Osteomyelitis nn

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Medical Surgical Nursing

Musculoskeletal Alterations:

Section 1 Infections


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Osteomyelitis Infection of the bone

May occur by:

Extension of soft tissue infections

Direct bone contamination

Blood borne spread from other foci of infection

Most common cause is trauma

70-80% caused by Staphylococcus aureus


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Osteomyelitis (cont.)

Who is at risk?

Poorly nourished

Elderly

Obese

Impaired immune system

Chronic illness

Long term corticosteroid therapy


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Bone infections are more difficult to

eradicate than soft tissue infections

because infected bone becomes walled of

Natural immune responses are blocked;

antibiotics penetrate less


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Clinical Manifestations: Sudden onset with clinical symptoms of

septicemia

Chills, high fever, rapid pulse, general malaise Extremity becomes painful, swollen, warm, and

tender

Pulsating pain that intensifies with movement

Abscess cavity contains dead bone tissue(sequestrum) which does not drain


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Assessment/Diagnostic Methods

X-rays show soft tissue swelling

Bone scans or MRI can be done

Blood studies and blood cultures taken

Chronic osteomyelitis: x-ray shows large,

irregular cavities, and a raised periosteum ordense bone formations


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Medical Management

Initial goal is to control and arrest the infective process

Affected area is immobilized, warm soaks

Blood cultures to identify organism

IV antibiotic round the clock

Once infectioncontroloral antibiotics for up to 3

months

Surgical debridement with irrigation


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Assessment:

Assess for risk factors

Observe for guarded movements

Observe for warmth and swelling, drainage,

elevated temperature

Chroniccases may have minimal temperatureelevation


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Nursing Diagnosis:

Painrelated to inflammationand swelling

Impaired physical mobility associated with

pain

Risk for extensionof infection: bone abscess

formation Deficient knowledge about treatment regimen


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Planning/Goals

Major goals include painrelief and improved

mobility,control and eliminate infection, andpatient education


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Nursing Interventions:

Restrict activity and immobilize

ROM to joints above and below affected

Handle with care to avoid pain Elevate to decrease swelling

Administer painmedications and use otherpainrelief measures

Monitor neurovascular status Encourage ADLssome restrictions due to

weakness of bone


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Monitor response to antibiotics

Watch for super-infections

Diet high inproteinand vitaminC to help

promote healing

Patient Education: importance of adhering

to therapeuticregimenof antibiotics, andpreventionof falls

IV equipment instruction


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Medical Surgical Nursing

Musculoskeletal Alterations:

Section 2 RheumaticMusculoskeletal Alterations


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Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is aninflammatory disorder that primarilyinvolves the synovial membrane of the

joints Occurs between the ages of 30 and 50;

peak between 40-60 years of age

Women affected 2-3x more than men

Believed to be an autoimmune response tounknown antigens


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Rheumatoid Arthritis (cont)

Clinical Manifestations:

Determined by the stage and severity of the

disease

joint pain, swelling, warmth, erythema, andlack of function

Palpitationof joints reveals spongy or boggy

tissue

Fluid canusually be aspirated from the

inflamed joint


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Begins with small joints inhands, wrists and feet

Progressively involves knees, shoulders, hops,

elbows, ankles, cervical spine, and TMJ

Symptoms are acute inonset, bilateral andsymmetric

Morning stiffness lasts for more than30 minutes

Deformities of the hands and feet result from

misalignment and immobilization


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Extra-articular features:

Fever, weight loss, fatigue, anemia, sensory

changes

Raynauds phenomenon Rheumatoidnodules, non-tender and movable;

found insubcutaneous tissue over bony

prominences


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Assessment and DiagnosticFindings Several factors lead to diagnosis of RA

Rheumatoid nodules, joint inflammation, extra-articular changes

Laboratory findings: Rheumatoid Factor (RF) found in80% of patients

ESR elevated

RBC and C4 decreased

C-reactive Protein(CRP) and antinuclear antibody(ANA) may be +

Arthrocentesis and x-rays canbe performed


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Medical Management

Includes education, a balance of rest and

exercise, and referral to community agencies

for support Early RA:

Medical management includes therapeuticdoses

of salicylates or NSAIDs; includes new COX-2

inhibitors, gold, penicillamine Occupational and physical therapy

Reconstructive surgery and corticosteroids


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Assessment:

Assess patients self-image

Assess joints by inspecting palpating, and

inquiring about tenderness, swelling, andredness

Assess joint mobility, ROM, and muscle

strength


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Planning and Goals

Goals include painrelief

Relief of fatigue

Optimal functional mobility Independence inADLs

Improved sleep

Absence of complications


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Nursing Interventions:

Painrelief measures

Relief of fatigue

Increasing mobility Improving sleep

Monitoring for potential complications

Increase knowledge of disease Promoting self-care


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Systemic Lupus Erythematosus (SLE)

Chronic inflammatory autoimmune

collagen disease resulting from disturbed

immune regulation that causes anexaggerated production of autoantibodies


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SLE (cont)

Pathophysiology

Broughtonby some combinationof genetic,

hormonal and environmental factors

Certainmedications have beenimplicated in

chemical- or drug-induced SLE

Some foods (alfalfa sprouts) have been

implicated Usual onsetduring childbearing years


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Pathophysiology cont In autoimmunity, the body produces antibodies

against its own cells

Formed antigen-antibody complexes cansuppress the bodys normal immunity and

damage tissues

Pts with SLE can produce antibodies against

many tissue components: red blood cells,

neutrophils, platelets, lymphocytes or any organ

or tissue in the body


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SLE Susceptibility Genetic predisposition

