1
Q
musculoskeletal system anatomy
A
- muscle
- connective tissue: bones, cartilage, ligaments, tendons, fascia
2
Q
Bone Functions
A
- support
- protection
- voluntary movement
- blood cell production
- mineral storage
3
Q
types of bones
A
- cortical: compact and dense
- cancellous: spongy
4
Q
three types of bone cells
A
- osteoblasts: build bone
- osteocytes: mature bone cells;
- osteoclasts: break down bone
5
Q
Gross Bone Structure
A
- epiphysis: top of bone
- diaphysis: middle long bone
- metaphysis: the curved part of the bone between the epiphysis and diaphysis
- epiphyseal plate:
6
Q
Gross Bone Structure
A
- epiphysis: top of bone
- diaphysis: middle long bone
- metaphysis: the curved part of the bone between the epiphysis and diaphysis
- epiphyseal plate: The epiphyseal plate (or epiphysial plate, physis, or growth plate) is a hyaline cartilage plate in the metaphysis at each end of a long bone. The plate is found in children and adolescents; in adults, who have stopped growing, the plate is replaced by an epiphyseal line.
- periosteum: membrane that covers the outer surface of all bones
7
Q
Bone Types
A
- long bone: femur, humerus, tibia
- short bone: carpals tarsals
- flat bone: ribs, skull, scapula, sternum
- irregular bone: sacrum, mandible, ear ossicles
8
Q
Joints
A
- articulation where two bones are in proximity to each other
- classified by the degree of movement
TYPES OF JOINTS
1) hinge joint - elbow, knee
2) ball and socket - shoulder, hip
3) pivot (rotary) - radioulnar joint
4) condyloid
5) saddle
6) gliding
9
Q
Joints
A
- articulation where two bones are in proximity to each other
- classified by the degree of movement
TYPES OF JOINTS
1) hinge joint - elbow, knee
2) ball and socket - shoulder, hip
3) pivot (rotary) - radioulnar joint
4) condyloid - wrist joint between radial and carpals
5) saddle - carpometacarpal joint of thumb
6) gliding - between tarsal bones
10
Q
Joints
A
- articulation where two bones are in proximity to each other
- classified by the degree of movement
TYPES OF JOINTS
1) hinge joint - elbow, knee
2) ball and socket - shoulder, hip
3) pivot (rotary) - radioulnar joint
4) condyloid - wrist joint between radial and carpals
5) saddle - carpometacarpal joint of thumb
6) gliding - between carpal bones
11
Q
cartilage
A
- hyaline: bronchi, trachea
- elastic: ear, epiglottis, larynx
- fibrous: shock absorber, verterae, pelvis, knee, shoulder
* functions: support, articulation, protection, growth
12
Q
cartilage
A
- hyaline: bronchi, trachea
- elastic: ear, epiglottis, larynx
- fibrous: shock absorber, verterae, pelvis, knee, shoulder
- functions: support, articulation, protection, growth
13
Q
muscles
A
- cardiac: striated, involuntary
- smooth: nonstriated, involuntary
- Skeletal: striated, voluntary (requires a nerve impulse to contract)
14
Q
Tendons
A
- attach muscle to bone
15
Q
ligaments
A
- attach bone to bone
16
Q
fascia
A
- layers of connective tissue
- provide strength to muscle
17
Q
bursae
A
- sacs of connective tissue lined with synovial membrane containing synovial fluid
- bursitis: inflammation of bursae
18
Q
Gerontologic considerations
A
- decreased bone density = osteopenia (first) and osteoporosis (progressed)
- decreased muscle mass and strength
- decreased flexibility
- functional problems: balance issues, functional status (get patients to do as much for themselves as they can)
19
Q
Gerontologic Age Groups
A
- 65-74: young old
- 75-84: middle old
- 84-100: old old (fastest growing population in US)
- 100+: elite old
20
Q
Gerontologic considerations
A
- decreased bone density = osteopenia (first) and osteoporosis (progressed)
- decreased muscle mass and strength
- decreased flexibility
- functional problems: balance issues, functional status (get patients to do as much for themselves as they can, prominant indicator of outcome)
21
Q
muskuloskeletal assessment subjective
A
- past health history: TB, polio, diabetes, parathyroid problems, hemophillia, rickets, bacterial infections
- medications: bad for bones = steroids, antiseizure meds, phenothiazines, diuretics; good for bones = vit d, calcium, Hormone replacement therapy
- nutrition: vit c & d, calcium, protein, obesity
- occupation: extremes can lead to MSK problems
