WEEK 12/ 13- MSK Challenges Flashcards
Osteoporosis
- Metabolic disease caused by bone demineralization = bone density = fractures
- Areas commonly affected: wrist, hip, vertebral column
Primary Osteoporosis
o Not associated with underlying disease
o Most common in women after menopause, men in later years
• Type I: postmenopausal: ages 55 to 65
• Type II: senile: over age 65
Secondary osteoporosis
Related to an associated medical condition
Treatment related to underlying cause
Risk Factors
o Age over 60 years o Family history o Caucasian or Asian race o Thin, lean body build o Low lifetime calcium intake o Estrogen deficiency o Smoking history/high alcohol intake o Lack of physical exercise/prolonged immobility o Parathyroid disorder
Parathyroid Hormone
regulates calcium in blood in part by promoting mov’t of Ca from the bone
↓ Ca in blood ► ↑ PTH prompt demineralization of the bone
Primary Manifestations
o “Dowager’s” hump= kyphosis of dorsal spine/shortened height
o Sharp, acute back pain
o Tenderness, restriction of spinal movement suggests compression vertebrae fracture/s
o Constipation/abdominal distention/reflux esophagitis
o Respirations compromised
o Fractures most common:
Between T8 and L3
Distal end of radius and hip
Diagnosis
o Bone mineral density (BMD) • values = T-scores Normal = less than -1 o Low bone mass (osteopenia) • T-score between -1 and -2.5 o Osteoporosis in postmenopausal women • T-score at or below -2.5 o BMD decreases rapidly as serum estrogen levels
Primary Osteoporosis – Interventions – Drug Therapy
Calcium -1200 mg/day from all sources (includes diet and supplementation)
Vitamin D - D-needed to promote Ca++ absorption
800-2000 IU/day
Bisphosphonates (BPs)- eg. Fosamax
• inhibit bone resorption
• Risk of esophageal ulcers if the pill is not completely swallowed-
• Caution to take with full glass of water on empty stomach
• Sit upright for 30 minutes afterwards
More Interventions
o Diet therapy o Prevention of falls o Exercise o Pain management o Orthotic devices
Weight-bearing (local stress)
Stimulate bone formation & remodelling
Avoid prolonged bed rest: bone loses calcium(resorption) & becomes osteopenic & weak
Falls
- # 1 cause of accidental death of persons >65 years
- Account for 65% of injuries to seniors each year
- 1/3 of Canadian seniors fall each year
- Account for 84% of injury admits to hospitals, 40% of nursing home admits
- High cost to person, family and HC system
- Research indicates falls are preventable with education/ awareness programs
- Major concern for health care providers as the Baby Boomers face their senior years
Risk Factors
- History of falls
- Age>80
- Multiple Illnesses
- Generalized weakness or immobility
- Confusion- or use of drugs that can cause confusion, mobility limitations or orthostatic hypotension
- Urinary incontinence
- Communication impairments
- Location of client’s room
- Major visual impairments
- Substance abuse
- Location of client’s room
Assess Risk for Fractures
Previous fracture after age 40 Parental hx of fracture High ETOH intake Use of steroids or smoker Hx of rheumatoid arthritis Falls: any in past year? >10% loss of weight since age 25 Get up and Go test
Classification of Fractures
- Complete - the break is across the entire width of the bone
- Incomplete - the break is through only part of the bone
- Compound - if the soft tissue around the fracture is open
- Pathological - occurs after minimal trauma to a bone that is weakened by disease (eg: bone cancer or infection)
Factors affecting healing times
- age
- displacement
- site of fracture
- nutritional level
- blood supply to the area of injury
CLINICAL MANIFESTATIONS
Pain: immediate, severe
Loss of function
Deformity; abnormal positioning of extremity
Shortening of extremity
Crepitation: palpable or audible
Edema
Paresthesia- burning or tingling sensation
Numbness
Motor weakness
Pulselessness, impaired capillary refill time and cyanotic skin
Nursing Assessment
• Pain - Continuous and increases in severity
o Muscle spasm accompanying the fracture is a reaction of the body to try and immobilize the fractured bone (mostly with hip and femur #)
• Deformity - Displacement, angulations or rotation of the fragments
• Crepitus - A grating sensation produced when the bone fragments rub each other
Complications- Fat Embolism
Occurs usually in fractures of the long bones
Fat globules may move into the blood stream because the marrow pressure is greater than capillary pressure
Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs
Onset within 24-72 hours after fracture
Sudden dyspnea and respiratory distress & hypoxia
Agitation, delerium
Tachycardia
Chest pain
Crackles, wheezes and cough
May have petechial rash over the chest, axilla and hard palate
Fat Embolis Prevention
Immobilization of fracture
Minimal fracture manipulation
Adequate support for fractured bone during turning and positioning
Maintain adequate hydration and electrolyte balance
Acute Compartment Syndrome
muscles are wrapped with dense leathery tissue called fascia , a dense, inelastic cover
Severe fractures, trauma, vascular injuries and electrical injuries can all produce muscle damage
As injured muscle swells, the pressure rises within the constricting compartment
Eventually, the internal pressure rises so high that local circulation is cut off and the affected muscle dies
Can also damage associated nerves resulting in a loss of both power and sensation.
