Week 6 Flashcards
What are bones composed of?
collagen fibers (Ca++, phos)
Cells: Osteoblasts (build bone) and Osteoclasts (break bone)
Functions of bones:
Provide support for body
Protect internal organs
Provide for movement in conjunction with muscles
Store calcium, phosphorus, other minerals
Produce red and white blood cells (long bone)
Guidelines for Musculoskeletal Assessment
Inspect for deformities
Inspect and palpate any swelling
Any visible deformities, swelling, or asymmetry can indicate trauma or underlying conditions.
Feel for increased temperature
- Observe for redness
- Palpate for tenderness around joint: location, intensity, and nature of the pain (sharp, dull, constant, intermittent). Use pain scale
- Assess ROM
Osteoporosis patho review
Chronic disease of cellular regulation
More osteoclast activity than osteoblast
Causes significant decreased density and possible fracture
Fragility fracture – caused by osteoporosis
Osteopenia to osteoporosis
Osteoporosis etiology and genetic risk
-Genetic, lifestyle, and environmental factors
Primary– Post menopause; low Ca++ or Vit D intake
Secondary – CKD, myeloma, endocrine, malabsorption disorders
What is osteoporosis lifestyle risk factor
Sedentary lifestyle like lack of weight-bearing and resistance exercises can weaken bones and decrease bone density
Excessive alcohol consumption, and smoking can contribute
What secondary etiology and genetic risk of osteoporosis
CKD, myeloma, endocrine, malabsorption disorders, malnutrition, immobility, alcoholism
What environmental factors example of osteoporosis?
poor living condition like easy to fall
Exposure to heavy metals like lead and cadmium can negatively impact bone health
Certain chemicals in the environment may disrupt hormone function and bone metabolism
Examples of endocrine in osteoporosis?
Hyperthyroidism: The condition leads to increased metabolism and can cause a loss of bone density over time. Excess thyroid hormone can interfere with the balance of bone remodeling, leading to bone resorption outpacing bone formation. This makes bones weaker and more susceptible to fractures
Lab assessment of osteoporosis
low or normal Ca, low or normal phosphate, high or normal PTH, high or normal ALP (alkaline phosphatase), low or normal magnesium
why osteoporosis is silent disease or silent theft?
because the first sign of
osteoporosis in most people follows some kind of a fracture.
Who majority can have most chance of having a fragility fracture?
Euro-American postmenopausal women have a 50% chance of having a
fragility fracture (fracture caused by osteoporosis; sometimes referred to
as a “bone aack”) in their lifetime. A woman who experiences a hip fracture has a greater risk
for a second fracture.
Non-modifiable risk factors
Assess for these nonmodifiable risk factors:
* Older age (over 50 years of age)
* Menopause or history of total hysterectomy, including removal of ovaries (bc these decrease in estrogen)
* Parental history of osteoporosis, especially mother
* Euro-Caucasian or Asian ethnicity
* Eating disorders, such as anorexia nervosa
* Rheumatoid arthritis
* History of low-trauma fracture after age 50 years
Modifiable risk factors are
- Low body weight, thin build or obese women (bc their body store estrogen in their tissues to maintain normal level of serum calcium better than thinner women)
- Chronic low calcium and/or vitamin D intake
- Estrogen or androgen deficiency
- Current smoking (active or passive)
- High alcohol intake (two or more drinks a day)
- Drug therapy, such as chronic steroid therapy (also see Table 45.2)
- Poor nutrition
- Lack of physical exercise or prolonged decreased mobility
-High protein diet or carbonated beverages drinker
what do we do first in nursing assessment?
Assess for pt’s risk factors = important for early detection and prevention, pt’s fall risk scale
Signs and symptoms of osteoporosis
Fractures after minor falls
Pathologic fractures (spine, femur)
Kyphosis
Height loss (2 to 3 inches/ 5 to 7.5 cm within 20 years)
Pain (common back pain after bending, stooping or lifting; worse with activity and relieved with rest)
Vertebral collapse
Imaging assessment for osteoporosis
X-rays of spine and long bones
DXA
what medications is for osteoporosis?
Bone resorption inhibitor
Hormone replacement therapy (HRT)
Calcium supplements with Vitamin D
serum calcium should be between for osteoporosis
9.0 and
10.5 mg/dL (2.10 and 2.50 mmol/L)
what is health promotion and wellness of osteoporosis?
