Exam 6 (Musc/connective) Flashcards
What is the most important factor in development of osteomalacia?
Vitamin D deficiency
What is osteomalacia?
Osteomalacia is loss of bone related to vitamin D deficiency. Because of softening of the bone resulting from inadequate deposits of calcium and phosphorus in the bone matrix. Normal remodeling of the bone is disrupted, and calcification does not occur. Osteomalacia is the adult equivalent of rickets, or vitamin D deficiency, and children.
Osteomalacia versus osteoporosis
Osteomalacia
Demineralized bone mass
Lack of vitamin D
Calcium & phosphate levels are low or normal
Parathyroid & Alkaline levels are high
Osteoporosis
Decreased bone mass
Lack of calcium
Calcium levels may be low but all other levels are normal
True or false
Osteomalacia is not common in the United States and Western Europe. However it is more common in countries where famine is common
True
What are some causes of osteomalacia?
- Vitamin D deficiency
- Kidney disease
- Familial metabolic error (hypophosphatemia )
What are some symptoms of osteomalacia?
In some cases, proximal muscle weakness in the shoulder and pelvic girdle area is the only presenting symptoms.
What is Paget’s disease?
It’s a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized causing dogs to be weak with increased risk for Boeing of long bones and fractures. Two types of Paget’s disease can occur familial and sporadic
True or false
Paget’s disease is second only to osteoporosis is one of the most common bone diseases in the United States
True
What is the most dreaded complication of Paget’s disease?
Cancer, most commonly osteogenic sarcoma
What is the most common type of osteomyelitis?
Hematogenous osteomyelitis is the most common type of osteomyelitis. It occurs more often children
What is osteomyelitis?
Bone infection
What is dupuytrens contracture?
Slowly progressive thickening of the Palmer fascia, resulting in flexion contracture of the fourth and fifth fingers of the hand
What is a ganglion?
Around, benign cyst, often found on the wrist or foot joint or tendon
What is the hallux valgus?
The hallex Vegas deformity is a common foot problem in which the great toe drifts laterally at the first metatarsal joint. The first metatarsal head becomes enlarged, resulting in a bunion.
What is planter fasciitis?
An inflammation of the planter fascia, which is located in the area of the arch of the foot.
What is scoliosis?
When the spinal column begins to move into a lateral curve, most commonly in the right lateral thoracic area is the degree of curvature increases, damage to the vertebral bodies results. Curvature of greater than 50° results in an unstable spine, and curvature of greater than 60° in the thoracic spine result in compromises cardiopulmonary function
What are some complications of fractures?
Acute compartment syndrome crush syndrome hypovolemic shock fat embolism syndrome Venous thromboembolism infection chronic complications such as ischemic necrosis and delete union
What is the pathologic or spontaneous fracture?
That occurs after minimal trauma to bone that has been weakened by disease. For example, a patient with bone cancer or osteoporosis can easily have a pathologic fracture.
What are the stages of bone healing?
- Hematoma formation
- Hematoma to granulation tissue
- Callous formation
- Osteoblastic proliferation
- Bone remodeling
- Bone healing completed
What is crush syndrome?
Crush syndrome occurs from an external crush injury that compresses one or more compartments in the leg, arm, or pelvis. It is a potentially life-threatening, systemic complications that results from hemorrhage and edema after a severe fracture injury. As muscles become ischemic and necrotic from pressure within the compartment, myoglobin is released into circulation, where can occlude the distal renal tubules and result in kidney failure
Fat embolism syndrome
Fat embolism syndrome is another serious complication and which fat globules are released from the yellow bone marrow into the bloodstream within 12 to 40 hours after an injury or other illness. These globules Clog small blood vessels that supply vital organs, most commonly the lungs, and impair organ perfusion.
What is the earliest manifestation of fat embolism syndrome?
