Embed Size (px)
Citation preview
Nursing Care of Clients with Musculoskeletal Disorders
Chapter 43
1
Gout
Inflammatory response to high levels of uric acid in body
Primary gout– characterized by elevated uric acid levels from
error of purine metabolism Secondary gout
– results from a treatment or disease leukemia, CRF, meds.
2
Gout Manifestations
– 1. hyperuricemia– levels 9-10mg/dL– recurrent attacks of inflammation of single joint– tophi in and around the joint– renal disease and stones
– 2. Acute gouty arthritis– single joint - red, swollen, hot, painful– triggered by trauma– elevated WBCs, ESR– last hours to weeks
3
Gout
3. Chronic gout– occurs when hyperuricemia not treated– tophi develop in cartilage, synovial membranes
tendons and soft tissue– urate crystals– may lead to kidney disease
Treatment– end acute attacks and prevent recurrence
4
Urate Crystals in a tophi
5
Gout Affects many Joints
6
7
Gout
Diagnostic tests– uric acid above 7.5mg/dL– elevated WBC and ESR
Medications– NSAIDs - indocin– cochicine - interrupts the uric crystal cycle– corticosteroids– Zyloprim - lowers serum uric acid levels
8
TABLE 43-6 (continued) Giving Medications Safely: Gout
Gout
Dietary– low-purine diet – avoid liver, meats, seafood,
beans– lose wt– avoid ETOH or foods known to precipitate gout
Other Treatments– acute attack
B/R, elevate joint with hot/cold compress, increase fluid intake
11
Gout
Definition
Clinical manifestations
Hyperuricemia
Acute gouty arthritis
Chronic gout
Treatment?
12
Osteoarthritis - Joints affected
13
Healthy Joint
14
15
16
17
18
Degenerative Joint Disease Osteoarthritis OA
Most common form of all arthritis loss of articular cartilage in joints and
hypertrophy of bones at articular margins causes are idiopathic or secondary Risk Factors
– age excessive wt– inactivity repetitive exercise
19
Osteoarthritis
Patho– degeneration of cartilage lining, bone thickens
and that reducing the ability to absorb energy in joint load
– osteophytes form, change the joint, these spurs enlarge, break off and lead to synovitis
20
Inflamed Joint Changes
21
Joint Narrowing
22
23
Osteoarthritis OA
Manifestations– gradual, insidious– pain, stiffness in one or more joints– pain aggravated by use and relieved by rest– immobility are followed by stiffness– decrease ROM, joint crepitus during movement– joint enlargement– flexion contractures
24
Changes in the hip
25
Patho of Osteoarthritis
26
Changes in the Knee
What might your client be feeling?
27
Osteoarthritis
Diagnostic tests– changes are seen on X-ray
Medications– pain management ASA, tyl., NSAIDs, topical creams– celebrex - fewer GI side effects– vioxx - recalled - heart arrhythmia, death– corticosteriod injection of joints
28
Osteoarthritis
Conservative treatment– P.T– rest of involved joints– using ambulation devices– wt loss– analgesic and anti-inflammatory meds
29
Late Stage Osteoarthritis
30
Osteoarthritis OA
Surgery– arthroscopy
debridement and lavage involved joints
– osteotomy incision into bone to realign affected joint shift joint load toward areas of less cartilage damage
– Joint arthroplasty reconstruction or replacement of joint
31
32
Osteoarthritis
Joint Arthroplasty– usually TJR - replaces both articulating surfaces– Cemented vs uncemented
most uncemented, porous, new bone growth 6 weeks, requires longer time of non-wt bearing, lasts longer
cemented - inflammation eventually loosen joint
33
Osteoarthritis OA
Complications– infections– dislocation– loosening of prosthesis– impaired circulation– thromboembolism
34
Osteoarthritis OA
Total Hip Replacement THR– articular surfaces of acetabulum and femoral
head are replaced success rate >90% Total knee replacement
– vigorous rehab, success rate > 80% Total shoulder and elbow
– indicated for unremitting pain and limited ROM
35
Total hip replacement
36
Total Joint Replacement Knee
37
Nursing Care
Promote comfort Maintain mobility Assist with adaptation of life-style Health Promotion
– maintenance of normal wt.– Regular moderate exercise
38
Gout vs. arthritis? Which is it?
