mobility part 2 (quiz 3)

Question 1

Exemplars of Mobility Disorders

Answer 1

• Osteomyelitis, Osteoporosis
• Bone cancer
• Fibromyalgia
• Gout, Systemic Lupus Erythematosus
• Multiple Sclerosis
• Guillain-Barré
• Amyotrophic Lateral Sclerosis
• Myasthenia Gravis
• Osteoarthritis and Rheumatoid Arthritis

Question 2


Osteomyelitis


Answer 2

Severe infection of the bone, bone marrow, surrounding soft tissue
Caused by variety of microorganisms
Most common microorganism is Staphylococcus aureus
Infecting microorganisms can invade by:
- indirect entry
- direct entry

Question 3


Osteomyelitis - Indirect Entry


Answer 3

• Infection is spread from blood to bone (bacteremia/septicemia)
• Frequently affects growing bone in boys <12
• Associated with increased incidence of blunt trauma
• Most common sites of indirect entry are distal femur, proximal tibia, humerus, radius
• Adults with increased risk - genitourinary and respiratory infections
• Pelvis, tibia, and vertebrae (vascular-rich sites of bone) are the most common sites of infection in adults

Question 4

Osteomyelitis - Direct Entry

Answer 4

• Can occur at any age
• Open wound where organisms can gain entry to body
• May also occur in presence of foreign body (implant, orthopedic prosthetic device)

Question 5

Osteomyelitis - Clinical Manifestations

Answer 5

Acute (< 1 month)
Local
- constant bone pain that worsens with activity
- swelling, tenderness, warmth at infection site
- restricted movement of affected part
- later signs: drainage from sinus tracts
Systemic
- fever, night sweats, chills, restlessness, nausea
Chronic (> 1 month)
- continuous/persistent or exacerbation/remission
- local signs more common than systemic

Question 6

Osteomyelitis - Diagnostics

Answer 6

• Bone or soft tissue biopsy
• Patient’s blood and/or wound culture
• WBC count, Erythrocyte sedimentation rate (ESR)
• Radiology (xrays)
• Radionuclide bone scans (gallium and indium)
• Magnetic resonance imaging (MRI)
• Computed tomography (CT)
  *

Question 7

Osteomyelitis - Management

Answer 7

• Prolonged IV antibiotics (Penicillin, Gentamycin, Vancomycin, Cefazolin, Ancef)
• Oral antibiotics may be given after acute IV therapy
• Response monitored through bone scans, ESR tests
• Delaying antibiotics may require surgical debridement and decompression
• Surgical treatment for chronic osteomyelitis, removal of poorly vascularized tissue and dead bone
• Orthopedic prosthetic devices, if source of infection must be removed
• Amputation may be indicated

Question 8

Osteomyelitis – Nursing Management

Answer 8

• Patient frequently on bed rest in early stages of infection, possible immobilization of affected limb
• Good body alignment and frequent position changes prevent complications
• Flexion contracture (hip or knee) is a common
• Foot supported in neutral position by a splint
• Instruct the patient to avoid any activities such as exercise or heat application that increase circulation and swelling and serve as stimuli to the spread of infection

Question 9

Osteomyelitis – Nursing Management

Answer 9

• Limb should be handled carefully to avoid excessive manipulation and ↑ pain
• Assess and manage patient’s pain level
• Patients often discharged to home care with IV antibiotics delivered via CVC or PICC
• Antibiotic therapy may be continued at home for 4 to 6 weeks or as long as 3 to 6 months
• Stress importance of continuing antibiotics after symptoms have subsided, on visits provide support and teaching to decrease anxiety

Question 10

Osteoporosis

Answer 10

• Chronic progressive metabolic bone disease
• Loss of bone density, structural changes = fragile bones/fractures hip, wrist, spine
• 80% hip fractures are osteoporosis related
• Canada: 1 in 4 women and 1 in 8 men (>50)
• Why women?
• Smaller frame = less bone mass
• Menopause causes bone resorption
• Pregnancy/breast feeding depletes calcium reserves, but child-bearing history not a factor
• Women live longer = greater risk