22
Q
musckuloskeletal assessment objective
A
- inspeciton
- palpation: cephalopedally (head to toe), warm hands
- range of motion: goniometer, active vs. passive
- muscle strength
- measurement: limb length, muscle mass
- scoliosis: can cause lung and heart problems
- straight leg raising test: tests for disc herniation, supine leg lift assess for pain
- gait: get up and go test
- assistive devices: safety, proper use
23
Q
common musculoskeletal abnormalities
A
- Rheumatoid arthritis
- genu varum: bow legged
- Genu valgum: knock knees
- torticolis
- osteoarthritis
24
Q
muskuloskeletal diagnostic studies
A
- Xray: most common
- diskogram: cray with contrast
- CT scan: injected with contrast - assess iodine and seafood allergies
- myelogram: disc herniation, spinal stenosis - injection into spine, common side effect is headache
- MRI: views soft tissue
- Bone mineral density: determines osteopenia or osteoporosis
- bone scan: osteomueltis, cancer; radioisotope attaches to abnormal tissue and bone
- arthrocentesis: joint aspiration - apsirate to see if infected or inflamed
- EMG: painful muscle test, needle put into muscle to wartch for electric impulses
- duplex venous doppler: US looking for DVT
- SSEP: similar to EMG but uses electrodes instead of needles
25
arthroscopy
- examines interior of joint cavity
- anesthesia
- needle inserted and cleans up area and repairs tissue
26
lab tests for musckuloskeletal system
- alkaline phosphatase: produced by osteoblasts, needed for mineralization; osteoporosis, osteomualgia, paget's
- serum calcium
- serum phosphorus: related to calcium: kidney diesase
- Rheumatoid factor
- erythrocyte sedimentation rate: indicated inflamamation; RA, osteomyelitis
- ANA: can destroy nucleous of cell; positive in 95% of patients w lupus or scleroderma
- uric acid: gout
- C-reactive protein: diagnoses inflammation dieases, infection, presents in serum 24 hours after tissue damage
- cratine kinase: muscle damage = inceased CK
- serium potassium: increased muscle trauma, when cells are destroyed they release k+, dysrhythmias
27
contusion
- bruise
- soft tissue injury from blunt force
- overlying skin intact, becomes black and blue from localized hemorrhage
- usually only painful if palpated
28
hematoma
- more concerning than contusion
- blood collecting from torn blood vessel
- pain occurs as blod accumualtes and places pressure on nerves
- pain occurs without palpation
- may burst or become infected
29
strain
- tendon
30
sprain
- ligament
31
RICE
rest, ice, compress, elevate
- analgesia as necessary
- after 24-48 hours, warm moist heat
- strains: change ergonomics, splints, heal in 3-6 weeks
- sprains: may need surgery if the ligament is torn
32
subluxation/dislocation
- dislocation is an emergency
- joint capsule and ligaments can be damaged
- S/S: shortened affected limb, loss of function, swelling, pain, deformity
- complications: joint fx, neurovascular damage, avascular necrosis
33
Fractures
- disruption of break in continuity of structure of bone
- majority of fractures from traumatic injuries
- some fractures secondary to disease process: cancer or osteoporosis
- open vs closed
- complete vs incomplete
- displaced: two ends separated from one another VS nondisplaced: periosteum is intact and bone is aligned
34
signs and symptoms of fracture
* S/S:
- swelling: can occlude circulation and damage nerves (compartment syndrome)
- deformity: can lead to union and functional problems if not corrected
- muscle spasm: can displace a nondisplaced fracture or prevent it from reducing on its own
- crepitation: can increase change for nonunion if bone ends are allowed to move about freely
35
healing process of bone
1) fracture hematoma
2) granulation tissue
3) callus formation
4) ossification
5) consolidation
6) remodeling
36
factors influencing healing
- displacement and site of fracture
- blood supply to area (can cause compartment syndrome)
- immobilization
- internal fixation devices
- infection of poor nutrition
- age
- smoking (constricts vessels)
37
complications of fracture healing
- delayed union (longer than expected to heal)
- nonunion (no callus forms)
- malunion (no realligning correctly)
- angulation (?)