Symptoms include:
Deep throbbing pain that is not relieved by analgesics
Decrease in sensation to the area,
Pale tissue colour
Weakened pulses
PARESTHESIA- first sign
PULSELESSNESS - late sign
Pain during passive motion that is greater than pain during active motion.
Treatment of ACS
Surgical treatment- a fasciotomy An incision is made through the skin and subcutaneous tissue into the fascia of the affected compartment. Relieves the pressure Wound is left open- packed and dressed May require skin grafting.
Fractures- Interventions
Emergency care
fracture may be accompanied by multiple injuries to vital organs
assess for respiratory distress, bleeding and head injury
Reduction or realignment
Immobilization
Bandages and splints
Used for certain areas of the body- such as the scapula and clavicle
Non weight-bearing bones!
Fracture Care
• Immobilize any suspected fracture
o Support the extremity above and below when moving the affected part from a vehicle
o Suggested temporary splints- hard board, stick, rolled sheets
o Apply sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged to the chest
Reduction or realignment
• application of a pulling force to a part of the body to provide reduction, alignment and rest
• Can also decrease muscle spasm (relieve pain), and correct a deformity and prevent tissue damage
• May be open (surgical) or closed (traction)
• Traction
o manual
o mechanical
Treatment of Fractures
Closed Reduction is most common
Uses a manual pull or mechanical traction to manipulate the bone ends so that they realign.
Casts
Purpose is to immobilize the bone fragments after reduction
Also allows early mobility
Reduces pain.
Materials
• Plaster o Takes 24-72 hours to dry o Feels warm when applied o Rough edges may cause irritation • Synthetic (fibreglass) o Dry more quickly and can support weight within ½ hour
Cast Care
• Tell patient about the heat while the cast is drying
• Do not cover the cast until it is dry
• Handle the cast with palm of the hand
• Turn client q2h to allow for drying
• If limb is to be elevated- use a pillow with a cloth cover (not plastic)
• Protect body casts from urine or feces with plastic
• Assess neurovascular status- q1h for first 24 hours
• After dry- inspect cast q8h for drainage, cracking crumbling alignment and fit
• Areas of drainage on the cast should be measured and documented.
• Risk of infection as a result of skin breakdown under the cast
o Symptoms- hot spots, cast may feel warmer, odour, fever and elevated wbc
Closed Reduction External Fixation
First, the facture is reduced
Then, percutaneous incisions are made and pins are screwed into the bones
Pins are held in place with an external device to prevent movement
Open Reduction
Is a surgical procedure during which the patient has the bone realigned
Provides immediate bone strength but risk for infection
ORIF - Open Reduction Internal Fixation
Allows for early mobilization
Often used for the elderly because they are susceptible to the hazards of immobility
Plates, pins and screws will be placed in the bone
Hip Fractures
• Common in elderly women
• Clinical manifestation:
o External rotation & adduction of affected extremity
o Shortening of the length of the affected extremity
o Severe pain & tenderness
• Treatment:
o Initially- Buck’s traction
o Surgery
• Neurovascular check
• Position: PREVENT FLEXION, ADDUCTION & INTERNAL ROTATION
• Do not adduct past neutral position
• Maintain in abducted position with A-frame pillow or pillows between legs
• Avoid flexion of hip of more than 90 degrees
• Prevent internal or external rotation by using sandbags, pillows, trochanter rolls
IMPAIRED PHYSICAL MOBILITY
Instruct patient to perform range of motion exercises, either passive or active
Provide support in ambulation with assistive devices
Turn and change position every 2 hours
Encourage mobility for a short period and provide positive reinforcements for small accomplishments
SELF-CARE DEFICITS
• Assess functional levels of the patient
• Provide support for feeding problems
o Place patient in Fowler’s position
o Provide assistive device and supervise mealtime
o Offer finger foods that can be handled by patient
o Keep suction equipment ready
• Assist patient with difficulty bathing and hygiene
o Assist with bath only when patient has difficulty
o Provide ample time for patient to finish activity
Osteoarthritis
Most common connective tissue disease Progressive deterioration and loss of cartilage "Wear and tear disease" Primary (idiopathic) Secondary Nodal/nonnodal
Etiology
Developmental-Age is main RF
Genetic-FHx-especially with nodal
Traumatic-usually excessive use
Clinical manifestations
Begins with mild stiffness
Usually pain diminishes after rest and increases with activity
May be unilateral or a single joint
Enlargement of the bone- bony hypertrophy
Rarely does the joint appear to be hot and inflamed
May have Heberden’s nodes or Bouchard’s nodes.