39
Autoimmune and Inflammatory Disorders - Rheumatoid arthritis Chronic systemic disease causing
inflammation to connective tissue in joints– 3x more likely in females– onset 20-40 years– course and severity variable– cause unknown - genetic, environmental,
hormonal, infectious agents - Epstein barr
40
41
Rheumatoid Arthritis
42
Rheumatoid arthritis Patho
– synovial membrane damaged from inflammatory and immune processes, leads to erosion of articular cartilage and inflammation of ligament and tendons
43
Rheumatoid arthritis
Joint Manifestations– Onset
insidious or after a stressor Systemic
– fatigue, anorexia, wt loss, non-specific aching and stiffness precede joint involvement
Joint– swelling, stiffness, warmth, tenderness and pain, multiple
joints and symmetric involvement– fingers, wrists knees, ankles and toes
44
Rheumatoid arthritis
Extra-articular – low grade fever, anemia, rheumatoid nodules in
subcutaneous tissue– pleural effusion, pericarditis, splenomegaly
Collaborative Care– relief of pain and inflammation– slow or stop joint damage– improve well-being and ability to function
45
47
Arthritic hands
48
Early and Late Stages
Ulnar deviationSwan neck deformity49
50
Knee
51
Arthritic Hip
52
Rheumatoid arthritis
Diagnostic tests– Rheumatoid factors (RF) autoantibodies to IgG– ESR - indicator of inflammation - often used to
evaluate effectiveness of treatment plan
– synovial fluid– X-rays– CBC
53
Rheumatoid arthritis
Medications– ASA, NSAIDs
tx symptoms, no effect on disease progression, many GI side effects
– corticosteroids reduce pain, inflammation, slows progression long-term side effects
54
Rheumatoid arthritis
Disease-modifying - antirheumatic drugs– gold compounds
weekly, IM injections watch for toxic reactions
– antimalarial agents, sulfasalzine– Immunosuppressive and cytoxic drugs
methotrexate
– intra-articular corticsteroids
55
Rheumatoid arthritis
Treatments– balanced program of rest and exercise
rest with exacerbation - utilize splints exercise to maintain ROM, muscle strength low impact exercises
– P.T. and O.T– heat and cold– assistive devices and splints
56
Rheumatoid arthritis
– Diet well-balanced, omega-3 fatty acids
– Surgeries synovectomy, arthodesis, joint fusion, arthoplasty, TJR
Nursing Diagnosis– Chronic pain, Fatigue, Ineffective Role
Performance, Disturbed Body Image
57
Normal - Rheumatoid - Osteo - Joint
58
Rheumatoid Arthritis
What is it?
How is it different from osteoathritis?
How would you assess for it?
What’s the treatment?
Nursing care?
59
60
Aids to promote usual ADL’s
61
Septic Arthritis
Occurs when joint space invaded by pathogens - staph, strep, E. coli, pseudomonas
Risk factors– persistent bactermia– previous joint damage– arthroscopic surgery and TJR
62
Septic arthritis
63
64
Septic Arthritis
– Onset abrupt with pain and stiffness, joint is red, swollen,
hot and tender to touch systemic - chills and fever
Collaborative Care– requires prompt treatment to preserve joint
function– joint aspiration and X-ray
65
Septic Arthritis
Treatment– rest, immobilization and elevation– antibiotics– recurrent joint aspiration– P.T.