Stop smoking
Lose weight
Fall prevention
Limit alcohol and carbonated beverages
Weight bearing exercises
Complementary and alternative: biofeedback, yoga, massage, reflexology
Patients
who have osteopenia usually have follow-up DXA scans every ____ years
2
The priority problem for patients with osteoporosis or osteopenia is
Potential for fractures due to weak, porous bone tissue (pathological/fragility fracture)
expected outcome for osteoporosis pt
The expected outcome is that the patient will avoid fractures by
preventing falls, managing risk factors, and adhering to preventive or treatment measures for bone loss.
Interventions of pt with osteoporosis
nutrition therapy, lifestyle
changes, and drug therapy are used to slow bone resorption and form new
bone tissue. Self-management education (SME) can help prevent
osteoporosis or slow the progress.
what is nutrition therapy
Avoid alcohol and caffeine. Drink milk, lactose free, soy, rice, bread, cereal
Which lifestyle changes is important?
Exercise is important in the prevention and management of osteoporosis.
It also plays a vital role in pain management, cardiovascular function, and
an improved sense of well-being.
Teach patients that
walking for 30 minutes three to five times a week is the single most
effective exercise for osteoporosis prevention.
Home care management?
Patients with osteoporosis are usually managed at home unless they have
major fragility fractures. Some patients do not know that they have
osteoporosis until they experience a fall and have one or more fractures.
Remind patients to have follow up DXA scans as prescribed to
determine the effectiveness of drug therapy
Non inflammatory arthritis
Osteoarthritis:
Related to overuse/ wear and tear
Unilateral and not systemic.
Inflammatory arthritis:
Connective tissue disease caused by inflammation
Systemic
Often autoimmune
Rheumatoid arthritis
Systemic lupus erythematosus
Defect in immunologic mechanism
Possible genetic component
Characterized by hypersensitivity
Tend to be systemic and chronic
Medications control or reduce immune system response
What is osteoarthriris/Degenerative joint disease (DJD)?
Osteoarthritis, also known as degenerative joint disease (DJD), is the most common type of arthritis affecting individuals over the age of 60. This condition is characterized by joint pain and a gradual loss of function, resulting from the progressive deterioration of cartilage within the joints. As collagen synthesis decreases and breakdown increases, the structural integrity of the joints is compromised. The formation of osteophytes—bony growths on the edges of the joints—can further exacerbate discomfort and limit mobility. In some cases, synovitis, or inflammation of the joint lining, may occur, leading to subluxation, where joints become partially dislocated. While the erythrocyte sedimentation rate (ESR) may remain normal or only slightly elevated, the impact of osteoarthritis on daily life can be profound, highlighting the importance of early intervention and management strategies.
What happens in osteoarthritis inside the synovial joint?
The sodium hyaluronate in synovial fluid does not stay there for a whole lifetime, but is continuously broken down and replaced. Normally, there is an exact balance between the breakdown of old sodium hyaluronate and the production of new sodium hyaluronate. In osteoarthritis, however, this balance is disturbed and breakdown happens faster than production. As a result, the synovial fluid becomes more watery and stops working properly.Due to the change in the synovial fluid - and for other, more complex reasons - the cartilage in the joint gradually wears away. In some places, in fact, the cartilage may eventually disappear altogether. The thinning of the synovial fluid and wearing away of the cartilage lead to the symptoms of osteoarthritis, which include pain, stiffness and swelling.
The sodium hyaluronate in the joint space becomes depolymerised and fragmented. The synovial fluid becomes less viscous and its lubricating, shock-absorbing and filtering abilites are reduced.
The coating over the surface of the joint breaks down, leaving the cartilage exposed to mechanical and inflammatory damage.
The synovial membrane becomes inflamed.
The cartilage is gradually destroyed.
Osteoarthritis etiology
Primary: Aging, Genetic factors
Secondary
Joint injury (Heavy manual occupations (e.g., carpet laying, construction, farming)
cause high-intensity or repetitive stress to the joints. The risk for hip and
knee OA is increased in professional and amateur athletes, especially
football players, runners, and gymnasts)
Obesity
Repetitive stress to joints
Clinical manifestations (cues) for osteoarthritis?
