissue◦Blunt trauma◦Penetrating wounds ◦Acceleration/deceleration injuries

http://www.unc.edu/~rowlett/units/scales/glasgow.htm

Increased Intracranial Increased Intracranial PressurePressure

(ICP)(ICP)

Increase is caused by an increase in the volume of any of the intracranial components

Drivers of increased ICP◦Hypoxia – triggers the vasodilatory

cascade◦Ischemia in acute brain injury

Increased ICPIncreased ICPNormal ICP 10-15mmHgNormal increases occur with

coughing, sneezing, defecationLeading cause of death for head

trauma

As ICP increases cerebral perfusion decreases causing tissue hypoxia, decrease serum pH, and increase in CO2

ICP continuedICP continued

3 types of edema◦Vasogenic: increase in brain tissue

volume ◦Cytotoxic: result of hypoxia◦Interstitial: occurs with brain

swelling

AssessmentAssessment

Hydrocephalus Hydrocephalus

abnormal increase in CSF volumeCauses: impaired reabsorption from

subarachnoid hemorrhage or menengitis

Brain HerniationBrain Herniation

Increased ICP will shift and move brain tissue downward

Central Herniation◦ Downward shift to brainstem

S/S Cheyne stokes , pinpoint pupils, hemodynamic

instability

The most life threatening is Uncal because it causes pressure on the 3rd cranial nerve◦ S/S

Dilated, nonreactive pupils, ptosis, rapidly decreased LOC

The brainThe brainHeadaches

◦3 MAIN types Migraine-genetic predisposition

s/s: sensitive scalp, anorexia, photophobia, N/V Spasming of arteries at the base of the brain

causing arterial constriction, decrease cerebral blood flow, platelets clump, and serotonin released. Other ateries release prostoglandins that cause swelling and inflammation

With aura- sensation that signals onset Most are without aura Atypical- less common Tx: tylenol, migraine medicine, beta blocker,

yoga, meditation, relaxation, etc.

Cluster headacheCluster headache one sided headache usually felt deep

around eye. They come and goOnset is associated with relaxation,

napping or REM sleeps/s: ipsilateral (one side) tearing of

the eye, rhinorrhea(runny nose), ptosis(droopy), eyelid edema, facial sweating, miosis (abn. Constriction of eye). There may be bradycardia, pallor, increased temp.

Tx: same as migraine, wear sunglasses, O2 for 15 minutes, surgery

Tension headacheTension headacheMuscle and shoulder tenderness,

base of skull and forehead pain. Similar s/s to migraines

Classic s/s:N/V, photophobia, phonophobia, aggravates with activity

Tx: NSAIDS,muscle relaxers

Seizures/EpilepsySeizures/EpilepsySeizure: abnormal sudden,

excessive, uncontrollable electrical d/c of neurons w/in the brain that may result in altered LOC, motor/sensory ability, and/or behavior.◦No known cause but may be from

tumors

Types of Seizures Tonic-Clonic: lasts 2-5 minutes

◦ Rigidity/stiffening arms/legs and Loss of Consciousness Tonic: loss of consciousness, muscle contraction and

relaxation Clonic: rhythmic jerking, may bite tongue, incontinence

◦ Post seizure lethargy Absence: more common in kids, runs in families, blank

staring, loss of consciousness (resembles daydreaming) Myoclonic: brief jerking or stiffening, symmetric or

assymetric movement Atonic (akinetic): sudden loss of muscle tone, lasts for few

seconds confusion after seizure. Partial: begin in one part of cerebral hemisphere, most

often in adults and are less responsive to medical treatment

Complex Partial: blacks out for 1-3 minutes and automatisms present (lip smacking, picking), amnesia after seizure,temporal lobe most affected

Simple partial: remains conscious, senses unusual sensation, smell, or pain before (déjà vu). Unilateral movement during seizure, and may have tachycardia, flushing, or psychic symptoms

Idopathic: account for ½ of seizures, no known cause

Causes Metabolic disordersETOH withdrawlElectrolyte

disturbancesHeart diseaseAltered gene function

◦ Defective genes for channels that regulate ions in/out of cell

◦ Myoclonus clients are missing cystain B protein

◦ Etc.

Triggers◦ Physical activity◦ Stress◦ Fatigue◦ Alcohol or caffeine◦ Certain foods

Epilepsy Def: chronic disorder

characterized by recurrent unprovoked seizure activity.◦May be caused from abnormality in

electrical neuronal activity, abnormal transmitters, or both.