Stress

Streptococcal or viral infections

Exposure to sunlight or UV light

Immunization

Pregnancy

Abnormal estrogen metabolism


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Drugs that spark SLE

Procainamide

Hydralazine

Isoniazid

Methyldopa

Anticonvulsants

Penicillins, sulfa drugs, and oral

contraceptives (less common)


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SLE (cont)

Clinical Manifestations

Onsetis insidious or acute

SLE cangoundiagnosed for many years

Clinical course is one of exacerbations andremissions

Multisystem features

Nephritis, cardiopulmonary disease, rashes,

evidence of systemicinflammation


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SLE (cont)

Musculoskeletal System: Arthralgias and arthritis, jointswelling, morning

stiffness

Integumentary system: Butterfly rash across bridge of nose and cheeks

Lesions canbe provoked by sunlightor artificial UVlight

Cardiovascular Pericarditis

Other: Pleuritis or pleural effusions

Renal involvement, HTN, depression


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SLE (cont)

DiagnosticStudies Complete history

Analysis of blood work

Nospecificlab workconfirms SLE

Other diagnosticimmunologictests supportbutdonot

confirm the diagnosis.

Anemia, leukopenia, lymphopenia, thrombocytopenia, and an

elevated ESR

Womenmay reportirregular menstruation 90% have jointinvolvementthatresembles RA

40% have Raynauds phenomenon


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SLE (cont)

PharmacologicTherapy

NSAIDs and corticosteroids

Topicalcorticosteroids for cutaneous

manifestations Immunosuppressive agents for mostserious

forms of SLE


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SLE (cont)

Nursing Interventions Generally the same as those for patients with

rheumaticdisease and address:

Fatigue

Impaired skinintegrity

Disturbed body image

Knowledge deficit


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Osteoarthritis (Degenerative Joint

Disease)Osteoarthritis (OA) is the most common joint disorder.

Characterized by a progressive loss of joint cartilage.

Risk Factors:

female

genetic pre-disposition

Obesity

Mechanical joint stress

Trauma

Congenital and developmental disorders

Inflammatory joint diseases

Endocrine and metabolic diseases


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OA(cont)

Classified as:

Primary (idiopathic)

Secondary (related torisk factors): mostcommonly -- trauma, congenital deformity, orobesity

Obesity increases the painand discomfortof the

diseaseOA peaks betweenthe fifth and sixth decades of

life


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OA(cont)

Clinical Manifestations: Pain, stiffness, and functional impairment

Stiffness is mostcommoninthe morninglasts lessthan30 minutes

Functional impairmentis related topain Aching during weather changes

grating of jointduring motion

Mostoftenoccurs inweightbearing joints (hips,knees, cervical and lumbar spine)

Bony nodes may be present(painless) Heberdensnodes: distal joints

Bouchardsnodes: proximal joints


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OA(cont)

Prevention:

Weightreduction

Preventionof injuries

Perinatal screening for congenital hip disease

PharmacologicTherapy

Acetaminophen; NSAIDs

COX-2 inhibitors Topical analgesics

New therapeuticapproaches


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OA(cont)

Conservative Measures

Heat, weightreduction, jointrest

Orthoticdevices

Isometricand postural exercises

OT and PT

Surgical Management

Jointreplacement


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OA(cont)

Nursing Management

Manage pain

Optimize functional ability

Assistwith weightloss strategies

Encourage use of assistive devices for

ambulation

Patient

safety


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GoutA heterogeneous group of conditions related

to a defect of purine metabolism and

resulting hyperuricemia

PathophysiologyOver secretion of uric acid or renal deficit in

excreting or combination of both

May be due to starvation, excessive intake ofpurine rich foods, or heredity


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Gout

Primary gout usually occurs in men over

age 30 and post-menopausal women who

take diuretics

Intermittent

Between attacks patient may be symptom

free for years


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Gout (cont)

Clinical Manifestations Four stages

Asymptomatichyperuricemia urate levels rise butdont produce symptoms

Acute gouty arthritis Most commonearly sign

Metatarsophalangel joint of the big toe

Acute attack triggered by trauma, alcohol, diet,medication

Abrupt onset occurs at night Early attacks go away spontaneously

May be months or years before the next attack


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Gout (cont)

Hyperuricemia

Few people develop clinically apparent urate crystal

deposits

Development of gout is directly related to durationan

magnitude of hyperuricemia

Tophi

Chalky deposits of sodium urate

Associated with frequent and severe inflammatory

episodes

High uricacid concentrations associated with tophi Found invarious places

Risk for urolithiasis


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Gout (cont)

Medical Management

Hyperuricemia, tophi, joint destructiontreated

after the acute inflammatory process

Uricosuricagents to correct hyperuricemia Colchicine or NSAIDs

Allopurinollimited due to risk of toxicity


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Gout (cont)

Nursing Management

Restrict consumptionof foods high inpurines

(organmeats, anchovies, sardines, sweetbreads)

Avoid alcohol Maintainnormal body weight

Painmanagement

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Osteomyelitis nn