- pseudoarthrosis (nonunion at fracture site, can develop false joint)
- refracture
- myositis ossificans (calcium in muscle tissue after blunt trauma)
38
goals of treatment for fracture
- anatomic realignment (reduction)
- immobilization
- restoration of normal or near normal function
39
closed reduction
- nonsurgical, manual realignment of bone fragments
- traction and countertraction applied
- under local or general anesthesia
- immobilization afterwords until it heals
40
open reduction
- incision required
- internal fixation
- risk for infection
- early ROM of joint to prevent adhesions
- facilitates early ambulation
- ORIF = open reduction internal fixation
41
traction
- prevent or decrease pain and muscle spasm
- immobilize joint or part of body
- reduce fracture or dislocation
- treat a pathologic joint condition
- pulling force to attain realignment - countertraction pulls in opposite direction
- two most common types of traction: skin and skeletal
42
skin traction
- used for short term treatment until skeletal traction is ok (48-72 hours)
- tape, boots, splints applied directly to skin
- traction weights 5-10lbs
- skin assessment and prevention of breakdown imperative
- assess skin (6Ps) every 4 hours
- buck's traction is an example (boot)
43
skeletal traction
- long term pull to maintain alignment
- pin or wire inserted into bone
- weight 5-45lbs
- risk for infection
- complications of immobility
- maintain counter-traction, eelvate end of bed
- maintain continous traction
- keep weights off floor
- inspect skin and pin sites carefully
- pin clean site every shift to prevent infection
- maintain ROM of inaffected joints
44
casts
- Arms: sugar tong splint, short arm, long arm
- slings: pad axillary area, be careful of neck, encourage movement of fingers
- long leg, short leg, jones dressing
- Hip spica: used for femoral fracture in peds, dont move using the support bar, can put pt prone, use fracture bedpan
- body jacket for vert immobilization: risk for cast syndrome, listen to bowel sounds, may need NG
* cast syndrome: compression of superior mesenteric artery against duodenum
45
cast care interventions
- do not cover a drying cast
- handle a wet cast with palms only, can support cast with pillows when wet
- elevate at or above heart level
- pad or petal rough cast edges
- do not scratch skin with any objects
- can use cool air form hair drying for itching
- apply ice for first 24-36 hours
- do not get cast wet
46
prevention of musckuloskeletal problems in older adults
- use ramps
- eliminate scatter rugs
- treat pain and discomfort from osteoarthritis
- use walker or cain
- proper nutrition, avoid obesity which adds extra stress to bones
- use shoes with good support
- gradually initiate and decrease activities
47
6Ps
- parasthesia, pain, pressure, pallor, paralysis, pulselessness
- asses with muskuloskeletal injuries
48
use of crutches
- never bear weight on axillary, bear weight in hands
- elbows at 15 degree angle
- canes held in opposite hand of involved extremity. cane and weak leg go together
- flat ground: involved limb and device first, followed by uninvolved limb
- stairs: good leg first going up, bad leg first going down
49
fracture complications
- direct: infection, inadequate bone union, avascular necrosis (bone death from lack of blood supply)
- indirect: compartment syndrome, VTE, rhabdo (can damage kidneys), fat embolism, shock
50
bone infection
- high incidence with open fracture or soft tissue injury
- need aggressive debridgement
- antibiotic beads
51
VTE
- venous thromboembolism
- esp after a hip fracture, total knee
- prevention - anticoags, SCDs, rom to unaffecte joints
52
compartment syndrome
- pressure that compromises neurovascular function
- causes: restrictive dressings, edema
- S/S: early = pain, unrelieved by drugs and out of proportion; late = no pulses, paralysis, dark brown urine
- tx: quick recognition, do NOT elevate, NO ice, loosen dressing, fasciotomy (opens muscle and relieves pressure)
53
Fat embolism syndrome
- main contibuting factor to death with people with fractures
- far globules transported to lungs cause a hemorrhagic interstitial pneumonitis
- risk with long bone, ribs, tibia, pelvis fx
- S/S: chest pain, tachypnea, dyspnea, change in mental status, hypoxia, petechiae on neck, chest, axilla, eyes, sense of impending doom
- tx: early recognition, reposition as little as possible, oxygen
- immobilize to drecrease risk of disloding fat embolism
- within 24-48 hours of broken bone
54
facial fractures
- maintain patent airway, provide adequate ventilation
- assume that they have a cervical injury
- always have suction available
55
jaw fractures
- position pt on the side with head slightly elevated
- wire cutter at bedside
- tach tray always available
- NG tube for decompression
- oral hygeine is important
