Exam 4: Chapter 41 - Management of Patients with Musculoskeletal Disorders Flashcards
Osteoporosis is the most prevalent
bone disease in the world; more than 1.5 million osteoporotic fractures occur each year
What is Osteopenia?
Low bone mineral density (BMD)
Osteoporosis: Normal homeostatic bone turnover altered, causing
the rate of resorption is greater than the rate of bone formation, resulting in loss of total bone mass.
What happens to bone is Osteoporosis?
Bone becomes porous, brittle, and fragile and breaks easily under stress.
Osteoporosis: Frequency results in
compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and Colles’ fractures of the wrist
Primary Osteoporosis occurs in
women after menopause and in men later in life
Failure to develop what leads to the development of osteopenia without associated bone loss?
Failure to develop optimal peak bone mass and low vitamin D levels
Inverventions to decrease the risk of fractures?
Early Identification of At-Risk Teenagers
Increased Calcium and Vitamin D intake
Regular Exercise
Modification in Lifestyle
Secondary osteoporosis is the result of
medications or diseases that affect bone metabolism
What medications can cause an increased risk for Osteoporosis?
Anticonvulsants (Phenytonin)
Thyroid Replacement Agents (Levothyroxine)
Antiestrogens (Medroxyprogesterone)
Androgen Inhibitors (Leuprolide)
PPI (Esomeprazole)
Prevelance of Osteoporosis in women older than 80 years old is
50%
Osteoporosis looks like ?
Swiss cheese. There is a lot of holes in the bone.
Doral Kyphosis is when they
hunch over
Cervical Lordosis is when
the back twists like the letter “s”
How often should someone try to get sunshine every week?
5-30 Minutes
Where is Vitamin D stored? And why don’t we need it everyday?
It is stored in fat, and stores a large amount
Vitamin D helps with the absorption of ?
Calcium
Osteoporosis is characterized by
Reduced bone mass, deterioration of boen matrix, and diminished boen architercutural strength
Bone turnover in Osteoporosis?
The rate of bone resorption by osteoclasts is greater than rate of bone formation by osteoblasts
Osteoporosis occurs most commonly as
compression fractures of the thoracic and lumbar spine, hip fractures, and Colles fracture of the wrist
What does Calcitonin do?
Inhibits bone resorption and promotes bone formation
What decreases with aging?
Calcitonin and Estrogen, which inhibits bone breakdown
What increases with aging?
Parathyroid Hormone increases with aging, thus increasing bone turnover and resorption. Consequence is net loss of bone mass over tim e
What surgery leaves people at an increased risk for Osteoporosis?
Bariatric surgery, because the duodenum is bypassed which is the primary site for absorption of calcium
What is most beneficial for developing and maintaining bone mass?
Resistance and impact exercises
Acronym to remember risk factors for Osteoporosis
“ACCESS”
Risk Factors: (A)CCESS
Alcohol Use
Risk Factors: A(C)CESS
Corticosteroid Use: Leach the calcium out of bone
Risk Factors: AC(C)ESS
Calcium Low/Low Vitamin D
Risk Factors: ACC(E)SS
Estrogen Low
Risk Factors: ACCE(S)S
Smoking
Risk Factors: ACCES(S)
Sedentary Lifestyle
If they are not walking to break down to rebuild the bone, they are at risk for osteoporosis
Nutrition Risk Factors for osteoporosis?
Low Calcium Intake
Low Vitamin D intake
High Phosphate Intake (Carbonated Beverages)
Inadequate Calories
osteoporosis diagnosed by
Dual Energy X-Ray Absorptiometry (DEXA), provides information about BMD at the Spine and Hip
DEXA scan data are analyzed and reported as
T-Scores (Number of SD’s above or below the average BMD value for a 30 year old healthy woman)
Baseline DEXA testing recommended for
all women older than 65 years old
Women who are postmenopausal older than 50 years
All people who have had a fracture occur bc of osteoporosis
BMD studies are also useful in assesing
response to therapy and are recommended 3 months post any osteoporotic fracture
Laboratory studies to test for osteoporosis
Serum Calcium/Phosphate/Alkaline Phosphate
Urine Calcium Excretion
Urinary Hydroxproline Excretion
hematrocrit
Erythrocyte Sedimentation Rate
X Ray STudies
Diet Education for osteoporosis
Increase Calcium and Decrease CAffeine
Education for osteoporosis
Exercise
Fall Prevention
Foods high in Calcium?
Cheese and Other Dairy Products
Steamed Broccoli
Canned Salmon with Bones
Recommended adequate intake level of Calcium for men 50-70 years in ____ and for men 71 and older is _____
1000 mg daily
1200 mg daily
Recommended Vitamin D Intake For Those Under 70?
For Those Over 70?
600 IU Daily
800 IU Daily
Exercise recommendation to prevent osteoporosis?
Regular Weight-Bearing Exercise
Need 20-30 Minutes of Aerobic, Bone-Stressing Exercise Daily
What Pharmacologic Method may be given to ensure adequate calcium intake?