– Nursing Care - education, prevent disease
66
Osteoporosis - loss of bone mass, increased bone
fragility, increased risk for fx Risk Factors
– depends on amount of bone mass achieved between 25-35 yrs old
– Unmodifiable aging gender
67
– Ethnicity– Endocrine disorders affecting metabolism
Modifiable risk factors– calcium– menopause, decreasing estrogen– cigarette smoking– excessive ETOH intake– sedentary life style
68
Osteoporosis
69
Osteoporosis
70
Osteoporosis
Patho– diameter of bone increases, thinning outer
supportive cortex– spongy tissue lost and outer cortex thins– minimal stress leads to fx
71
Cross Section of Bone
72
Bone X-ray
73
Osteoporosis of the Spine
74
Osteoporosis
Manifestations– “silent disease”– loss of height– progressive curvature of spine– low back pain– fx of forearm, spine or hip
75
Osteoporosis
Complications– fx
may be spontaneous or resulting from every day activities
– persistent pain and posture changes Diagnostic Tests
– X-ray– DEXA - measure bone density mass
76
How Injuries can occur
77
Osteoporosis
Medications– estrogen replacement therapy
reduces bone loss increases bone density in spine and hip controversial - increase risk of endometrial and
breast cancer, cardiovascular disease
– Biphosphonates - fosamax– Calcitonin - can be nasal spray
78
Osteoporosis
Health Promotion– Calcium intake– Exercise
activity that is wt. Bearing
– Health related behaviors no smoking limit ETOH, caffeine, soda
79
Ospeoporosis
80
Osteoporosis
81
82
Paget’s Disease - bone enlarging and softening
83
Paget’s Disease
Progressive skeletal disorder where bones become larger and softer– femur, pelvis, vertebrae, sternum, skull
Manifestations– bone pain, aggravated by pressure and wt.
Bearing and noticed at night– warmth over bones
84
Paget’s Disease
Complications– osteoarthritis– pathological fx
Treatment– hip or knee replacement– braces
85
Osteomalacia
Is a metabolic bone disease
Affects the structure and integrity of bone
Known as adult rickets
86
Osteomalacia
Caused by inadequate mineralization of bone– Insufficient amounts of calcium or phosphate– Bone does not harden– Bone is deformed and unable to bear weight– Pathologic fractures occur
87
Osteomalacia
Pathophysiology– Lack of vitamin D
Obtained by certain foods and radiation from the sun Vitamin D is necessary to maintain calcium and
phosphate levels
Risk factors Inadequate intake and/or impaired absorption Chronic kidney or liver disease
88
Osteomalacia
Manifestations– Bone pain– Difficulty changing positions– Muscle weakness– Waddling gait– Dorsal kyphosis– Pathologic fractures
89
Osteomalacia Diagnostic tests
– Bone x-rays– Lab tests – calcium and alkaline phosphatase
TreatmentAdequate vitamin D, calcium, and phosphate intake
or supplements
Bisphosphonates and calcitonin
Teach exercise and how to prevent falls
90
Paget’s - bone enlarging and softening
91
Lets Review
Osteoporosis
definition
risk factors
clinical manifestations
#1 complication
92
Oops, did I pump it too high?
94
Ankylosing Spondylitis
Chronic inflammatory arthritis affecting axial skeleton leading to pain and progressive stiffening and fusion of the spine
Patho– inflammation - scar tissue - gradual
calcification - joint consolidations and immobility
95
96
Ankylosing Spondylitis
97
Ankylosing Spondylitis
Manifestations– gradual and insidious– bouts of low back pain worse at night, followed
by morning stiffness relieved by activity– back motion become limited– intermittently wit mild to moderate acute
episodes
98
Ankylosing Spondylitis
Collaborative Care– P.T. and daily exercise– NSAIDs, topical or intra-articular
corticosteroids
99
Changes in the axial spine
100
Ankylosing Spondylitis
Which part of the skeletal system is affected?
What are the clinical manifestations?
Nursing care?
101
More Ortho
Here’s the BIG question
What will be be discussing next?
102
Systemic Lupus Erythematosus
Affects Connective Tissue Chronic inflammatory immune complex
connective tissue disease affecting multiple body systems
affects females of child bearing years cause unknown mild chronic cases with remissions and
exacerbation.
