2.8 Musculoskeletal Flashcards
Complications of Immobility In SCI-
Musculoskeletal
Musculoskeletal: Joint stiffness, contractures, foot drop Bone demineralization Muscle spasms/atrophy Joint contractures Osteoporosis
Complications of Immobility In SCI-
Respiratory
Respiratory:
Risk for pneumonia
Decreased chest expansion
Decreased cough reflex
Complications of Immobility In SCI-
Cardiovascular
Cardiovascular:
Orthostatic hypotension
DVT
Decreased venous return
Complications of Immobility In SCI-
Genitourinary
Genitourinary: Urine retention/incontinence Impotence Inability to ejaculate Decreased vaginal lubrication
Complications of Immobility In SCI-
Gastrointestinal
Gastrointestinal:
Stool incontinence
Constipation/paralytic ileus
Stress related ulcers
Complications of Immobility In SCI-
Integumentary
Integumentary:
Pressure ulcers
Spinal Cord Injury (SCI)Causes
MVA Falls Violence Other/unknown Sports related accidents
What Happens in SCI?
Injury occurs to either:
Vertebrae & ligaments
Blood vessels
Damage to vertebrae ligaments, blood vessels makes spinal cord unstable increasing possibility of compression or stretching of cord with further movement.
Rarely is spinal cord completely severed.
SCI
Primary?
Primary injury to the spinal cord
The initial mechanical disruption of axons.
SCI
Secondary
Secondary injury to the spinal cord
The ongoing, progressive damage that occurs to spinal cord neurons from:
Further swelling
Demyelination
Necrosis
Edema extends level of injury 2 cord segment levels above and below. Extent of injury cannot be determined for up to one week.
Paralysis
Paralysis
Partial or complete loss of muscle function
Complete SCI
Complete SCI:
Complete interruption of motor & sensory pathways
Results in total loss of motor & sensory function below level of injury
Incomplete SCI
Incomplete SCI:
Partial interruption of motor & sensory pathways
Variable loss of function below the level of injury
Paresis
Paresis
Partial paralysis/weakness.
What is Upper Motor Neurons responsible for?
Upper Motor Neurons
Responsible for voluntary movement.
Upper Motor Neurons
Injury leads to?
Injury leads to: Increased muscle tone/ spastic paralysis Decreased muscle strength Inability to carry out skilled movement Hyperactive reflexes.
What are the Lower Motor Neuron responsible for?
Lower Motor Neuron Responsible for innervation and contraction of skeletal muscles.
Lower Motor Neuron
Injury leads to?
Injury leads to:
Decreased muscle tone
Muscle atrophy/ flaccidity/weakness
Loss of reflexes.
Loss of voluntary & involuntary movements.
Partial to full paralysis depending on how many motor neurons affected.
Some or All motor neurons effected, what happens?
If only some of the motor neurons supplying a muscle are affected only partial paralysis is experienced.
If all motor neurons to the muscle affected= complete paralysis and hyporeflexia.
Paraplegia
Damage to thoracic, lumbar or sacral area of the cord.
Loss or impairment of motor and /or sensory function the trunk, legs, and pelvic organs.
Arms are spared
T6 level injury= use of arms & upper chest
L1 level injury use of all but legs.
Full independence in self care in w/c.
Sacral Sparing
Some incomplete SCI patients experience this phenomenon where sensation is preserved in sacrum. Positive finding!
Patients with sacral sparing, then, may have fewer problems with bowel functioning and elimination than those with a complete injury.
Sacral Sparing
results in?
Results in: Bowel & bladder training possible Perianal sensation Rectal function Highest possibility of sexual function
Sacral Sparing
Bowel training with sacral sparing
Bowel training: Digital stimulation, stool softeners, suppositories High fiber high fluid diet Upright position Assess usual patterns
Sacral Sparing
Bowel training without sacral sparing
Bowel Maintenance without Sacral sparing:
Digital removal, enemas
Abd. massage to stimulate peristalsis.
Sacral Sparing
Teaching
Teach:
Home self cath=clean technique
Voiding triggers:
Stroke inner thigh
Pull on pubic hair
Tap on abdomen
Pour H20 over vulva
Crede, manual pressure on the abdomen at the location of the bladder, just below the navel.
Monitor residual urine <80 ml ok
Highest level of sexual function in sacral sparing patients.
Most people with SCI can have satisfying sexual relationship regardless of the level of injury
Tetraplegia
Tetraplegia
(Quadriplegia). Cervical damage causing loss or impairment of motor and/or sensory function in the arms, trunk legs and pelvic organs.