A calcium supplement with Vitamin D may be prescribed and taken with meals or with a beverage high in Vitamin C to promote absorption
Common side effects of Calcium supplements?
Abdominal Distention and Constipation
What drugs could be given as a supplement to Vitamin D and Calcium to treat osteoporosis?
Bisphosphonates
Estogen Agonist/Antagonists
Receptor Activator of Nuclear Factor Kappa-B Ligand (RANKL ) Inhibitors
Osteoporotic compression fractures of the vertebrae are managed
conservatively
Osteoporosis: Health History focuses on
Family History, Previous Fractures, Dietary Consumption of Calcium, Exercise Patterns, Onset of Menopause, and Use of Certain Medications
Osteoporosis: What are some nursing diagnoses that may be assigned?
Deficient Knowledge about osteoporotic process and treatment regimen
Acute pain RT fracture and muscle spasm
Risk for Constipation RT immobility
Risk of injury
Relief of back pain resulting from compression fracture may be accomplished by
short periods of resting in bed in a supine or side-lying position
What measure could be performed to increase comort?
Knee flexion increases comfort by relaxing back muscles
What promotes muscle relaxation?
Intermittent local heat and backrubs
Nurse instructs the patient to move the trunk as a
unit and to avoid twisting
Constipationis a problem RT
immobility and medications
What can be done early to relieve constipation?
Early institution of a high-fiber diet, increased fluids, and the use of prescribed stool softeners help prevent or minimize constipation
If the vertebral collapse involves the T10-L2 vertebrae, the patietn may develop
paralytic ileus
Osteomalacia is
a metabolic bone disease characterized by inadequate mineralization of bone
Result of osteomalacia?
Skeleton softens and weakens, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures
Major defect is osteomalacia is a
deficiency of activated Vitamin D, which promotes clacium absorption from the gastrointestinal tract and facilitates minerization of bone
Osteomalacia may result from
failced calcium absorption or from excessive loss of calcium from the body (kidney failure)
GI Disorders that cause Osteomalacia?
Caliac Disease, Chronic Biliary Tract Obstruction, Chronic Pancreatitis, Small Bowel REsection
Severe renal insufficiency results in
acidosis
To combat acidosis, what does the body do?
Body uses available calcium and PTHstimulates release of skeletal calcium in an attempt to reestablish a physiologic pH. Skeletal calcium is drained.
Osteomyelitis is
an infection of the bone that results in inflammation, necrosis, and formation of new bone
Osteomyelitis can be classified as
Hematogenous Osteomyelitis
Contiguous-Focus Osteomyelitis
Osteomyelitis with Vascular Insufficiency
What is Hemaogenous Osteomyelitis
Due to bloodborne spread of infection
What is Contiguous-Focus Osteomyelitis
From contamination from boen surgery, open fracture, or traumatic injury (gunshot wound)
What is Osteomyelitis with Vascular Insufficiency
Seen most commonly in patients with diabetes and peripheral vascular disease, most commonly affecting feet
Patients who are at high risk for Osteomyelitis
Older Adults who are Poorly Nourished or Obese
Those with Impaired Immune System
Those with Chronic Illnesses
Those receiving long-term corticosteroid therapy or immunosuppressive agents
Postoperative surgical wound infections typically occur within
30 days after surgery
Postoperative Surgical Wound Infections classified as
incisional (superifical, located above the deep fascia layer) or deep (involving tissue beneath the deep fascia)
If an implant has been used, infections for Osteomyelitis may occur within
a year
Osteomyelitis occurs when
bacteria grows in the bone
Treatment for Osteomyelitis
Antibiotics.
How do you test to see what Antibiotic will work for Osteomyelitis?
Surgery. A portion of the boen is removed and tested. Different antibiotics are tested to see what will kill it.
More than 50% of boen infections are caused by
Staphyloccus Aureus (S. Aureus) and incresingly Methicillin-Resistant S. Aureus (MRSA)
Surgical Site Ink Markers have been linked to
infections by cross contamination between preoperative patients who use their mrkers
Other pathogens that cause bone infections?
Gram-Positive Organisms Streptococci and Enterococci
Gram NegativePseudomonas
Initial response to infection is
inflammation, increased vasculatirty, and edema
2-3 days after bone infection..
thrombosis of the local blood vesels occurs resulting in ischemia with bone necrosis
2-3 days after bone infection, it extends into
the medullary cavity and under the periosteum and may spread into adjacent soft tisseus and joints
IF the bone infection is not treated promptly, what occurs?
Bone abscess forms
The abscess cavity contains
sequestrum (dead bone tissue) which does not easily liquefy and drain. This means the cavity cannot collapse and heal.
What surrounds the sequestrum?
New bone growth, the involucrum forms and surrounds it
Why is Involucrum problematic?
