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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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Osteomyelitis (cont.)
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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Osteomyelitis (cont.)
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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Osteomyelitis (cont.)
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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Osteomyelitis (cont.)
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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Osteomyelitis (cont.)
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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Osteomyelitis (cont.)
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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Osteomyelitis (cont.)
Planning/Goals
Major goals include painrelief and improved
mobility,control and eliminate infection, andpatient education
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Osteomyelitis (cont.)
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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Osteomyelitis (cont.)
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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Rheumatoid Arthritis (cont)
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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Rheumatoid Arthritis (cont)
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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Rheumatoid Arthritis (cont)
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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Rheumatoid Arthritis (cont)
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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Rheumatoid Arthritis (cont)
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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Rheumatoid Arthritis (cont)
Planning and Goals
Goals include painrelief
Relief of fatigue
Optimal functional mobility Independence inADLs
Improved sleep
Absence of complications
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Rheumatoid Arthritis (cont)
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
In
struc
tion
toc
on
tin
ue medic
ation
s tomaintaineffectiveness