Persistent joint pain and stiffness
Crepitus
Joint deformity
Muscle atrophy
Joint tenderness
Morning stiffness, better with movement
Pain with overuse of joint
Osteoarthritis nursing management
Highest priority: pain relief (NSAIDs (short-term use); Acetaminophen; Other analgesics)
Heat and cold applications
Complementary and alternative therapies
Exercise, firm mattress, splints
Fall protocol in hospital and at home
Promotion of independence
Mobility aids
Fall prevention
Weight loss
Psychosocial support
Patient education
what is rheumatoid arthritis
Chronic, progressive, systemic inflammatory autoimmune disease affecting primarily the synovial joints
Autoantibodies (rheumatoid factors) formed that attack healthy tissue, especially synovium, causing inflammation; development of a pannus
Cartilage becomes fibrous and calcified
Affects connective tissue of any organ or body system
Rheumatoid arthritis clinical manifestations
Remissions and exacerbations
Physical and emotional stresses are linked to exacerbations
Early disease manifestations—joint stiffness, swelling, pain, fatigue, and generalized weakness
Systemic Manifestations – Swollen glands, dry mouth, pleuritis, anemia, decreased WBCs, vasculitis
Late disease manifestations—as the disease worsens, the joints become progressively inflamed and quite painful
Ex: ulnar deviation, swan neck deformity
RA more examples of systemic complications
Weight loss, fever, and extreme fatigue
Exacerbations
Subcutaneous nodules
Pulmonary complications
Vasculitis
Periungual lesions
Paresthesias
Cardiac complications
Respiratory complications
Correlations:
*Heart disease
*Blood clots
*Sleep apnea
RA Laboratory and Diagnostic Procedures
Radiologic imaging
Blood tests include:
Rheumatoid factor
Antinuclear antibodies
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)
interventions for RA
Pharmacologic interventions:
Disease-modifying antirheumatic drugs
NSAIDs
Biologic response modifiers
Other drugs:
Glucocorticoids
Immunosuppressive agents
Gold therapy
Analgesic drugs
Surgical interventions
Synovectomy, arthrodesis, and/or reconstructive surgery
Adequate rest
Proper positioning
Ice and heat applications
Plasmapheresis
Gene therapy
Complementary and alternative therapies
Joint mobility, preventing contractures
Rest during flare-ups, safeguarding joints
Heat/ cold application
Promotion of self-care
Support, referral
what is SLE?
Chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail.
Characterized by spontaneous remissions and exacerbations.
Autoimmune complexes tend to be attracted to the glomeruli of the kidneys.
Most patients with SLE have some degree of kidney involvement.
SLE clinical manifestations
Lupus is a chronic autoimmune disease characterized by a range of symptoms that can affect multiple body systems. A common sign is the “butterfly rash,” a red, macular facial rash that appears across the cheeks and nose. Many people also develop discoid rashes on sun-exposed areas like the face and scalp, often triggered by sunlight. Other symptoms include joint pain from nonerosive arthritis and inflammation of serosal membranes, which can affect organs. Patients may experience chronic lesions on mucous membranes, neurological issues, and hematological problems. Additionally, lupus can have significant psychosocial effects, impacting emotional well-being and daily life. Understanding these symptoms is crucial for effective management and support.
SLE lab assessment
Laboratory assessment
ESR
Serum complement levels for C3 and C4
ANAs, and other antibodies to nuclear membrane phospholipids
Other diagnostic assessment
Blood and urine tests (kidney involvement)
SLE focus of care
Focus of Care
Pain
Fatigue
Tissue integrity
Self-esteem/role performance
SLE patient teaching
Disease process and interventions
Therapeutic regimen
Minimizing triggers
Preventing complications
Psychosocial of OA
Persistent pain that affect daily lives activities
And how person deal with changes
Lab assessment of OA
The primary health care provider uses the history and physical
examination to make the diagnosis of OA instead; however
The erythrocyte
sedimentation rate (ESR) and high-sensitivity C-reactive protein (hsCRP)
may be slightly elevated when secondary synovitis occurs. The ESR also tends to rise with age and infection.