103
Systemic Lupus Erythematosus
Manifestations– Early
fever, anorexia, malaise, wt. Loss, multiple arthalgias and symmetric non-deforming polyarthritis
– Skin red butter fly rash across cheeks and bridge of nose photosensitivity alopecia
104
Butterfly Rash
105
106
Figure 43-10 The multisystem effects of systemic lupus erythematosus.
Systemic Lupus Erythematosus
– renal– hematologic– cardiovascular– pulmonary– neurological– ocular– GI
108
Multi-system effects of Lupus
109
Systemic Lupus Erythematosus
Diagnostic– difficult due to diversity of symptoms– anti-DNA of various antibodies elevated– ESR, CBC, UA, Kidney bx
Treatment– ASA, NSAIDs, anti-malarial, corticosteriods– avoid sun, ESRD - dialysis and kidney
transplant
110
Polymyositis
Systemic connective tissue disorder with inflammation of connective tissue and muscles leading to muscle weakness and atrophy– auto-immune– affects >females – between ages 40-60
111
Polymyositis
Manifestations– Initial
muscle pain, tenderness weakness rash arthralgias fatigue, fever, wt. Loss
– Later increase weakness, dysphagia, cough
112
Erythematous rash
113
114
Polymyositis
No specific dx test Treatment
– rest, corticosteroids, immunosuppressive therapy
Nursing Care - supportive– comfort, nutrition, skin care, medications,
maintain mobility
115
116
Lyme Disease
117
Geographic locations
118
Lyme Disease
Inflammatory disorder caused by spirochete Borrelia burgdorferi and transmitted by ticks carried by deer and mice– prevalent in mid-Atlantic and north central U.S.
Manifestations– Initial
flu-like and skin rash “bull’s eye” lesion at site of tick bite
119
Bull’s eye rash in lyme disease
120
Lyme Disease
Followed by fatigue, malaise, fever, chills, myalgias later, more skin lesions and muscle and joint pain
Weeks to months later– Bell’s palsy and meningitis– H/A and neck stiffness
Months to years later– arthritis
121
Lyme Disease
Treatment– antibiotics for up to a month
Nursing Care– avoid tick infested areas– appropriate dress, insect repellant– inspect skin - remove ticks
122
Let’s review Lupus
Definition? Early Manifestations? Systemic Manifestations? Treatment?
Nursing Diagnosis?
123
Let’s Review Polymyositis
How is it different from Lupus?
Clinical Manifestations?
Nursing Care?
124
Lyme Disease
Definition? Clinical Manifestations?
– Initial– Weeks to months later– Months to years later
Treatment Nursing Care
125
Infectious Disorders Osteomyelitis Infection of the bone - interferes with
vascular supply, necrosis occurs Patho
– usually bacterial - staphylococcus aureus direct contamination complication of surgery extension of chronic ulcers
127
128
Osteomyolitis - leg wound
129
Figure 43-2 Osteomyelitis. (A) Bacteria enter and multiply in the bone.