Tetraplegia
C1-C4
C1-C4 injury C1-C2 injuries could result in death Often fatal at scene Respiratory paralysis common Require ventilator assistance. Head and neck movement only Require 24 hour care. Cannot live independently May use an electric wheel chair with mouth stick, and head rest.
Tetraplegia
Below C4 and C6
Below C4
May not be ventilator dependent
C6
Shoulder movement
IM Injections in SCI
I.M. injections should be given above the level of injury.
Clients with spinal cord injuries have reduced use and reduced blood flow to muscles (ventral gluteal) and legs (vastus lateralis).
IM Injections in SCI
decreased blood flow to muscle?
Decreased blood flow to muscle can result in:
Impaired drug absorption
Increased risk of local irritation and trauma
May result in ulceration of the tissue.
Autonomic Dysreflexia
what is it?
What is it?
Exaggerated sympathetic response in SCI patient’s at or above T6 level injuries.
Triggered by stimuli that normally causes abdominal pain.
Autonomic Dysreflexia
Pathophysiology
Pathophysiology:
Stimuli is unable to ascend the cord.
Causes stimulation of sympathetic nerves below level of injured cord resulting in massive vasoconstriction.
Vagus nerve causes bradycardia & vasodilation above level of injury.
Autonomic Dysreflexia
triggers?
Triggers: Full bladder (most common) Fecal impaction Pressure ulcers Dressing changes Ingrown toenails Surgical procedures Labor contractions
Autonomic Dysreflexia
S/S
Signs & Symptoms:
Pounding HA
Bradycardia & HTN (high as 240/120 risk of CVA)
Vasodilation with warm flushed skin & profuse sweating above level of injury.
Pale, cold (gooseflesh), dry skin below level of injury
Neurologic Emergency!!!!!
Autonomic Dysreflexia NI
1st Raise HOB/ sit patient up!!!
Identify cause (full bladder, bowel?)
Remove stockings or boots to decrease b/p.
Best intervention is through prevention.
May be hypotensive after stimulus removed.
**Bladder and bowel are most frequent causes of AD.
Complications of extremely high blood pressure
Complications of extremely high blood pressure: Loss of consciousness Seizures Death Stroke
Halo Traction
External fixation device
Used to provide stabilization if no significant involvement of ligaments.
Stability for fracture of the cervical and high thoracic vertebrae without cord damage.
4 pins inserted into the skull & ring attached to plastic vest.
Halo Traction
Pro’s
Pro’s
Greater mobility
Self-care
Participation in rehab programs
Halo
Nursing Interventions
Inspect pin & traction sites for looseness.
Never use halo ring to reposition patient.
Assess sensation
Pin care per agency policy.
Turn immobile patients q 2 h
Tape wrenches to HOB for emergency intervention.
Straws for drinking, cut food small pieces
Monitor fatigue and balance
Assess skin under vest
Do not drive
Amputations defined
Definition:
Partial or total removal of an extremity.
Amputations causes?
Causes:
PVD- primary reason
PVD risk factors: smoking, DM, HTN, hyperlipidemia.
Peripheral neuropathy (loss of sensation leads to injury)
Untreated infections.
Trauma (MVA, machinery accidents).
Amputations
post-op complications
Post-op Complications: Infections Hemorrhage Delayed healing Phantom limb pain Contractures
Amputations NI
Nursing Interventions:
Keep incision clean & dry
Maintain stump dressings to decrease edema. Replace if comes off
Medicate for pain including phantom limb pain. Teach: common to have phantom pain.
AKA (above the knee) patients avoid prolonged sitting (increased risk contractures).
BKA (below the knee) elevate stump keeping joint extended.
Amputations nursing care goals
Nursing care goals:
Relieve pain
Promote healing
Prevent complications
Support the patient and family with grieving and adaptation to body image and restore mobility.
Bone Tumors
Benign
Benign bone tumors:
More common
Grow slowly
Do not often destroy surrounding tissues (symmetrical)
Bone Tumors
Malignant
Malignant bone tumors.
Primary: rare <0.2% of all adult cancers.
Secondary: more common (primary lung, prostate, breast cancers)
Grow rapidly (invade surrounding tissues and blood supply)
Metastasize
Bone Tumors
3 main symptoms
1. Pain Develops slowly Lasts > week Constant or intermittent May be worse at night 2. Mass Firm swelling or lump on the bone Slightly tender Palpable 3. Impaired function May interfere with normal movement and/or cause a fracture.