Athough healing appears to take place, a chronically infected sequestrum remains and produces recurring abscesses through the patients life. This is referred to as chronic Osteomyelitis
When the infection is bloodborne, the onset is usually
sudden, often occuring with the clinical and laboratory manifestations of sepsis (chills, high fever, rapid pulse, general malaise)
The sysemic symptoms at may may overshadow the
local signs
AS the infection extendss through the cortext of the bone, it involves
the periosteum and the soft tisseus
The infected area becomes
painful, swollen and extremely tender
With a bone infection, the patient may describe
a constant, pulsating pain that intensifies with movement as a result of the presure of the collecting purulent material
When Osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no
manifestations of sepsis
The surface area that lies over the infected bone is
wollen, warm, painful, and tender to touch
The patient with chronic osteomyelitis presents with a
nonhealing ulcer that overlies the infected bone with a connecting sinus that will intermittently and spontaneously drain pus
Diabetic osteomyelitis can occur without
any external wounds
With those who are diabetic, micro and macrovascular pathophysiologic changes can
exacerbate the spread of infection from other sources
In acute Osteomyelitis, early X-ray findings demonstrate
soft tissue edema
2-3 Weeks after bone infection, what is evident?
Areas of Periosteal Elevation and Bone Necrosis
What helps with early definitive diagnosis?
Radioisotope Bone Scans and MRI and Bone Scan
Blood Studies for Bone Infection reveal
leukocytosis and an elevated ESR
With chronic osteomyelitis, what is seen on a X-Ray
Large, Irregular CAvities, Raised Periosteum, Sequestra, or DEnse Bone Formation
In Chronic Osteomyelitis, ESR and WBC are?
normal. Anemia may be present however.
Osteomyelitis Prevention: Surgery should be postponed if
The patient has a current infection (UTI, Sore Throat)
What Antibiotic is gen to achieve adequate tissue levels?
Prophylactic Antibiotics. Given to achieve adequate tissuee levels at the time of surgery and for 24 hours after surgery
The initial goal of therapy is to
control and halt the infective process. Hydration, Diet high in Vitamins and PRotein, and Correction of Anemia are instituted.
Area affected with osteomyelitis is immobilized to
decrease discomfort and to prevent pathologic fracture of the weakened bone
Signs and Symptoms of Bone Infection include
localized pain, edema, erythema, fever, drainage
With chronic Osteomyelitis, fever may be
low grade and occur in the afternoon or evening
If the infection is chronic and does not respond to antibiotic therapy, what is recommended?
Surgical debridement is indicated
What occurs during surgery for someone with Bone Infection?
Infected Bone Exposed
Purulent and Necrotic Material Removed
Area Irrigated With Sterile Saline
This is a Sequestrectomy
What is a Sequestrectomy?
Removal of enough involucrum to enable the surgeon to remove the sequestrum
Debrided cavity may be packed with
cancellous bone graft to stimulate healing
In Osteomyelitis, patient resports an acute onset of
localized pain, edema, erythema, fever, or recurrent drainage of an infected sinus with associated pain, edema, and low-grade fever
Risk factors for someone with Osteomyelitis
Older Age
Diabetes
Long-Term Corticosteroid Therapy
History of previous injury, infection, or orthopedic surgery
Physical Examination in Osteomyelitis reveals
an inflamed, markedly edematous warm area that is tender. Purulent drainage may be noted. With Elevated Temperature
Temperature with someone with chronic Osteomyelitis
temperature elevation may be minimal, occuring in the afternoon or evening
Nursing Diagnosis for Osteomyelitis
Acute Pain RT Inflammation and Edema
Impaired Physical Mobility RT Pain
Risk for Infection: Bone Abscess Formation
Deficient Knowledge RT Treatmetn REgimen
Patients goals for Osteomyelitis
Relief of Pain, Improved Physical Mobility Within Therapeutic Limitations, Control and Eradication of Infection, Knowledge of treatment knowledge
Relieving Pain Osteomyelitis: Affected Part may be
immobilzied with a splint to decrease pain and muscle spasm. Nurse monitors skin and neurovascular status.
RElieving Pain Osteomyelitis: Elevation reduces
swelling and associated discocmfort. Pain is controlled with prescribed analgesic agents and other pain-reducing techniques
Improving Physical Mobility: Osteomyelitis - Treatment regimens restrict
weight-bearing activity. Bone is weakened by the infective process and must be protected by avoidance of stress on the bone.
Improving Physical Mobility in Osteomyelitis: Jones above and below affected part should be
gently momved through their range of motion.
Controlling the infectious Process in Osteomyelitis: Nurse monitors the
paitents response to antibiotic therapy and observes the IV access site for evidence of phlebitis, infection, or infilitration
Controlling the infectious Process in Osteomyelitis: With long-term intestive antibiotic therapy, nurse monitors the patient for signs of
superinfection (oral or vaginal candidiasis, loose or foul smeeling stools). And monitors for development of additional sites that are painful or suddent increases in body temperature
If surgery is necessary, nurse takes measures to ensure
adequate circulation to the affected area (wound suction to prevent fuluid accumulation, elevation of the area to promote venous drainage, avoidance of pressure on the grafted area,) to maintain needed immobility and to ensure patietns adherence to weight-bearing exercies