Approximately 2 million people in the USA with epilepsy

can be defined as abnormal, uncontrolled electrical activity in brain cells.

Nerve cells transmit signals to and from the brain in two ways by ◦(1) altering the concentrations of salts

(sodium, potassium, calcium) within the cell◦(2) releasing chemicals called

neurotransmitters (gamma aminobutyric acid). The change in salt concentration conducts the impulse from one end of the nerve cell to the other.

At the end, a neurotransmitter is released, which carries the impulse to the next nerve cell.

Neurotransmitters either slow down or stop cell-to-cell communication (called inhibitory neurotransmitters) or stimulate this process (called excitatory neurotransmitters).

Normally, nerve transmission in the brain occurs in an orderly way, allowing a smooth flow of electrical activity. Improper concentration of salts within the cell and overactivity of either type of neurotransmitter can disrupt orderly nerve cell transmission and trigger seizure activity.

Types of EpilepsyPrimary or idopathic

◦ Not associated with identifiable brain lesionSecondary

◦ Most common cause is brain lesion, tumor or trauma

Status epilepticus◦ Prolonged seizures that last greater than 5

minutes or repeated seizures over the course of thirty minutes. Causes:

Med withdrawl Infection Acute alcohol withdrawl Head trauma Cerebral edema Metabolic disturbances

CONVULSIVE STATUS EPIEPTICUS IS A NEUROLOGICAL EMERGENCY AND MUST BE TREATED PROMPTLY AND AGGRESSIVELY.◦ Call 911or staff emergency◦ Get airway established if needed by RT,

Anesthesia ◦ O2 as needed◦ Establish large bore IV access◦ Start NS◦ Get ABGs◦ Transfer to ICU

Education of seizure/epilepsy patientTeach importance of taking meds

as prescribedPromote balanced diet, rest, and

stress reduction techniquesInstruct pt. to keep a seizure

diary to identify causative factors

Phases of seizuresPreicteral phase: aura present.. The first phase

involves alterations in smell, taste, visual perception, hearing, and emotional state. This is known as an aura, which is actually a small partial seizure that is often followed by a larger event.

Ictus: The seizure.. There are two major types of seizure: partial and generalized. What happens to the person during the seizure depends on where in the brain

the disruption of neural activity occurs. Postictal state: The period in which the brain

recovers from the insult it has experienced. Drowsiness and confusion are commonly experienced during this phase. the period in which the brain recovers from the insult it has experienced

DiagnosticsEEGCTMRIPET

TREATMENTNonsurgical

◦ Antiepileptic drugs◦ Seizure precautions

During: Protect the client from

injury Do not force anything

into mouth Turn client to side Loosen restrictive

clothes Do not restrain

After Take vitals Perform neuro checks Keep on side Allow rest document

Teach family◦ Info about disease◦ Info about medication◦ Support groups

available◦ Teach about alcohol

avoidance◦ To investigate state

laws pertaining to driving and working with machinery

◦ Care of seizure client

Surgical treatmentVagal nerve stimulation

◦ For simple or complex partial seizures◦ Stimulating device is surgically placed in

the left chest wall with a lead wire on the vagus nerve

◦ Activates with hand held magnetCorpuscalostomy

◦ Used for tonic-clonic seizures◦ For those not candidates for other surgical

procedures◦ Sections of the anterior and 2/3 of the

corpus collosum are created to prevent neural discharges

Nursing diagnosisRisk for fallsIneffective copingRisk for ineffective breathing

Parkinson’shttp://www.youtube.com/watch?v

=TtM-aP9Gr28

Alzheimer’s Disease

http://www.youtube.com/watch?v=Z6lA1P2tF0o&feature=related

Stages Early

◦mild Middle

◦moderate Late

◦severe

s/ss/sAggressiveRapid mood swingsIncreased confusion at nite

(sundowner’s)Decrease interest in personal

appearanceInappropriate clothing selectionLoss of bowel/bladderDecreased appetite

diagnosisdiagnosisCBCBMPFolate level checkedThyroid and liver function testTest for syphilisDrug tox screening (OTC)Alcohol screeningCTMRIPETEEG

Nursing diagnosisNursing diagnosisChronic confusionRisk for injuryDisturbed sleep pattern

Tx Tx MedsPrevent overstimulationBe consistentReorientPromote independence Bowel/bladder trainingPromote facial recognitionSpeech therapySafety precautionsMinimize agitations

Spinal Cord InjurySpinal Cord Injury(SCI)(SCI)