Altered mental status, which is caused by a low arterial oxygen level. Dyspnea and chest pain may follow. Petechiae is a late sign
Running versus balanced traction
In running traction, the pulling force is in one direction in the patient’s body axis counter traction. Balance suspension provides the counter traction so that the pond force of attraction is not altered when the better patient is moved. This allows for increased movement and facilitates care. The two most common types of traction our skin and skeletal traction. Skin traction and both the use of the Velcro boot belt or halter which is usually secured around the affected leg. The primary purpose of skin traction is to decrease painful muscle spasms that accompany hit fractures. And skeletal traction, pins, wires or screws are surgically inserted directly into the bone. Skeletal traction aids in bone realignment
Gout
Primary gout is the most common it’s caused by excessive uric acid
Fibromyalgia
Chronic pain syndrome noninflammatory disease
mental health overlay
women 30 to 50 years old
A simple versus compound fracture
In a compound fracture the skin surface over the broken bone is disrupted and in a simple fracture it does not extend to the skin and therefore has no visible wound
Diagnostic tests for osteomalcia
Pseudofractures or Looser’s lines
Etiology of pagets disease
Unknown but my be latent viral infection
Symptoms of pagets disease
Physical Manifestations 80 % are asymptomatic Bone and joint aching pain* Enlarged thick skull Pathologic fractures Flushed warm skin Fatigue, lethargy Hyperuricemia or gout
Diagnosing Pagets disease
Increased serum alkaline phosphate levels
Elevated hydroxyproline levels
Xrays show thickened areas or punched out areas
Treatment for pagets disease
NSAIDS for pain relief Calcitonin: increases calcium absorption Biphosonates – Didronel : helps strengthen bones Heat Massage
What is osteomyelitis?
Infectious organism invades the bone tissue and initiates an inflammatory response
Infection in another part of the body moves to and invades bone tissue from bacteremia
Direct inoculation from a penetrating trauma
Staph can cause it, elderly and diabetics are at risk
What are some risk factors for osteomylitis?
Bacteremia UTIs Long term IV catheters Animal bites Puncture wounds Bone surgery Open fractures
(more common in children)
Symptoms of osteomyelitis?
Acute: Fever >101 Swelling Erythema Bone pain – pulsating Increased WBC Elevated ESR
Chronic Lasting > month Slightly elevated WBC Ulceration of the skin Localized pain Drainage from infected area
Treatments for osteomyelitis
IV Antibiotics for several weeks to months
Hyperbaric oxygen therapy to increase tissue perfusion
Surgical managment
An 80 yr old male of European decent presents to the clinic complaining of aching bone and joint pain, especially in his lower back, which is aggravated by walking. His skull is thick and enlarged and his skin is flushed and warm.
What do you suspect?
Pagets disease
Because older adult, european decent, thick skull, bone pain, warm flushed skin
What tests do you expect to run: Alkaline phosphate, hydroxyproline….both will be elevated. Then xrays, CTs, MRIs
Mr. Hanson, a 70 yr old male with a history of alcoholism and secondary malnutrition presents to ER with a mild fever and complaints of pain in his lower right right leg. Upon assessment, his right leg area reveals a 10x10 cm ulcer with serosanguinous drainage.
What do you suspect?
Osteomyelitis
Because hes male, ETOH, malnutrition, low grade fever, pain, drainage
What tests do you expect to run: Blood and wound culture, Bone scan, MRI. Labs: WBC, ESR, SED rate
Mr. Salsi, an 86 yr old Ethiopian male who lives in a local nursing home complains of bone pain in both legs and lower back which worsens at night. He has recently experienced weakness in his legs which contributed to a recent fall at the nursing home. Mr. Salsi has a history of alcohol abuse.
What do you suspect?
Osteomalacia
Because ethiopian, famine, ETOH, bone pain, fall, leg weakness
What tests do you expect to run: XRAYS to check for pseudofractures
Labs: calcium, phosphate…both decreased….Alkaline phosphate, paratyhroid hormone…..both increased
What is Muscular Dystrophy ?
Muscular Dystrophy
Group of inherited disorders that cause progressive muscle weakness.
Cause
Muscular dystrophies are caused by genetic defects
Pathophysiology of muscular dystrophy
Pathophysiology
Faulty action of muscle protein called dystrophin
Dystrophin maintains muscle integrity by sending signals to coordinate muscle fiber contraction
Diagnostic test for muscular dystrophy
Diagnosis
Muscle biopsy
Analysis of serum muscle enzymes
EMG : stick probes in muscles/ electrical shocks
Orhtopedic sensory assessment
Deep peroneal – Great toe and second toe
Superficial peroneal – top/dorsal area of foot
Posterior tibial – sole of foot both laterally and medially
Types of fractures
Closed: nondisplaced
Open: (compound)
Comminuted: (fragmented)
Fractures and blood loss
Comminuted fracture – broken into pieces, at least 3
Fracture of femur – lose 1500-3000 mls of blood or 3-6 units of blood
Fracture of tibia – lose approx 500 cc or 1 unit of blood
The human body contains 10-12 units of blood or 5-6 Liters
What is the first thing you should do if your patient is complaining of swelling or pain?