Osteoporosis
what is it
Porous bones/ Loss of bone mass
Osteoporosis
non-modifiable
Non-modifiable risk factors Older age Family history of osteoporosis Female (Caucasian or Asian) Thin and/or having a small frame. **Weight bearing exercises like walking, running increases blood flow to bones therefore bringing growth-producing nutrients to the cells
Osteoporosis
Modifiable
Modifiable risk factors
Low estrogen
Low testosterone
Low lifetime calcium intake, Vit. D deficiency
Medications: corticosteroids, some anticonvulsants
Lifestyle: inactivity, cigarette smoking, excess alcohol use.
Osteoporosis and smoking
Smoking lowers estrogen levels in both men and women. Estrogen is important because it helps the bones to hold calcium and other minerals that make them strong. At menopause, a woman’s body makes much less estrogen, and this puts her naturally at risk for osteoporosis. Smoking increases her risk even more.
Osteoporosis and steroid use
Steroidmedications have major effects on the metabolism of calcium, vitamin D and bone. This can lead to bone loss,osteoporosis, and broken bones. Inhaled steroidsare less likely to cause bone loss thansteroidstaken by mouth. However, in higher doses, inhaledsteroidsmay also cause bone loss.
Osteoporosis
complications
Complications
Fractures: spontaneous & everyday activities.
Hip and vertebral fractures increase risk of death and disability.
Osteoporosis
diagnosis
Diagnosis
Bone mineral density test (BMD) estimate skeletal mass or density.
Duel-energy x-ray absorptiometry (DXA) Highly accurate. Measures bone density of spine or hip.
Osteoporosis
Treatment Goals
Treatment Goals Early identification of risk Stop or slow the process Alleviate symptoms Exercise
Osteoporosis
medications
Treatment: Calcium Vitamin D Bisphosphonates (Fosamax, Boniva) Estrogen replacement Calcitonin (hormone that increases bone formation)
Inflammatory Conditions
Bursitis
Bursitis
Inflammation of a bursa (fluid sac acts as gliding surface)
Shoulder, elbow and hip most common, also occurs in knee, heel and the base of big toe
Pain and decreased ROM.
Inflammatory Conditions
Tendonitis
Tendonitis
Inflammation of a tendon
Tendonitis is most often caused by repetitive, minor impact, or acute injury (shoveling, skiing)
Pain and tenderness
Synovial fluid what is it?
Synovial fluid: Fluid in joints that lubricates the joint to reduce friction between cartilage of synovial joints during movement.
Inflammatory Conditions
Myositis
Myositis
Inflammation of a muscle.
Injury, infection, or autoimmune causes.
S/S: fatigue after activity, tripping or falling, difficulty swallowing or breathing.
Inflammatory Conditions
Myositis treatment
Treatment:
Rest, cold, anti-inflammatory meds
Inflammatory Conditions
Synovitis
Synovitis
Inflammation of the synovial membrane of a joint.
Common with knee injury.
Swelling, decreased mobility, pain, effusion in joint.
Inflammatory Conditions
Synovitis treatment
Treatment
Synovectomy (reduces inflammation)
Rest, ice
Osteomyelitis what is it?
Infection of the bone. Can be acute or chronic
Osteomyelitis
risk factors
Risk Factors:
Older adult (decreased immune system & more chronic illnesses)
Hemodialysis & IV drug users
Joint replacement & fracture stabilizing hardware
Osteomyelitis
causes
Causes: Penetrating wound Bacteremia Skin breakdown with vascular insufficiency Usually by Staph Aureus
Osteomyelitis
Symptoms
Symptoms:
Local: swelling, redness, warmth, pain.
Systemic: fever, malaise, tachycardia, anorexia.
What is ESR= erythrocyte sedimentation rate
ESR= erythrocyte sedimentation rate: detects inflammation associated with infections and autoimmune diseases.
Osteomyelitis
Diagnosis
Diagnosis
Bone scan, ultrasound, MRI
Blood tests: ESR & WBC elevated
Blood and tissue cultures, biopsy
Osteomyelitis
Treatment
Treatment IV Antibiotics (4-6 weeks) Oral Cipro for chronic Surgery Debridement is primary treatment with chronic osteomyelitis
Osteoarthritis (OA) aka Degenerative Joint Disease (DJD)
risk factors
Most common form of arthritis Leading cause of pain and disability in older adults. Risk factors Increasing age Genetics Obesity (knee and hip) Inactivity Repetitive joint use.