Causes of SCICauses of SCI

Primary◦ Hyperflexion (moved forward excessively)◦ Hyperextension (MVA)◦ Axial loading (blow at top of head causes

shattering)◦ Excessive rotation (turning beyond normal range)◦ Penetrating (knife, bullet)

Secondary◦ Neurogenic shock◦ Vascular insult ◦ Hemorrhage◦ Ischemia◦ Electrolyte imbalance

TypesTypes

Complete: spinal cord severed and no nerve impulses below level of injury◦Cervical/Thoracic

Incomplete: allow some function and movement below level of injury◦Includes:◦Central cord syndrome ◦Anterior cord syndrome◦Brown-Séquard syndrome

CompleteComplete

Tetraplegia (quadriplegia): paralysis from neck down◦Loss of bowel and bladder control◦Loss of motor function◦Loss of reflex activity◦Loss of sensation◦Coping issues*Christopher Reeve is example of this

injury*

IncompleteIncompleteCentral Cord Syndrome

◦Hyperextension damage to center of spinal cord

◦Greater loss of function in upper extremities

Anterior Cord Syndrome◦Cause: Direct injury to anterior spinal cord

or disrupted anterior spinal artery ◦Paralysis, loss of pain and temperature

sensation ◦Light touch, vibration, proprioception

preserved◦Prognosis for recovery is variable

IncompleteIncompletePosterior cord lesion

◦Damage to posterior white and gray matter

◦Motor function intact, but loss of vibratory sense, crude touch, and position sensation

Brown Sequard syndrome◦Result of penetrating injury that causes

hemisection of spinal cord.◦Motor function , proprioception, vibration,

and deep touch are lost on the same side as injury (ipsilateral)

◦On the other side (contralateral) the sensation of pain, temperature and light touch are affected

AssessmentAssessment1st -respiratory status2nd - intra-abdominal hemorrhage

(hypotension, tachycardia, weak and thready pulse)

3rd assess motor function◦ C4-5 apply downward pressure while the client shrugs◦ C5-6 apply resistance while client pulls up arms◦ C7 apply resistance while pt straightens flexed arms◦ C8 check hand grasp◦ L2-4 apply resistance while the client lifts legs from bed◦ L5 apply resistance while client dorsiflexes feet◦ S1 apply resistance while client plantar flexes feet

ComplicationsComplicationsCerebral ischemiaDVT/PEPneumonia/AtelectasisVomiting and AspirationGI stress ulcersConstipationUTIPressure Ulcers

Autonomic DysreflexiaAutonomic DysreflexiaSevere HTN, bradycardia, sever headache,

nasal stuffiness, and flushing Caused by noxious stimuli like distended bladder or

constipation

Immediate interventions◦ Place in sitting position◦ Call doctor ◦ Loosen tight clothes◦ Check foley tubing if present◦ Check for impaction◦ Check room temp◦ Monitor BP q10-15 minutes◦ Give nitrates or hydralazine per md order

TreatmentTreatmentImmobilize fx- C-collarProper body alignment

◦ Traction is possibleMonitor VS q4 hr and prnNeuro checks q4 hr and prnMonitor for neurogenic shock

(hypotension and bradycardia)Prepare for possible surgeryTeach skin care, ADLs, wound

prevention techniques, bowel and bladder training, medications, and sexuality

NRSG DX for SCINRSG DX for SCI

Ineffective tissue perfusion r/t interruption of arterial flow

Ineffective airway clearance r/t SCI

Ineffective breathing pattern r/t SCI

Impaired gas exchange r/t SCI

HUNTINGTON’S DISEASEHUNTINGTON’S DISEASEFormerly huntington’s choreaHereditaryTransmitted as an autosomal

dominant trait at time of conception25000 people in usa have2 main symptoms are progressive

mental status changes and choreiform movements (rapid, jerky) in the limbs trunk and face

No known cause No known treatmentOnly prevention is to not have

childrenAntipsychotics and monoamine

depleting agents used to manage movement

TX: PT, OT, speech therapy, meal planning by dietician, HHC, social work to line up community resources

OsteoporosisOsteoporosis

Metabolic conditionBone demineralizesEasy to fractureWrist, hip, and vertebrae are

most affected

Osteopenia: low bone massOsteoclasic: bone resorptionDecreased bone mineral density40-45% loss in women throughout

lifespanTrebecular (Spongy bone) is lost firstThen Cortical (compact bone) lost 2nd Pathophysiology is unknown

classesclassesGeneralized:involves many structures

◦Primary: more common Post menopausal women Men in 60s-70s

◦secondayRegional: limb involved

◦r/t fx, injury, paralysis, joint inflammation◦Immobilization greater than 8-12 weeks◦Weightless environment (astronauts)