Elevate the extremity, if that doesnt work THEN you should split the cast open
What type of syndrome can you get from wearing a cast?
Can get internal compartment syndrome from swelling in cast
What is traction typically used for?
Femur breaks
What is the purpose of traction?
Purpose of traction
Reduces fracture
Maintains normal alignment of bone ends
Decreases muscle spasms and contractions pre and post-operatively
Skin traction
Applied directly to skin – temporary Weights 5-7 lbs Traction boot i.e. Buck’s traction Buck’s is used to immobilize hip fractures Cervical traction
Complications of skin traction
Skin Traction decreases muscle spasms and helps immobilize the limb
Complications:
Vascular obstruction
Peroneal nerve palsy
Skin necrosis over bony prominences
Skeletal traction
Skeletal traction Weight 15-25 lbs Pulling force of traction is applied directly to a metal pin or wire inserted surgically through bone Steinmann pin Kirschner wire Never interrupt or release traction
Complications of skeletal traction
Nonunion of bone fragments Skin breakdown Impairment of neurovascular status Pin sites – potential for infection Complications of immobility
True or false
External fixator devices have a high risk of infection
True,
ESRs elevate as a sign of inflammation/infection
What is hypovolemic shock
Bone is very vascular
Fractures involving thorax, pelvis, spine or extremities (femur) are at risk for shock
Restore blood volume by rapid infusion of fluids
What is compartment syndrome?
A condition in which increased pressure within a limited space compromises the circulation and the function of the tissues within that space”
Causes of compartment syndrome
Compartment size can increase due to:
Anticoagulant use
Vascular injuries
Crush syndrome
Compartment size can decrease due to:
Dressing too tight
Casts too tight
Common sites of compartment syndrome
Fractures of:
Proximal tibia
Distal humerus
Hand, shoulder, thigh, buttocks not as common
Symptoms of compartment syndrome
Classic Symptoms: Pain out of proportion to injury Tenseness of the compartment Weakness of the muscles involved in the compartment Pain on passive stretch Hyperthesia
Lab indicators of compartment syndrome
Compartment Pressure
Normal 0-8 mmHg
Lab Indicators
Myoglobinuria
Increased muscle enzymes (CPK, LDH, SGOT)
Increased potassium and phosphate levels
Nursing interventions for compartment syndrome
Identify patients at risk
Minimize external pressure
Do not apply ice or elevate extremity above heart because blood can’t flow to the already compressed compartments
Document neurovascular status
Complications of compartment syndrome
Sensory changes Muscular weakness Contractures Amputations Infection Renal failure Death
Renal failure due to myoglobin release from the muscle cells which is toxic to the kidneys
Death is due to cardiac arrest 2ndary to K+ being released from the cells and the damaged kidneys. The kidneys can’t get rid of K+, hyperkalemia
Fat emboli
Pathogesis: Fat globulin release from long bones Breakdown to free fatty acids Irritate pulmonary vasculature/decrease surfactant – alveoli collapse Aggregate with RBC’s and platelets
When does fat embolism usually occur
Typically occur 48-72 hours after injury
Risk factors for fat emboli
Trauma to the femur, tibia, humerous, or pelvis
Inadequate or delayed fracture
Immobilization
Surgical reaming of the femur or tibia
Fat emboli symptoms
Restless, agitated, confused & stuporous Tachypnea – RR > 30/min Diffuse crackles Tachycardia – HR > 140 Fever – as high as 103 F Petechial skin
True or false
Petechiae more common with fat emboli than with skin emboli
True
Diagnostic test for fat emboli
ABG’s- P02 <60
Chest X-Ray – diffuse infiltrates
Fat emboli cont..
Laboratory Indicators Hypoxemia Thrombocytopenia Decreased hemoglobin Prevention: Early immobilization Adequate oxygenation Effective shock management
Traction key notes
- Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest or to decrease muscle spasm and prevent or correct deformity and tissue damage.
- Mechanical traction can be either continuous or intermittent, for relief of muscle spasm in trauma such as cervical nerve root compression.
- Skeletal pins or wires can be inserted through the skin and into bone for the purpose of skeletal traction or external fixation.