Osteoarthritis (OA) aka Degenerative Joint Disease (DJD)
Pathology
Pathology
Progressive loss of joint cartilage causing increased friction in joint = pain, stiffness, loss of joint motion and gait disturbances. Bone-on-Bone over time
**Develops in hand, neck, low back, hip, knee.
Osteoarthritis
Symptoms
Symptoms Onset is gradual and slow progression. Pain (deep ache) and stiffness Pain may be relieved by rest Joint stiffness after long periods of rest. Few min of activity relieve stiffness ROM of joint decreased Grating sound or crepitus with movement. Herberden’s nodes on distal phalangeal joints
Osteoarthritis
Diagnosis
Diagnosis:
Patient history
Physical exam
X-ray of joints
Osteoarthritis
Treatment goals
Treatment goals
Control pain
Improve or maintain joint function and mobility
Reduce or prevent physical disability
Osteoarthritis- Treatments
Mild analgesics: Tylenol for long term use ok less side effects.
NSAIDS: reduce inflammation not for long term use.
COX-2 inhibitors (Celebrex) Less GI risk good for intolerant to NSAIDS.
Topical Creams: Less systemic adverse effects proven to help (Capsaicin, Biofreeze).
Rest, Exercise (especially H2O exercises)
Steroid/ Lidocaine injections
Surgery (arthroplasty hips/ knees/ shoulders)
Assistive Devices (braces, canes, walkers)
Weight loss
Gout what is it?
Acute inflammatory arthritis caused by excess amount of uric acid in the blood. Occurs in stages.
Uric acid is product of purine metabolism is excreted in kidneys.
Deposits urates into the joints causing crystallization. Crystals stimulate and continue inflammatory process.
Acute Gout
Acute Gout:
Inflammation of joint usually great toe (also fingers, wrists, knees, elbows, ankles)
Pain wakes you up at night.
Joint hot, swollen, & very tender, Fever
Last hours to days
Elevated uric acid >8.5, WBC, & Sedimentation Rate
Gout
Advanced Gout
Advanced Gout:
Occurs when hyperuricemia not treated.
Urate deposits called Tophi seen most common in helix of ear, tendons of fingers, tissues surrounding joints (elbows & knees).
Gout
Advanced Gout
Complications
Complications:
Kidney stones from urate can lead to kidney failure.
Tophi may develop in tissue of heart & spinal epidural compressing nerves.
Gout- Treatment Prophylactic
Prophylactic Colchicine Allopurinol (Zyloprim): lowers urate levels & mobilizes tophi. Dietary & lifestyle modifications. Avoid high purine foods such as: Beer / grain liquors Red meat, organ meats Spinach, asparagus, cauliflower Seafood especially shellfish.
Gout- Treatment
Acute Treatment
Acute Treatment
NSAIDS = reduce swelling
Colchicine= stops urate crystal deposits in joint.
Steroids
Gout NI
Nursing Interventions:
Medicate for Pain relief during acute attack.
Diet low in purine (avoid organ meats, sardines, shellfish, alcohol, drinks sweetened with high fructose corn syrup)
Rest, ice, elevation
Teach uric acid levels should decrease with proper treatment
Protect joint from pressure.
Increase fluids. Desired output of 2000ml/day (promotes urate excretion & reduce risk of kidney stone formation)
Auto-Immune
Systemic Lupus Erythematosus (SLE) what is it?
What is it?
Chronic inflammatory disease that occurs when your body’s immune system attacks your own tissues and organs.
Inflammation can affect many different body systems — including joints, skin, kidneys, blood cells, brain, heart and lungs.
Auto-Immune
Systemic Lupus Erythematosus (SLE)
Risk factors
Risk factors: Women 10:1 ratio to men. Family history Environmental (viruses EBV). Women who use estrogen contraceptives or HRT. (hormone replacement therapy)
Auto-Immune
Systemic Lupus Erythematosus (SLE)
Pathophysiology
Pathophysiology:
Autoantibodies produced= target specific tissues= inflammatory response= destructive enzymes produced causing tissue damage.
Causes multisystem effects on body
Auto-Immune
Systemic Lupus
Clinical Manifestations
Clinical Manifestations:
Extreme fatigue
Unexplained fever
Swollen joints & muscle pain (mimics RA)
Red butterfly rash across the cheeks and bridge of nose(most specific sign indicative of lupus)
Photosensitivity (rash with skin exposure) Avoid the sun. UV light can trigger acute onset of symptoms. Rashes interrupt skin integrity & increase infection risks.