Question 11

osteoporosis risk factors

Answer 11

• Risk factors: age > 65 yr plus …
• female, family history, small boned or light-weight, early menopause, anorexia, smoking, oopherectomy, sedentary, ↓ calcium intake, hyperparathyroidism
• Associated diseases: GI malabsorption, kidney disease, rheumatoid arthritis, hyperthyroidism, alcoholism, cirrhosis, diabetes
• Drugs that interfere with bone metabolism: corticosteroids, antiseizure, antacids, heparin, anti-neoplastics, excessive thyroid hormone

Question 12

Fibromyalgia

Answer 12

• Non-articular musculoskeletal “burning” pain and fatigue, multiple tender points, worsens and improves throughout day, difficult to discriminate pain
• Non-restorative sleep, morning stiffness, irritable bowel syndrome, anxiety, depression
• May be a genetic susceptibility; stress is a factor
• Manifestations overlap those of chronic fatigue syndrome
• Cognitive manifestations (memory, concentration difficulties, feelings of being overwhelmed)

Multiple physiological abnormalities:
- increased levels of substance P in the spinal cord
- low levels of serotonin and tryptophan
- low levels of blood flow to the thalamus
- dysfunction of the HPA axis - abnormalities in cytokine function
Treatment based on symptoms - rest, Tylenol, NSAIDS, antidepressants, benzodiazepines for anxiety, gabapentin/pregabalin for pain

Question 13

gout

Answer 13

• Gouty arthritis – dusky, swollen, very tender joints due to urate crystals, a few days or chronic
• Primary (90%) - error in purine metabolism, overproduction or retention of uric acid
• Secondary – result of drugs known to inhibit uric acid secretion or other disorder (kidney under- secretion)
• ↑’d intake of purine-containing foods worsens condition, causes flare-ups/attacks
• Hyperuricemia can cause urolithiasis, pyelonephritis
• Serum uric acid levels to diagnose but not definitive
• Treatment – drug therapy

Question 14

Systemic Lupus Erythematosus (SLE)

Answer 14

• Chronic, multisystem inflammatory disease
• From relatively mild to rapidly progressive
• SLE affects 17,000 Canadians (10 x in ♀)
• Etiology of abnormal immune response unknown; genetic link suspected
• Autoimmune reactions directed against constituents of cell nucleus, DNA
• Commonly affects skin (rash), musculoskeletal (polyarthralgia), lungs (tachypnea), heart (dysrhythmias), nervous tissue (seizures), and kidneys (lupus nephritis)

clinical manifestations
remissions, exacerbations, highly variable course
complement activation = immune complexes deposited in kidneys, heart, skin, brain, joints

Question 15

Multiple Sclerosis (MS)

Answer 15

• Chronic, progressive, degenerative disorder of the central nervous system (CNS)
• Usually affects young to middle-aged adults, onset between 20 - 50 years of age
• Women are affected more than men
• Cause is unknown, related to infectious, immunological, and genetic factors
• Association between precipitating factors and MS is controversial
• Autoimmune disease - autoreactive T cells
• Activated T cells migrate to CNS, causing blood-brain disruption
• Antigen-antibody reaction leads to demyelination of axons
• Initially, myelin sheaths in the brain/spinal cord are attacked, but the nerve fibre is not affected
• Nerve impulses slow down without myelin
• Disease process eventually results in plaque formation throughout the CNS

Question 16

MS – Clinical Manifestation

Answer 16

• Vague symptoms occur intermittently over months and years.
• Disease may not be diagnosed until long after onset of the first symptom
• Chronic, progressive deterioration in some
• Remissions and exacerbations in others
• With repeated exacerbations, however, progressive scarring of the myelin sheath occurs, and the overall trend is progressive deterioration in neurological function

Question 17

MS - Diagnostics

Answer 17

• Based primarily on history, clinical manifestations, and presence of multiple lesions over time measured by MRI
• Cerebral spinal fluid (CSF) analysis
• Certain laboratory tests may be used as adjuncts to clinical examination
• There is no definitive diagnostic test for MS