- Provide pin care for patients with skeletal traction or external fixation; assess for manifestations of infection at the pin sites.
- Open reduction with internal fixation is one of the most common methods of reducing and immobilizing a fracture and is often the preferred surgical method for an older adult who is susceptible to the complications of immobility.
Treating a fat emboli
Oxygen
Mechanical ventilation with PEEP
Optimum fluid replacement
Corticosteroids
Treatment for gout
Drugs
- Indocin (NSAID)
- Colchicine
- Allopurinol
- Probenecid
Labs for gout
SED rate and WBC will be elevated
During treatment of the patient with an acute attack of gout, the nurse would expect to administer what?
Colchicine
The patient with gout is treated with drug therapy to prevent future attacks. The nurse teaches the patient that is the most important to….
Avoid all foods high in purine, such as organ meats
Pathophysiology of gout
- Attack starts
- Crystals form
- White blood cells attack
- Crystals pop the cell
- Cell releases proteins
- Proteins call in more white blood cells and cause inflammation and pain
- Proteins lower pH making it possible for more crystals to form
What is scleroderma?
Patho: autoimmune
The skin thickens and becomes hide like
Drug therapy for scleroderma
- Systemic steroids
- Immunosuppressants
- imuran and Cytoxan
Symptoms of scleroderma
CREST
Calcinosis: calcium deposits in the skin
Raynaud’s phenomenon : spasm of blood vessels in response to cold or stress
Esophageal dysfunction: acid reflux and decrease in motility of esophagus
Sclerodactyly: thickening and tightening of the skin on the fingers and hands
Telangiectasis: dilation of capillaries causing red marks on surface of skin
Clinical manifestations of scleroderma include
- Decreased ventilation due to lung scarring
- Dyspnea due to fibrotic cardiac tissue
- Dysphasia due to hardening of the esophagus
When caring for patient with crest syndrome associated to scleroderma, the nurse teaches the patient to do what?
Protect the hands and feet from cold or heat exposure
Systemic lupus erythematosus
Patho: autoimmune, vasculitis
Causes: unknown
Women 15-40 years
10x more likely to get than men
Symptoms of lupus
- Fever
- Fatigue
- Loss of appetite
- Ulcers in the mouth and nose
- ’ Pleural effusions
- Pericarditis
- Nephritis ( leading cause of death)
- Butterfly rash
- Joint inflammation
Diagnostic test for lupus
SED rate and CBC
Drugs for lupus
Prednisone (steroids)
Plaquenil (antimalarial)
The pathophysiology of systemic lupus is characterized by what?
Destruction of nucleic acid and other self proteins by autobodies
The Single most important medication for the treatment of lupus is?
Corticosteroid
What is allopurinol ?
It is a drug that is used to treat gout and sometimes kidney stone. It lowers the amount of uric acid in the blood
What is enbrel?
It is a drug that treats autoimmune diseases by interfering with tumor necrosis factor by acting as TNF inhibitor. It is used to treat rheumatoid arthritis and psoriasis.
Fibromyalgia treatment
- NSAIDs
- Antidepressants ( increase release of serotonin, norepinephrine in brain to treat nerve pain. Also promotes sleep)
- Muscle relaxant
- Physical therapy/exercise
During assessment of the patient diagnosed with fibromyalgia, the nurse would expect the patient to report what?
Non-restorative sleep with resulting fatigue
Nurses teaching a patient how to reduce the pain that she often experiences of fibromyalgia. Which statement does the nurse including the teaching?
Make sure that you get enough sleep each night
True or false
Bone mineral density determines bone strength
True
Osteoporosis pathophysiology
Before and during the peak years which are 25 to 30 years of age, osteoclastic activity and osteoblastic activity work at the same rate. After the peak years, bone resorption activity exceeds bone building activity, and bone density decreases
ESR
Definition
The erythrocyte sedimentation rate (ESR), or sedimentation rate (sed rate), is a measure of the settling of red blood cells in a tube of blood during one hour. The rate is an indication of inflammation and increases in many diseases.
Purpose
ESR is increased in rheumatoid diseases, most infections, and in cancer. An advanced rate doesn’t diagnose a specific disease, but it does indicate that an underlying disease may be present.
A physician can use ESR to monitor a person with an associated disease. When the disease worsens, the ESR increases; when the disease improves, the ESR decreases. The ESR doesn’t always follow the course of cancer.