132
133
Osteomyelitis
Hematogenous osteomyelitis– carried by the blood– older adult, sickle cell anemia, IV drug users
Osteomyelitis from contiguous infection– deep penetrating wounds, TJR, decubitis ulcers
Osteomyelitis associated with vascular insufficiency– PVD
134
135
Osteomyelitis
Collaborative Care– pain relief– infection elimination or prevention– early dx to prevent bone necrosis– bone debridement and long term antibiotic
therapy Diagnostic Tests
– MRI, CT Scan, Bone Scan, cultures
136
Osteomyelitis
Medications– antibiotics, 4-6 weeks
Surgery– debridement, wound is opened, irrigated,
drainage tubes inserted for irrigation, suction and antibiotic instillation
137
Osteomyelitis
Nursing Care– frequent and lengthy treatment– awareness of recurrent infections– prognosis is uncertain
Home Care– home care agency - wound treatment, antibiotic
adm. Supplies and nutritional teaching
138
139
Bone tumors
140
Bone tumors
141
Neoplastic Disorder - Bone Tumors Tumor may be malignant or benign
– benign grow slow and do not invade– malignant grow rapidly and metastasize – most often are mets from breast, prostate,
kidney, thyroid and lung Manifestations
– often hx of a fall or blow to extremity brings mass to attention
142
Bone Tumors
– Pain, mass, impaired function Diagnostic tests
– X-ray benign - sharp margins malignant “moth eaten” pattern
– C-T Scan, MRI– needle bx
143
Bone Tumors Treatments
– Chemotherapy shrink tumor before surgery control reoccurrence tx metastasis
– Radiation pain control combo with chemo to eliminate tumor after surgery
144
Treatment Bone Graft
145
Nursing Diagnosis
Risk for injury
Acute Pain
Chronic Pain
Impair Physical Mobility
Knowledge Deficit
146
Many Faces of Scleroderma
147
Connective Tissue DisordersScleroderma Chronic disease, formation of excess
fibrous connective tissue and diffuse fibrosis of skin and internal organs– cause unknown - person exposed to chemicals?– more common in females
Prognosis– localized -good systemic - poor
148
Scleroderma
Manifestations– thickening of skin, diffuse non-pitting swelling– eventually skin atrophies, becomes taut and
hyperpigmented– arthralgias and Raynaud’s phenomenon– Visceral organ involvement
dysphagia, pulmonary hypertension, pericarditis, G.I. Renal failure
149
Multi-system effects
150
Hand Changes
151
Scleroderma
Diagnostic tests– confirmed by skin bx
Treatment– meds
immunosuppressive, corticosteroids, tx symptoms
– P.T– Nursing care - supportive
152
153
Inspection leads your assessment
154
Fibromyalgia
Common rheumatic syndrome, musculoskeletal pain, stiffness, tenderness
No inflammatory structural or muscle changes
Cause– unknown
155
Fibromyalgia
Manifestations– gradual onset of chronic, achy muscle pain– tightness or muscle spasm– pain when palpating localized tender points– fatigue, sleep disruption H/A, IBS
Diagnosis– based on H & P– check thyroid
156
157
Fibromyalgia
Treatment– heat applications– massage– stretching exercises– sleep improvement– stress-reduction– anti-depressant therapy
158
Low Back Pain Difficult to Treat!
159
160
Low Back Pain
Most often due to strain of muscle/tendons caused by abnormal stress/overuse
Collaborative Care– pain relief– correct underlying condition prevent
complication client education
161
Low Back Pain
Diagnostic tests– conservative tx for 4 weeks– X-rays, CT Scans MRI
Medications– NSAIDs, analgesic, muscle relaxants– epidural steroid injection for intractable pain
162
Low Back Pain
Nursing Care– health promotion
exercise lose wt. Body mechanics ergonomically appropriate work places
163
Treatment
164
Foot Disorders
Types– Hallux valgus - bunion– Hammer toe– Morton’s neuroma
Collaborative Care– pain relief– correct structural deformity– prevent recurrence
165
Foot Disorders
Hallux Valgus
Morton’s Neuroma
Hammer toe
166
Foot Disorders
Treatment– conservative - corrective shoes, orthotic devices
analgesics– Surgery
bunionectomy shortening or lengthening of ligaments pins to correct toe positioning casting
167
Muscular Dystrophy - progressive muscle wasting
Muscular Dystrophy MD
Inherited muscle disease, progressive degeneration and wasting
Duchenne’s muscular dystrophy– most common– mother to male child– dx in early childhood , 15 year life span
Muscular Dystrophy
Manifestations– progressive muscle weakness with cardiac and
endocrine abnormalities– possible mental retardation
Collaborative Care– preserve and promote mobility– support child and family
Now ambulating
Gait Assessment?
Posture Changes
Muscular Dystrophy
Diagnostic tests– creatine kinases (CK-MM) elevated– muscle bx– electromyelogram (EMG)
Nursing Care– promote independence, mobility– psychological support– assist with self care deficits
Yes, we are done!
174
175