Question 18

MS – Drug Therapy

Answer 18

• Corticosteroids - treat acute exacerbations by reducing edema and inflammation at the site of demyelination
• Immunosuppressive therapy
• Immunomodulators
• Others - Muscle relaxants, CNS stimulants, tricyclic antidepressants, antiseizure drugs

Question 19

MS – Collaborative Care

Answer 19

• Because there is currently no cure for MS, collaborative care is aimed at treating the disease process and providing symptomatic relief
• Physiotherapy - relieve spasticity, improve coordination, train patient to substitute unaffected muscles for impaired muscles
• Water therapy
• Nutritional therapy – high protein, low fat, high fibre with supplementary vitamins

Question 20

MS – Nursing Management

Answer 20

• Help patient identify triggers of exacerbations and develop ways to avoid them or minimize their effects
• Focus teaching on building general resistance to illness - avoiding fatigue, extremes of hot and cold, exposure to infection
• During acute exacerbation, prevent major complications of immobility
• Teach patient good balance of exercise and rest
• Teach self-catheterization if necessary

Question 21


Guillain-Barré Syndrome


Answer 21

• Inflammatory, autoimmune process
• Triggers: viral/bacterial infection, vaccine
• Results in a process of demyelination of heavily myelinated peripheral nerves
• Saltatory conduction is impaired
• Affects motor and sensory pathways of the peripheral nervous system
• Results in the development of an ascending paralysis in the affected limbs
• Motor weakness
• Parethesias (numbness, ‘pins and needles’)
• Cranial nerve dysfunction (3, 7, 9 – 12)
• Begins with lower extremity weakness, flaccidity
• Ascends over hours to days
• Usual course is over 4 – 6 weeks
• Motor loss is usually symmetric, bilateral
• Elevated protein levels in CSF
• Nerve conduction studies show reduction in velocity
• In severe cases paralysis can ascend to respiratory muscles
• Intubation, mechanical ventilation may be required
• After inflammatory process stops, the demyelinated nerves are reinsulated
• Resolution of paralysis and weakness is reverse, descending
• Recovery is dependent on length of time ventilator support required, complications, age and previous medical history
• Normal neurological function should return

Question 22

Amyotrophic Lateral Sclerosis (ALS)

Answer 22

• Also known as Lou Gehrig’s disease
• Rapidly progressing, degenerative, fatal
• Affects more male than female
• Cause is unknown
• Time from onset of symptoms to death is approximately 3 years
• Destruction/degeneration of motor nuclei in brain stem and motor cells, pyramidal and corticospinal tracts of the spinal cord
• Initially wasting/weakness of upper extremities
• Lower limbs affected last
• Muscle spasticity and hyperreflexia
• Atrophy of the tongue, muscles of speech, chewing and swallowing affected
• May have emotional lability, fatigue
• Intellectual ability, sensory function, vision and hearing not affected

Question 23

ALS management

Answer 23

Management:
- occupational, physical and speech therapy
- gastrostomy tube feeding
- ongoing counseling and family support
- drug treatment for spasticity, cramps, increased salivation
- ICU for ventilatory support?
Death occurs due to aspiration, infection or respiratory failure

Question 24

Myasthenia Gravis

Answer 24

• Autoimmune, results in fluctuating weakness of skeletal muscle
• Antibodies attack acetylcholine (ACh) receptors, preventing ACh from attaching at neuromuscular junction and stimulating muscle contraction
• Affects eye/eyelid movement, chewing, swallowing, speaking, breathing, facial mobility
• Also neck, shoulder, hip more than distal muscles
• Remission, stable or worsening (chronic illness)
• Myasthenic crisis can develop
• Exacerbated by stress, pregnancy, menses, trauma, hypokalemia, some medications
• Diagnosis – antibodies to ACh receptors in blood in 85-90%
• Treatment – anticholinesterase drugs (Neostigmine), corticosteroids, immunosuppressives, surgery (removal of thymus gland)
• Nursing management – assess respiratory status, reduce aspiration risk, modify diet (easy to chew and swallow)
• The muscles are generally the strongest in the morning and become exhausted with continued activity. Consequently, by the end of the day, muscle weakness is prominent.