- protein suppliments
- liquid diets
56
Pelvic Fracture
- can be life-threatening
- s/s: bruising on abdomen, pelvis instability, swelling, tenderness
- tx: bed rest, may need traction, hip spica cast, ORIF, only turn when ordered by HCP
- complications: paralytic ileus, internal bleeding, fat embolism, other GI problems
- rule out internal bleeding first
57
hip fracture
- 30% die within 1 year of injury
- s/s: external rotation, spasm, shortening of affected leg, severe pain
- complications: nonunion, avascular necrosis, dislocation, arthritis, DVT
- tx: surgery, may temp use buck's traction
- can shorten the leg and impair mobility
58
femoral shaft fracture
- can have lots of blood loss, risk of fat embolism
| - tx: ORIF with traction after, hip spica cast
59
tibia fracture
- risk of compartment syndrome
| - neurovascular assessment q 2 hours x 48 hours
60
stable vertebral fracture
- fracture with no spinal cord injury
- logroll, orthotic devices, ard vervial collar
- vertebroplasty (inject cement)
- kyphoplasty (balloon and then cement)
61
joint procedures
- synovectomy: removal of synovial membrane
- osteotomy: remove a wedge of bone
- debridement: removal of degenerative debris
- arthroplasty: reconstruction or replacement of a joint
62
knee arthoplasty
- reason: unremitting pain and instability r/t severe destructive deterioriation of the knee joint
- may replace all or part of the knee joint
- post op: will be in extension while abulating for 4 weeks, exercises on 1st day progressing to gentle ROM until 90 degree flexion, CPM, full weight bearing before discharge
63
total hip arthroplasty
- pillow abductor splint between knees esp when turning, avoid extreme hip flexion, dont turn on affected side, OOB on first post op day, in hispital for 3-4 days
- posterior and anterior (bettwe outcomes) approach
- home care instructions: cant drive or take tub bath for 4-6 weeks; knees must be kept apart; dont cross legs; dont twist to reach behind; quadriceps and hip muscle exercises; high risk for thromboembolism; no high-impact exercises/sports
64
teaching for amputation
- sterile technique for dressing changes
- immedaite prosthesis vs delayed
- dont sit in chair > 1 hr
- lie on abdomen 3-4 times a day to keep hip in extension
- residual limb bandaging
65
osteomyelitis
- severe infection of bone, bone marrow, and surrounding soft tissue
- most common microorganism is STAPHYLOCOCCUS AUREUS but can be caused by many organisms
* etiology: indirect entry - hematogenous, young boys, blunt trauam, DM, GI and respiratory infections; direct entry - via open wound, foreign body presence
* patho: microorganisms frow in area of slow cirrculation --> increase pressure in bone --> ischemia and vascular compromise
- infection spreads through bone --> cortex devascularization and necrosis
- dead bone separates from living bone forming sequestra
- sequestra is surrounded by pus and is very hard for antibiotics and WBCs to get
- must be removed surgically or will turn into chronic infection
66
clinical manifestations of acute osteomyelitis
- infection of 10 days after symptoms appear
67
clinical manifestations of chronic osteomyelitis
- infection losting longer than >1 month or has failed to respond to initial course of antibiotic therapy
- continuous and persistent or process of exacerbations and remissions (flair ups)
- may result in amputation
- systemic signs diminished
- local signs of infection more common (pain, swelling, warmth)
- granulation tissue turns to scar tissue --> avascular --> ideal sire for microorganisms to grow --> impenetrable by antibiotics
68
collaborate care, acute osteomyelitis
- vigorous and prolonged IV antibiotic therapy (4 weeks to 6 months)
- cultures or bone biopsy prior to
- surgical debridement and decompression if antibiotic therapy delayed
69
collaborate care, chronic osteomyelitis
- surgical removal of dead bone (amputate)
- extended use of antibiotics
- antibiotic impregnated beads
- intermittent or constant irrigation with antibiotics
- wound VAC
- hyperbaric oxygen
- removal of prosthetic devices
70
osteomyelitis interventions
- absorbent dressings using sterile technique
- bed rest
- immobilization, NSAIDS
- no exercise or heat application
- observe for antibitoic side effects: hearing problems, jaundice, photosensitivity, achilles tendon rupture
* follow up: monitor patient response to therapy with bone scans and ESR
- rare complications: septicemia, septic arthritis, pathologic fractures, amyloidosis
71
osteoporosis risk factors
```
Alcohol use
Corticosteroid use
Calcium low
Estrogen low
Smoking
Sedentary lifestyle
- heredity, sex, race, early menopause, poor nutrition, sedentary lifestyle, thinness, smoking, alcohol, low testosterone, endocrine diseases, - drug related causes: glucocorticosteroids, anticonvulsants, some antacids, diuretics, thyroid meds