ESR is called an acute-phase reactant test, meaning that it reacts to acute conditions in the body, such as infection or trauma. The rate increase follows a rise in temperature and white blood cells count, peaks after several days, and usually lasts longer than the elevated temperature or white blood cells count.
Osteomalacia key notes
• Osteomalacia is loss of bone related to a vitamin D deficiency caused by inadequate deposits of calcium and phosphorus in the bone matrix.
o Normal remodeling and calcification of the bone is disrupted.
o Osteomalacia can be caused by liver and pancreatic disorders, chronic kidney disease, and bone tumors.
o The major treatment for osteomalacia is vitamin D.
Pagets key notes
• Paget’s disease or osteitis deformans is a chronic metabolic disorder in which bone is excessively broken down and reformed.
o Bone matrix is structurally disorganized resulting in bone weakness with increased risk of bowing of long bones and fractures.
o Two types of Paget’s disease can occur—familial and sporadic.
o Teach patients the importance of genetics in familial Paget’s disease and refer them to the appropriate genetic counseling resources.
o Paget’s disease is second only to osteoporosis in occurrence.
o Eighty percent of patients with Paget’s disease are asymptomatic and discovered during a routine laboratory or x-ray examination, with deformity confined to one bone.
o In more severe cases, the manifestations are potentially fatal.
o Pathologic fractures may be the presenting clinical manifestation
Muscular dystrophy key notes
• Muscular dystrophy can be categorized as slowly progressive or rapidly progressive, with slowly progressive being more common in adults.
• Assess the genetic risk for patients who have parents with muscular dystrophy. Recognize that most major types of muscular dystrophy are genetic and manifest usually in childhood.
o The most common forms are Duchenne and Becker muscular dystrophy.
o Both are X-linked recessive disorders.
• Care is supportive.
• Refer patients with musculoskeletal problems to appropriate community resources, such as The Paget Foundation and the National Osteoporosis Foundation.
• In collaboration with the health care team, provide supportive care for the patient with muscular dystrophy
Primary nursing concern in fractures
• The primary nursing concern is assessment and prevention of neurovascular dysfunction or compromise.
Traction key notes
- Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest or to decrease muscle spasm and prevent or correct deformity and tissue damage.
- Mechanical traction can be either continuous or intermittent, for relief of muscle spasm in trauma such as cervical nerve root compression.
- Skeletal pins or wires can be inserted through the skin and into bone for the purpose of skeletal traction or external fixation.
- Provide pin care for patients with skeletal traction or external fixation; assess for manifestations of infection at the pin sites.
- Open reduction with internal fixation is one of the most common methods of reducing and immobilizing a fracture and is often the preferred surgical method for an older adult who is susceptible to the complications of immobility.
The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the physician will request which medication?
Osteomalacia is loss of bone related to vitamin D deficiency. The major treatment for osteomalacia is vitamin D in an active form such as ergocalciferol (calciferol).
The nurse plans to refer a client diagnosed with osteoporosis to which community resource?
Hospital support group
Which nursing intervention helps to prevent the incidence of osteomyelitis for a client receiving hemodialysis?
Brush teeth after every meal
Proper dental hygiene helps prevent periodontal infection, which can be a causative factor in osteomyelitis of the facial bone.
The nurse is teaching a client newly diagnosed with osteoporosis about dietary and lifestyle interventions to decrease risk factors for osteoporosis. Which is the best way to decrease the risk for osteoporosis?
Walk for 30 min 3x a week
Walking for 30 minutes three to five times a week is the single most effective exercise for osteoporosis prevention. Walking is a safe way to promote weight-bearing and muscle strength.
The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis?
Working at a desk and playing the piano for a hobby
Sedentary lifestyle and prolonged immobility produce rapid bone loss.
The nurse is assessing a client with osteomalacia. Which findings will the nurse expect to observe?
Hypophosphatemia
Looser’s lines or zones
Unsteady gait
The nursing instructor asks a nursing student to identify risk factors that are shared by clients who have osteoporosis or osteomalacia. Which statement by the student is correct?
“High alcohol intake is a risk factor for both conditions.”
The nurse admits a client diagnosed with Paget’s disease. The nurse anticipates that the client will have which condition?
Enlarged thick skull
Which finding will the nurse expect to observe for a client with suspected common chronic osteomyelitis?
Ulceration of the skin
The client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon?
Paresis of right lower extremities
Paresis indicates a neurovascular compromise that must be reported immediately to the surgeon