Complications: Renal failure & stroke
Lupus Treatments MILD
Mild: little to no treatment except supportive care Tylenol, NSAIDs, aspirin.
Skin & arthritic manifestations: hydroxychloroquine (Plaquenil). Effective in reducing frequency of acute episodes. Retinal toxicity & blindness side effects! Eye exam every 6 months.
Lupus Treatments SEVERE
Severe SLE: high dose corticosteroids to manage symptoms & prevent organ damage. May need steroids long term.
NI: monitor steroid side effects: HTN, wt gain, infections, osteoporosis, moon face, hypokalemia.
Lupus Treatments
Immunosuppressive
Immunosuppressive Meds: Monitor infections, labs, kidney & liver function.
Lupus labs
Monitor labs: WBC, ESR, Platelet, Liver function, Kidney function,
Polymyositis what is it?
Autoimmune systemic connective tissue disorder causing inflammation of connective tissue & muscle fibers.
Polymyositis risk factors
Risk Factors:
Unknown cause.
Women > men
Polymyositis Manifestations
Manifestations:
Skeletal muscle weakness is the main symptom. Pelvic & neck muscles particularly
Muscle pain & tenderness
Weakness progresses over weeks to months.
Dusky red rash on face and upper trunk.
Polymyositis
Diagnosis
Diagnosis
No specific test for diagnosis
Creatine kinase (CK) elevated (25-170 normal ranges)
Polymyositis Treatment
Treatment
Rest
Corticosteroids
Immunosuppressive agents if no response from steroids.
Polymyositis
NI
Nursing Interventions
Monitor for aspiration with feeding
Assist with ADLs, promote comfort & independence
Communication alternatives if speech involved.
Family trained in Heimlich and CPR
Rheumatoid Arthritis(RA) what is it?
what is it?
Chronic systemic autoimmune disease causing inflammation of connective tissue primarily in joints.
Cause unknown
Rheumatoid Arthritis(RA) Risk factors
Risk factors Thought to be genetic Emotional stress can cause flare ups. Women 3:1 to men Heavy Smoking Speculated that infectious agent such as a virus plays role in initiating abnormal immune response.
Rheumatoid Arthritis(RA) Clinical Manifestations
Clinical Manifestations
Joint swelling, stiffness, tenderness, warmth. Stiffness > in AM >1 hour ROM limited in affected joint. Deformity of joints. Joints feel sponge-like on palpation.
Rheumatoid Arthritis(RA) Diagnostic Tests
Diagnostic Tests
Elevated c-reactive protein & ESR. Anti-CPA blood test more specific marker for RA.
Synovial fluid from joint cloudy.
X-rays of joints most specific test for RA.
Rheumatoid Arthritis(RA) Treatment Goals
Treatment Goals
No Cure. Relieve pain Reduce inflammation Slow or stop joint damage Improve well-being & function.
Rheumatoid Arthritis(RA) Meds
Meds
NSAIDS & Steroids : reduce inflammation & pain
Disease Modifying Anti-Rheumatic Drugs:
Slows bone erosion
Improves ROM
Monitor for blood dyscrasias (nonspecific term that refers to a disease or disorder, especially of the blood)
DMARD’s (Disease-modifying anti-rheumatic drugs) Methotrexate Remicade Rituxcan Humira
Rheumatoid Arthritis(RA) rest and exercise
Important to balance rest & exercise with RA. Short period of bed rest in acute period.
Balanced program of rest and exercise critical to maintain muscle strength and joint mobility.
Rheumatoid Arthritis(RA) Labs
Labs:
Monitor for WBC, platelets, neutrophils during DMARDs (Disease-modifying anti-rheumatic drugs) therapy r/t possibility for blood dyscrasias (nonspecific term that refers to a disease or disorder, especially of the blood)
Rheumatoid Arthritis(RA) Surgery
Surgery
Synovectomy (synovial membrane) to relieve pain and reduce inflammation.
Arthrodesis (joint fusion) to stabilize joints wrists, ankles& cervical)
Arthroplasty (total joint replacement) improved mobility, decrease pain.
Osteotomy (cut bone) to change alignment or correct deformity.
Rheumatoid Arthritis(RA) other treatments
Other PT and OT Heat and cold Assistive devices and splints Nutrition (well-balanced with Omega 3)