Interventions for OA
Goal- pain control – Analgesics- Acetaminophen – NSAIDS Rest- – immobilize the joint – Adequate sleep – Psychological rest • Positioning- joint should be in a functional position • Avoid contractures • Weight control • TENS
Clinical Manifestations
Onset may be acute or slow
Early- fatigue, generalized weakness and stiffness, anorexia and weight loss
Sometimes there is a low grade fever
Joints (usually upper extremity) are reddened, warm, stiff, swollen and tender
Later Manifestations
Increasing pain
On palpation- joints are soft due to synovitis and effusions
Most or all joints are affected
Common deformities of the hands
lab assesment- Rheumatoid Factor (RF)
Measures the presence of unusual antibodies
Normal range is negative
The higher the titer, the more active the disease process is
Drug Therapy for RA
NSAIDs- eg: Ibuprofen
Corticosteroids-eg: prednisone
DMARDs-disease-modifying anti-rheumatic drugs-eg: methotrexate
Biologics –eg: Remicade
Gold salts- reduce pain and inflammation
Analgesics
Salicylates- ASA
Other Therapies
Rest, positioning, ice, heat
TENS
Management of fatigue
Care of altered body image
Total Joint Replacement
Procedure of last resort for pain management
Most often hips and knees
Contraindication would include- infection, inflammation
Care of the patient following THR
– Pain control- usually PCA morphine pump for the first 24-48 hrs which will be replaced with oral analgesics (T3s/oxycodone) and NSAIDs – May have femoral nerve block or epidural instead of PCA – Aggressive Physiotherapy! – DVT/PE prophylaxis- o LMW Heparin o coumadin or o rivaroxaban (Xarelto) – Replace blood lost during surgery prn – Calcium and iron supplementation – Nutritional support
Moving the Patient following THR
Legs must remain abducted
Hips never flex more than 90 degrees
Keep operative leg in neutral position
Turn to operative side or back only
Nursing Interventions & Teaching to Prevent Complications of TJR
Dislocation (less common with knee replacement) Infection DVT/PE Hypotension, bleeding Neurovascular compromise Pain
Total Knee Replacement
– Nursing care is similar to that with a THR
– Maintenance of abduction is not needed
– May use a Continuous Passive Movement (CPM) machine- to keep the prosthetic knee in motion and prevent the formation of scar tissue.
– Ice to reduce inflammation.
amputations
The psychosocial effects may be more devastating than the physical impairment
goal of amputations
Preserve extremity length and function while removing necessary tissue
Amputation: Post Op Care
Monitor:
VS, dressing, circulation, warmth, sensation
Post Op prosthesis may mask bleeding
Prevention of Infection- Monitor temperature, WBC, administer antibiotics as ordered, wound care
Phantom Limb Pain
– Should be distinguished from stump pain
– Feels like limb is still present
– Burning, itching, tingling, or aching sensation
– Coldness, heaviness, cramping, or shooting pain
– Can become chronic, but resolves with time
– Pain is real to the patient, thus treat as if it is real
Analgesics
Opioids for Residual limb pain
Beta blockers, anticonvulsants and antispasmodics for PLP
Complementary and Alternative Rx for PLP
– TENS – Ultrasound therapy – Massage – Exercise – Biofeedback – Distraction therapy – Hypnosis – Psychotherapy
Prevention of Infection
– Inspect the wound for:
o inflammation, erythema, warmth, tenderness/pain, drainage
– Record character of drainage
o Serous, sero-sanguinous, sero-purulent, purulent
– Change dressing daily
– Below knee amputation may be casted in OR making it difficult to assess
– Antibiotics
Exercise
– Avoid hip flexion (ie: sitting in chair and leaning forward)
– Avoid pillows under the surgical site (to avoid flexion contractures)
– Lie on abdomen for 30 min TID
– Hip should be in extension while prone
Bandages
• May use rigid or soft dressings
– Used to mold/shape residual limb
– Reduces edema
When using Tensor type pressure bandage
– Re-wrap q 4h
– Use figure 8 pattern
– Pressure should be greater distally than proximally
– Re-wrap if wrinkles noted or pain reported
– No metal clips
– Must be snug but not cut off circulation
Residual Limb Care
- Inspect area daily
- Wash area qhs with bacteriostatic soap, pat dry, and expose to air x 20 min
- Do not use lotions, alcohol, powders, or oils
- Change limb sock daily
- ROM & strengthening exercises OD
- Do not elevate limb on pillow
- Lay prone with hip extension for 30 min TID
Altered Body Image
Pt may go through grieving stages similar to death
Denial, anger, bargaining, depression, acceptance
Recognize and support patient’s struggle
Include family in healing process
Help them to achieve a realistic and positive attitude about the future
Refer to War Amps or other community supports
look at the doc at pnh in the course docs
..
