Nursing of Adult Patients with Medical & Surgical Conditions Musculoskeletal Disorders

Nursing of Adult Patientswith

Medical & Surgical Conditions

Musculoskeletal

Disorders

Assessment Scoliosis

• Lateral curvature of the spine

Assessment Kyphosis

• A rounding of the thoracic spine• Hump-backed appearance

Assessment Loradosis

• An increase in the curve at the lumbar region

Assessment

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 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

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

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 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

• 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

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

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 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

• support extremity

• joint rest for 12 hours

• ice to joint for 24 - 48 hours

• assess for s/s of infection

Diagnostic Tests

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 Etiology/Pathophysiology

• 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

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)



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 Treatment

• Medications• Salicylates (Aspirin)

• Nonsteroidal Anitinflammatory Drugs (NSAID’s)– 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)


• 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


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

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


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



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


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


Prognosis• Chronic disease• Lasts about 20 years leaving permanent damage

Degenerative Joint Disease (Osteoarthritis)

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.



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



Diagnostic Tests• Radiographic studies• Arthroscopy• Synovial fluid examination• Bone scans


Treatment• Exercise balanced with rest• Heat applications• Gait enhancers (canes, walkers, etc.)• Medications

• Salicylates (aspirin)• NSAID’s (Motrin)• Steriods (cortisone)

• Surgery• Osteotomy• Joint replacement


Prognosis• Chronic disease that ultimately causes

permanent destruction of affected cartilage and underlying bone.

Gout (Gouty Arthritis) 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)

Signs & Symptoms• Excruciating pain• Edema• Inflammation• Most common in the great toe• Tophi

• calculi deposits



Diagnostic Tests• Serum and uric acid levels• Complete blood count• ESR• Radiography studies

• reveal cysts

• Synovial fluid aspiration• contain urate crystals

Gout (Gouty Arthritis) 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


• Encourage fluid intake• at least 2000 cc/day

• Monitor intake and output• Bed rest and joint immobilization• Diet

• Avoid high purine foods– organ meats– anchovies– yeast– herring– mackerel– scallops


Prognosis• Signs and symptoms are usually recurrent• Can progress to destructive joint changes

Osteoporosis Etiology/Pathophysiology

• Reduction of bone mass• Most common in women ages 55-65

• possibly related to lack of estrogen

• Contributing Factors• Immobilization

• Use of steroids

• High intake of caffeine

• Diet low in calcium

• Smoking

• Excessive protein in diet

• Sedentary lifestyle

Osteoporosis

Magnification of:

Healthy Bone Bone with Osteoporosis

Osteoporosis

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

Diagnostic Tests• CBC• Serum calcium• Phosphorus• Alkaline phosphatase• Blood urea nitrogen• Creatinine level• Urinalysis• Liver and thyroid function tests• Radiography studies

Osteoporosis Treatment

• Calcium supplements• 1000 mg for men• 1500 mg for women

• 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

Prognosis• Chronic disorder• Prevention should begin before bone loss

occurs

Osteomyelitis

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

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

Diagnostic Tests• Radiography studies• Bone scan• CBC (esp WBC)• ESR• Cultures of blood and drainage

Osteomyelitis 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

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)

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.



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


Diagnostic Tests• Radiography studies• CT• Myelogram• Electromyelography (EMG)


Treatment• 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

Etiology/Pathophysiology• May be primary or secondary• Benign or Malignant• Osteogenic sarcoma

• 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

Signs & Symptoms• Spontaneous fractures• Anemia• Pain esp. with weight bearing• Edema and discoloration of skin at site

Tumors of the Bone

Diagnostic Tests• Radiography studies• Bone Scan• Bone biopsy• CBC• Platelet count• Serum protein levels• serum alkaline phosphatase level

Tumors of the Bone

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

Prognosis• Survival rates with aggressive treatment are

approximately 50% at 5 years

Traumatic Injuries

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

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 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

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

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

Dislocations• Etiology/Pathophysiology

• Temporary displacement of bones from their normal position

• May be caused by:– congenital

– disease process

– trauma

Traumatic Injuries

• Signs & Symptoms• 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 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

– computer usage

– basket weaving

– meat carving

– typing


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

• 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


Diagnostic Tests• Physical exam

• Tinel’s sign– increased tingling with gentle tap over tendon sheath on

ventral surface of central wrist

• Electromyogram• MRI


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 1-2

hours for 24 hours


Prognosis• Mild symptoms may be relieved by nonsurgical

treatment• Severe symptoms may be relieved by surgical

treatment• Pregnancy induced usually subside after

delivery

Documents

Nursing of Adult Patients with Medical & Surgical Conditions Musculoskeletal Disorders