```
72
osteoporosis
- 44 million people have it in US
- 1/2 women and 1/4 men over 50 will sustain an osteoporosis-related fracture
- known as the "silent thief"
- porous bone
- chronic, progressive metabolic bone disease characterized by low bone mass, structural deterioration, increased bone fragility
73
etiology and patho of osteoporosis
- remodeling: osteoblasts deposit bone, osteoclasts resorb bone
- bone resorption exceeds bone deposition
74
clinical manifestations of osteoporosis
- occurs most commonly in spine, hips, and wrists
- back pain
- spontaneous fractures
- gradual loss of height
- dowager's hump (kyphosis)
75
osteoporosis prevention
- regular weight-bearing exercise
- fluoride
- calcium and vitamin d
- stop smoking
- decrease alcohol intake
- nutrition - foods high in calcium (milk, cheese, yogurt, seafood)
76
screening guidelines for osteoporosis
- intial bone scane in women before age 65
- repeat in 15 years if normal
- earlier and more frequent if high risk
- men screened before age 70, by age 50 if iat high risk (history of prostate cancer)
77
osteoporosis collaborate care
- treatment of existing disease
- prevent further loss with supplements and meds
- keep ambulatory
- gait aid to prevent falls/fractures
- brace for vertebral fracture
- vertebroplasty and kyphoplasty to treat osteoporotic vertebral fracture
78
drug therapy for osteoporosis
* bisphophonates: inhibit bone resportion
- side effects: anorexia, weight loss, gastritis
- proper administration: take with full glass of water, take 30 minutes before food or other meds, remain upright for 30 minutes
*calcitonin: inhibits bone resportion, give IM form at night to minimize side effects, alternate nostrils when using nasal form, must use calcium supplementation
79
low back pain
- very common
- causes: strain, instability, osteoarthritis, Degenerative Disk Disease, disk herniation
- straight leg raising test: test for disk herniation (usually in low back) - supine lift leg 60 degrees assess for pain
80
low back pain treatment
- analgesics, muscle relaxants, massage, heat and cold
- avoid prolonged bed rest
- stop smoking
-
81
nursing care for back pain
- proper body mechanics
- no twisting
- sleep with head up and knees flexed and no pillows under upper back
- dont life above level of elbows
- avoid prolonged sitting or standing
- exercise to strengthen back and abs
- may sometimes use a corset-like brace to provide support
82
Intervertebral disk disease
- progressive degeneration: normal process of aging that can lead to herniated disks
- most common sites of slipped disks: l4-5, l5-s1, c5-6, c6-7 (low lumbar and neck area)
- s/s: low back pain, radiuclar pain to buttox and below the knee, for cervical disk have radicular pain to arms/hands, static nerve
83
diagnosis and treatment of back pain
- straight leg test is usually positive
- xrya, myelogram, MRI, CT
- conservative treatment first
- may need laminectomy, diskectomy, or spinal fusion
84
spinal fusion
- must maintain proper alignment until healing has occured
- oullows under thights when supine, between legs when side laying
- IV opioids for 24-48 hours, muscle relaxants
- watch for CSF leak
- movement and sensation should be unchanged after surgery, check every 2-4 for 48 hours
- clarify if they need brace or corset
- check donor site, usually more painful
- avoid sitting or standing for prolonged times
- no twisting movement of the spine
- firm mattress or bed board
85
NSAIDS
- block production of prostaglandins by inhibiting cox1 and cox2
- ibuprofen, naproxen, indomethacin, diclofenac, celecoxib
- side effects: GI irritation, bleeding, renal problems, cardiac problems
- nursing care: give with food, watch for bleeding s/s, don't combine with aspirin
86
salicylates
- inhibit synthesis of prostaglandins
- aspirin most common
- side effects: GI irritation, bleeding, tinnitus, worsening of asthma
- nursing care: give with good, watch for bleeding, don't combine with NSAIDS
87
acetaminophen
- tylenol
- analgesic and antipyretic, not an antiinflammatory
- side effects: live toxicity
- nursing care: primary tx for OA and mild pain, limit to 4 grams/day, DO NOT take if alcoholic or have liver disease
88
topical analgesics
- block pain by locally interfering with substance P thus interrupting pain signals to the brain
- capsaicin cream, voltaren gel
- side effects: skin irritation
- nursing care: dont use creams with a heating pad, avoid oral NSAIDs
89
corticosteroids (intraarticular injections)
- inhibit synthesis and/or release of mediators of inflammation
- methylprednisolone, triamcinolone
- side effects: local osteoporosis, tendon rupture, skin changes, local infection
nursing care: HCP should use strict sterile technique, often makes the pt feel worse for 24-48 hours, can last for weeks to months