Health preventionHealth preventionTeach about exerciseTeach about diet rich in calciumTeach about bone healthTeach about safety

Assessment Assessment Risk for fallsHead to toe assessment

◦Inspect and palpate vertebraeAssess painAssess for fallophobia No definitive lab testsBone scan to check density

Nursing diagnosisNursing diagnosisRisk for fallsImpaired physical mobilityAcute or chronic pain

InterventionsInterventionsClient education is #1Hormone replacementsCalcium supplementsMultivitaminsDiet Fall preventionExercisePain managementBraces

Osteomalacia Osteomalacia Softening of the bone tissueInadequate mineralization of osteoid

(mature compact and spongy bone)Vitamin D deficiency is a key playerSimilar characteristics with

osteoporosisRare in USAPrevent with vitamin D, sun

exposure, and diet

s/s: early stages : nonspecific◦Muscle weakness◦Bone pain◦Hypophosphatemia◦Hypocalcemia◦Generalized bone tenderness

Paget’s DiseasePaget’s Disease

Metabolic disorder of bone remodelingBone deposits that are weak, enlarged, and

disorganizedPhases:

◦ Active increased osteoclasts cause massive bone destruction Osteoclasts are multinuclear

◦ Mixed◦ Inactive 2nd phase

New bone becomes sclerotic and very hard Osteoclasts return to normal amount

2nd most common bone diseaseMost common sites are vertebrae, femur, skull,

sternum, and pelvisUnknown cause

Assessment Assessment 80% asymptomaticAssess past history of fractures, skin color and

temp, gout, hyperparathyroidism, lethargy, hyperuricemia

Pain that is aching, deep, poor descriptionPain worsens with weight bearing and pressurePain most noticeable at nite or at restArthritis at infected jointsAssess posture, gait, and balanceAssess vision, speech, and swallowing,

hydrocephalus, Neoplasm is the dreaded complication

Diagnostics Diagnostics Serum alk phosphate

◦Those treated for paget’s need ALP drawn 3-4 times/year

Urine hydroxyproline◦Shows bone collagen turnover and

degree of severityCalcium levels are normal or elevatedIncrease noted in uric acid

◦May initially be thought to be goutX-rays, CT, MRI, bone biopsy

Treatment Treatment Drugs for pain reliefDrugs to decrease bone resorptionCalcitonin (thyroid hormone)Mithramycin (antineoplastic)BiphosphanatesHeat therapyGentle massageExercisePTDietOsteotomy or joint replacement

osteomylelitisosteomylelitis

Inflammatory processIncrease in vascularity and

edemaVessel becomes thrombosed

once inflamedIschemia is next Then necrosisSequestrium forms and retards

bone healing

Categories Categories Exogenous: infection enters from

outsideEndogenous: infection enters from

insideContiguous: results from skin infection

The most common offending organism is pseudomonas aeruginosa

Staph, salmonella are aslo culprits

s/s and assessments/s and assessmentPainFeverErythemaHeatSwellingAssess circulationAssess for septic shock

Treatment Treatment Contact precautionsIV antibx therapyPICC lineUse sterile techniquesPain medsHyperbaric oxygen therapyBone graftsMuscle flapsAmputations

Bone tumorsBone tumors

Chondrogenic Chondrogenic Osteochondroma: most common,

benign, tumor…onsets in childhood, grows until skeletal maturity..has a bony stalk like appearance..may become malignant

Chondroma: lesion of mature hyaline cartilage of the hand and feet. Ribs, sternum, spine, and long bones can also be affected…can get at any age or gender

Osteogenic Osteogenic Osteoid osteoma: pinkish granular

appearance..any bone affected..femur and tibia most affected

Osteoblastoma: affects vertebrae and long bones..large in size and lies in spongy bone..reddish granular appearance

Giant cell tumor: origin unknown..aggressive and extensive..affects women 20s-30s

Assessment/ tx Assessment/ tx Assess pain Palpate involved areaCT scan and MRI done for

diagnosisInterventions

◦Meds and surgery combination◦Pain meds◦Meds taken with meals or milk◦

Malignant bone tumorsMalignant bone tumors Primary: originate in bone / 2nd ary: mets to bone

◦ Primary Osteosarcoma: most common

◦ Large lesion, pain and swelling of short duration, warm site, central portion is sclerotic, usually mets to lung in 2 yrs then death

Ewing’s sarcoma: most malignant◦ Pain and swelling, fever, anemia, leukocytosis, pelvis and lower

extremities most affected, any age..but kids and young adults age 20s more

◦ Pelvic yields poor prognosis Chondrosarcoma: dull pain, swelling for long period..

◦ pelvis and femur fore affected

◦ Destroys bone and often calcifies

◦ Affect middle age to elders and more in men

Fibrosarcoma: from fibrous tissue; most common in long bones of legs and mets to lungs◦ Histiocytoma is most malignant type

◦ Local tenderness, with or w/o mass palpated

Bone Mets Bone Mets Primary tumors are in prostate,

breast, kidney, thyroid, and lungFractures are major problem with

management◦Femur and acetabulum

Primarily affects those under 40

Assess/ diagnosticsAssess/ diagnosticsAssess pain, swelling, palpate for

massesMonitor vsAssess ADLsAssess support structuresAssess coping skillsCheck ALP levels for elevationCT scanStage tumor

Nursing diagnosis/tx Nursing diagnosis/tx PainAnticipatory grievingDisturbed body imageFearAnxiety Tx

◦Pain management, chemo, radiation, surgery, dressing changes, be active listener, establish goals, safety precautions, HHC

Carpal tunnelCarpal tunnel

Education Education Use ergonomic work stationsTeach client to take regular

breakss/s

◦Parathesia in hands◦Weak pinch, clumsiness, weakness◦Hand activity worsens symtoms◦Swelling may occur

Tx: nsaids, surgery

Dupuytren’s contracturesDupuytren’s contracturesSlow progressive contractureCommon problemAffects 4th or 5th digit of the hand Trigger finger release surgery

performed to fix

Disorders of the footDisorders of the foot

Hammertoe: fix with surgeryTarsal tunnel syndrome: ankle version

of carpal tunnelPlantar fasciitis: inflammation of the

plantar fascia located in the arch of the foot◦s/s: pain in arch, pain worsens w/ wt

bearing◦Tx: ice, rest, stretches, strapping, nsaids,

surgeryHallux valgus: aka bunion

Rheumatoid ArthritisRheumatoid Arthritis

Most common connective tissue disorders

Most destructive to jointsRA factors looked for in lab Assess sedrate Assess immunoglobinsMRIs performedEMGs are performed to measure

function

Assessment/ S/S continuedAssessment/ S/S continuedJoint stiffnessSwellingPainFatigueWeight lossReddened jointsDeformity of jointsBaker’s cysts may occur and cause painDry eyes, dry mouth, dry vaginaAssess ADLs, coping, pain

interventionsinterventions

NsaidsImmunosuppressive drugRest Proper positioningPain managementIceHeart parafin waxPlasmapheresisFish oil tablets

Lupus Lupus Characteristic sign is butterfly

rashAlso alopecia is commonAutoimmune disorderMay have kidney involvementWomen b/w 15-40African american more than

caucasian

s/s continueds/s continuedfeverFatigueAnorexiaWeight lossPleural effusionsPericarditisAbd painJaundice

Assessments and txAssessments and txSteroids, nsaids Monitor wtMonitor social response

◦May become withdrawnSkin biopsy may be done for

diagnosisMonitor CBC for pancytopeniaRheumatology consultAvoid prolonged UV exposure

GoutGoutType of arthritisUrate crystals deposit in jointsPrimary gout is most commonInflammation is key sign2nd ary is when too much uric acid

in bloodCan affect kidneysMeds to treat Pain management

Marfan syndromeMarfan syndromeInherited, dominant autosomal traits/s: excessively tall and lanky with

elongated hands and feet, scoliosis, funnel shaped chest, glaucoma

Avg life span is 32 yearsMitral valve prolapse and AAA are

commonTx is palliative and preventitive

Fibromyalgia Fibromyalgia

Chronic pain syndromePain is burning or gnawingHeadache and jaw pain are also

commonChest pain is commonPain control is the key

◦Muscle relaxers, nsaids, antidepressants

glaucomaglaucoma

2 types◦Primary open angle: most common ◦Angle closure: less common..emergency

s/ss/sOpen angle: small cresent

shaped defectAngle closure: visual fields

quickly decrease, severe pain around eye, headache, n/v, halos, blurred vision

Macular degenerationMacular degenerationCentral vision declinesMild blurring or distortionMore rapid to produce in smokers

Muscular distrophiesMuscular distrophies9 typesProgression is slow or fastMost common is severe X linked

recessiveDiagnosis is difficultComfort is key Treat symptoms