90
corticosteroids (systemic)
- inhibit synthesis and/or release of mediators of inflammation
- solu-cortef, solu-medrol, dexamethasone, prednisone
- side effects: cushing syndrome, HTN, psychosis, diabetes, acne, menstrual problems, hirsutism, immunosupression, bruising
- nursing care: tape dose and use shrot term when possible, watch for side effects closely, nt for osteoarthritis
91
hyaluronic acid (HA)
- lubricates, maintains normal joint cushioning
- orthovisc, synvisc, hyalgen
- side effects: not many, pain, redness, rare to have an allergy
- nursing care: typically given as 3 weekly injections directly into joint space, may give pain relief up to 6 months
92
antimalarials
- unknown acton, but may supress formation of antigens
- plaquenil
- side effects: retinopathy, ototoxicity, low BP, ecg changes
- nursing care: have pt immediately report vision changes and hearing changes, may take up to 6 months to take full effect
93
diease modifyin antirheumatic drugs (DMARDs)
- rapid, antiinflammatory effect, inhbiits DNA, blocks immunce cell over production
- methotrexate, sulfasalazine, arava
- used aggresively for RA to prevent irreversible join changes
- side effects: hepatotoxicity, bone marrow dpression, teratogenic
- nursing care: monitor CBC, hepatic, and renal function
94
biologic/targeted therapy
- slows disease progression in RA
95
immunosupressants
- inhibit DNA, RNA, and protein synthesis
- imuran, cytoxan, cellcept
- side effects: n/v, rash, anorexia, teratogenic, hemorrhagic cystistis with cytoxan, infection
- nursing care: avoid live vaccines, watch for bleeding, infection
- may take up to 3 months to work
96
disease modifying osteoarthritis drugs (DMOADs)
- slow progression or support joint healing
| - still under investigation
97
arthritis
- number one chronic complaint and cause of disability in the US
- rheumatic disease incolving bone, muscle and joints
- 2 common types: osteoarthritis, Rheumatoid arthritis, gout
98
osteoarthritis
- involves formation of new joint tissue in response to cartilage destruction
- not a normal part of aging
- lose flexibility
- bone on bone, decreased cartilage
- risk factors: age, menopause, genetics, obesity, overuse, trauma
99
OA signs and symptoms
- no systemic symptoms
- joint pain ranging from mild discomfort to significant disability; pain worse with joint use;
- early morning stiffness resolving within 30 minutes, stiffness worse with rest or static positions
- over activity may cause mild joint effusion, stiffness
- crepitus
- deformities: heberdens nodes, bouchards nodes, knee joint misalignment, leg length discrepancy
100
OA diagnosis and treatment
- xrays, mri, ct scan, bone scan
- labs: will be normal, synovial fluid will be clear yellow with little/no sign of inflammation
* tx: aimed at symptom reduction - exercise, prevent joint stress, coping/managing pain, control weight, assure patient that OA is localized disease and severe deforming arthritis is not the usual course
- rest/joint protection: balance rest and activity, rest and splint with acute inflammation, use assistive devices
- heat/cold
- drugs: tylenol q 6 hours, topicals, nsaids for more severe pain, intraarticular corticosteroids
101
Rheumatoid arthritis
- more common in women than men
- characterized by gradual onset and remissions and exacerbations of inflammation within the joint
- fingers, wrists, knees, spine
- chronic inflamm that can cause severe joint deformities and loss of function over time
- thought to be an autoimmune disease
102
RA risk factors
- women
- predisposing gene
- exposure to an infection
- advanced age
- smoking over a period of years
103
RA S/S
- malaise/fatigue
- symmetirical pattern of joint inflamm
- pain, stiffness, swelling
- gelling, joints stiff after rest
- elevated sedimentation rate
- presence of serum rheumatoid factor
- elevated WBC in synovial fluid of inflamed joint
- erosion of bone
- pain more prevealanet
- more debilitaiton than with OA
104
RA goals of care
- can avoid permanent joint damage if diagnosis and tx start early
- educate: exercise and mobility, individual PT/OT, independence with ADLs
105
RA diagnosis
- labs: RF, ESR, CRP, ANA titers, anti-cpa
- synovial fluid is straw colored with fibrin flecks and high WBC count
- bone scan can diagnose, not xrays
-
106
RA complications
- joint destruction
- cataracts, vision loss
- ulcerated nodules
- hoarseness
- cardipulmonary effects
- carpal tunnel syndrome
107
RA Nursing care
- prevention is not possible
- refer to arthritis foundation
- help make easy drug regimen
- plan around morning stiffness
- alternate scheduled rest periods with activity
- encourage positions of extension, not flexion
- no pillows under the knees an use only a small pillow under the head and shoulders
- heat cold and exercise
108
gerontologic considerations
- OA is most common type of arthritis in elderly, but consider other types
- lab values may be affected by aging
- be careful with NSAIDs and corticosteroids
109
gouty arthritis
- disease in which acute attacks of arthrits pain occur as a result of elevated levels of serum uric acid
- joint inflamm caused by sodium urate crystals in joint
- most commonly affected joint is great toe
- affected joint becomes hot, reddened, tender
- most common in middle aged men
- risk factors: obesity, HTN, diuretic use, excessive alcohol use, genetics, AA; diet high in purine wont cause gout but can trigger an attack
110
S/S of goutry arthritis
- may occur in 1-3 joints
- joints may be cyanotic, tender
- onset usually at night with sudden swelling and excruciating pain
- may have low grade fever
- tophi
111
diagnosis and treatment of gouty arthritis
- - uric acid >6, may need 24 hour uric acid levels, joint aspiration
- if colchicine works, then diagnostic
- tx: colchine, NSAIDs, prevent future attacks with alloprinol
- avoid alcohol and high purine foods
-
112
nursing care for gouty arthritis
- nutrtion: weight control, limit alchol, limit foods with purine
- nursing: careful jandling to avoid causing pain, bed rest with joint immobilization, elevation doesnt help = pain is due to crystals
113
Lyme Disease
- spriochetal infection caused by borrelia burgdorferi (transmitted by bite of deer tick), no person-to-person transmission
- minics MS, mono, meningitis
- S/S: erythema migran appearing 2-30 days after exposure
- actue viral like symptoms
114
lyme disease diagnosis and treatment
- dx: E lesion , hx of exposure, CBC/ESR are noral
- tx: oral antibiotics, doxycycline can be given to prevent infection within 3 days after tick bite
- prevention: DEET, remove attached ticks with tweezers and pull out, wash with soap and water
115
septic arthritis
- infectious or bacterial arthritis with invasion of the joint cavity with microorganisms (staph aurus)
- usually affects large joints; severe pain, swelling, erythema; fever and chills
- diagnosis by joint aspiration
- tx: antibiotics, may take 2-8 weeks, getnle ROM, local hot compression
116
spondyloarthropathies
- group of interrelated multisystem inflammatory disorders that affect the spine, peripheral joints, and peri-articular structures
- all are negative for RF
- HLA-B27 antigen is strongl assocaited with these
- most common is ankylosing spondylitis, psoriatic arthritis, reactive arthritis
117
ankylosing spondylitis
- primarily affects the SI joints, disc spaces, costovertebral joints
- men are 3-5 times more likely,
118
S/S anylosing spondylitis
- symmetric sacrolitis
- low back pain, and stiffness with limitation of motion worse during the night and in the morn but improvs with mild activity
- chest pain, sternal costal cartilage tenderness
- fixed kyphosis
- can have heart and lung complications
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diagnosis and treatment of ankylosing spondylitis
- xray, Ct scan, mri
- elevated ESR, mild anemia, HLA-B27
- tx: cant prevent, heat, NSAIDS, asa, local corticosteroids, exercise once pain and stiffness are better, postural control, hydrotherapy, surgery for severe deformities
120
nursing care of ankylosing spondylitis
- baseline ROM
- stop smoking
- proper positioning at rest
- firm mattress
- sleep in bac with flat pillow
- avoid heavy lifting, prolonged exercise
121
psoriatic arthritis
- inflammatory skin disorder with red, scaly patches
- 4 forms: small joints of hands/feet, asymmetric extremely joints, symmetric polyarthritis, arthrisits of SI joings and spine
- looks a lot like RA
- elevated ESR, mild anemia, elevated uric acid
- tx: splinting, PT, NSAIDs, DMARDs
- psoriasis of skin, plaques of skin
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reactive arthritis (reiter's syndrome)
- more common in young men
- includes conjuntctiviti, muscotaneous lesions
- caused by GU or GI infections (chylmidia)
- disease develops within 1-2 weeks after infection
- asymmetric involvement of large joints of lower extremeties and toes
- tx: doxycycline, OT
- most pts recover within 2-16 weeks
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systemic lupus erythematosus
- SLE
- multisystem inflammatory autoimune disease n which circulating immune complexes are deposited in organs causing inflammation
- can be genetic, hormonoal (worses with onset of menarche), sun exposure, sunburns, infection; drugs: procainamide, hydralazine, antiseizure
- affects skin, joints, serious membranes, renal, hematologic, neurologic systems
- usually occurs in women of child-bearing age
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S/S systemic lupus erythematosus
- renal: lupus nephritis in 50%
- nervous system: neuropsychiatric symptoms, seizures, anxiety, psychosis, headaches
- hematologic: antibidoies against blood cells
- infection: increase susceptibility, major cause of death esp pneumonia
- dx: no specific test to diagnos, ANA positive
- tx: manage the active phase of the disease while preventing complications of tx that cause long term tissue damage
125
SLE medications
- NSAIDs
- hydroxychloroquine for fatigue and skin/joint problems
- need regular eye exams
- limit corticosteroid use except when severe
- immunosupressants
- anticoagulants for blood clots
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SLE nursing care
- prevention is not possible
- disease is unpredictable, even with regimented meds
- many psychosocial issues to deal with
- avoid sun
127
systemic sclerosis
- fibrotic, degenerative and inflamm changes in skin, blood vessels, synovium, skeletal muscle and internal organs
- 2 types: limited cutaneous disease, diiffuse cutanous
- more common in AA
128
systemic sclerosis patho and etio
- cause is unknown, think autoimmune
- risk factors include occupational exposure to coal, plastics, silica dust
- collagen is overproduced
129
systemic sclerosis: CREST
- calcium deposits
- raynaud's syndrome
- esophageal dysfunction
- sclerodactly - tightening of skin
- telangiectasia - red spots on hands, forearm, palms
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systemic sclerodis: diagnosis treatment
- dx: labs - SCL-70 or anticentromere antibody
- xray to show calcification
- tx: PT, OT, no drugs are affective
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systemic sclerosis nursing care
- prevention is not possible
- no finger stick blood tests
- good oral hygeine, job modifications
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polymyositis and dermatomyositis
- diffues, idiopathic, inflamm myopathies of striated muscle that produce bilateral weaknes
- common in women 45-65
- etio/patho: associated with humoral immunity
- dx: MRI, EMG, muscle bipsy, CK elevated, myoglobin elevated, ESR elevated in active disease
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S/S polymyositis and dermatomyositis
- weight loss, fatigue, weakness
- unable to move muscles against resistenace or gravity
- demal: classic violet colored cyanotic or erythematous symmetric rash with eema around eyelids
- joint redness, pain, inflamm
- weka pharyngeal muscles
- interstitial lung disease
134
treatment and nursing care polymyositis and dermatomyositis
- high dose corticosteroids, if that doesnt work use immunosupressants
- IV immunoglobin for dermatomyositis
- PT, massage
- daily ROM
135
sjorgren's syndrome
- comomon autoimmune disease that targets moisture producing glands causing xerostomia and keratoconjuncitivits sicca
- affects mainly women (90%0 > age 40
- s/s: tearing, gritty sensation in the eyes, burining, blurry vision
- risk of non-hodgkin's lymphoma
- dx: eye exam, salivary gland tests
- tx: symptomatic, artifical tears, increased fluids with meals, good dental hygeine
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soft tissue rheumatic syndromes
- myofacial pain syndrome
- fibromyalgia syndrome
- chronic fatigue syndrome
- need multidisciplinary approach
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myofacial pain syndrome
- chronic muscle pain typically in chest, neck, shoulders, hips, low back
- results from muscle trauma or chornic strained muscles
- deep, aching, burning stinging, stiffness pain
- simialr to fybromyalgia
- dx: palpation of trigger pints with hardness and muscle twitch
- tx: PT, lidocaine, acupuncture
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fibromyalgia syndrome
- chornic, widespread, nonarticular musculoskeletal pain and fatiuge with multiple tender pints, nonrestorative sleep, morning stiffness, IBS, anxiety
- major cause of disability
- patho: recent viral illness or trauma may trigger
- dx: must have pain at 11 tender points and hx of widespread pain for at least 3 months
- S/S: widespread burning pain that worsesn and improves thorughout teh day, 11 tender pints, difficiuly concencentrating depression, IBS, diff swallowing, diffi menstruating
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tx and nursing care fibromylagia
- rest
- motivated pt
- low dose flexeril, SSRIs at high dose
- manage with NSAIDs
- antianxiety meds
- neurontin, lyrica, cymbalta
- nursing care: massage, heat and cold, yoga, limit sugar, caffeine, alcohol, relaxation strategies
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chornic fatigue syndrome
- debillitating fatigue an immune problems
- recover is more common if disease has acute onset
- may be triggered by flu like illness
- dx: need to rule out other disorders
- nursing care: take all complaints seriously, NSAIDs, exercise, well-balanced diet
Med Surge 1
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