Routine X-ray, MRI
Priority problem of OA
The priority collaborative problems for patients with osteoarthritis (OA)
include:
1. Persistent pain due to joint swelling, cartilage deterioration, and/or
secondary joint inflammation
2. Potential for decreased mobility due to joint pain and muscle
atrophy
Desire outcome of OA
The patient with OA is expected to have a pain level that is acceptable to
the patient (e.g., at a 3 or less on a pain intensity scale of 0 to 10).
surgical management of fractues
TJA (Total joint replacement) is a procedure used most often to manage the pain of fractures and
improve mobility, although other conditions causing cartilage and bone destruction may require the surgery
Total hip arthroplasty
pre-op for patient who need total hip arthroplasty
nutrition assessment
Pain assessment and management
VTE
Infection prevention
THA precautions
- Do not sit or stand for prolonged periods.
- Do not cross your legs beyond the midline of your body.
- For posterolateral or direct lateral surgical approach patients: Do not bend
your hips more than 90 degrees. - For anterior surgical approach patients: Do not hyperextend your
operative leg behind you. - Do not twist your body when standing.
- Use the prescribed ambulatory aid such as a walker when walking.
- Use assistive/adaptive devices as needed (e.g., sock aids, shoehorns,
dressing sticks, extenders [also see Chapter 7]). - Do not put more weight on your affected leg than allowed and
instructed. - Call 911 if you experience any signs and symptoms of hip dislocation,
including sudden difficulty bearing weight on the surgical leg, leg
shortening or rotation, or a feeling that the hip has “popped” with
immediate intense pain. - Resume sexual intercourse as usual on the advice of your surgeon
Fractures
Break or disruption in continuity of a bone that affects mobility and causes pain
Classification
Complete or incomplete
Open (compound) or closed (simple)
Fragility (pathologic or spontaneous)
Fatigue or stress
Compression
Open vs closed fractures
Open fracture:
Tear in soft tissue, bone exposed to outside
Potential for contamination
Higher morbidity and mortality
Closed fracture: no opening
Clinical manifestations of fractures
Pain at fracture site
Swelling
Tenderness
Bruising
Shortening of a limb
Deformity
Displacement
Lab assessment of fractures
Hemoglobin &Hematocrit
ESR
WBC
Serum calcium, and phosphorus
Image assessment
X-rays
CT
MRI
Fractures nursing care
Managing acute pain
Increasing mobility
Preventing and monitoring for neurovascular compromise
Preventing infection
Fractures medical treatment
Fixation and/or union must occur within 6–8 hours
Cast (watch for swelling, no access to soft tissues)
Fixtures
Splint or brace
Traction
External fixation
Open reduction internal fixation
Intramedullary rod
Neurovascular assessment
(6 Ps and cap refill): pain, poikilothermia, paresthesia, paralysis, pulselessness, and pallor.
Color of limb
Movement
Temperature
Sensation
Complications of fractures include
VTE (DVT and PE)
Bone or soft tissue infection
Neurovascular compromise
Acute compartment syndrome
Fat embolism syndrome
Complex regional pain syndrome (CRPS)
Avascular necrosis (chronic)
Patients with ACS may need a _____
surgical procedure known as a
fasciotomy. In this procedure, the surgeon cuts through the fascia to relieve
pressure and tension on vital blood vessels and nerves. The wound remains
open and requires care to begin to heal from the inside out. The surgeon usually
closes the wound with a skin graft in several days
Fat embolism?
Fat globules fro long-bone fracture enter the circulatory system
Can produce multi-system organ failure
Symptoms
Respiratory failure
Neurological dysfunction
Petechial rash
What to do for fat embolism and treatment
On the medical-surgical floor
Close monitoring for the first 4 to 12 hours
Incentive spirometer
Early ambulation
Treatment
Intubation, mechanical ventilation with PEEP
Supportive care
Hip fractures Clinical Manifestations
Joint surfaces become rough
Pain, swelling, deformity
Discomfort to groin, buttock, thigh
Stiffness in morning
Increasing pain with activity
Inability to rotate, flex, extend hip
Total hip arthroplasty
Removal of femoral head
Creation of post-hole in femur for implant
Repair and placement of
head and stem
Artificial joint may
need replacing in 15
to 20 yrs
Nursing care post THA
DVT Prevention
Early ambulation
Pain management
Incisional care
Traditional post-op care
Hip Precautions after THA
Do not bend the hip more than 90 degrees.
Do not cross legs or feet.
Do not roll or lie on your unoperated side for the first 6 weeks.
Do not twist the upper body when standing.
Sleep on the back for the first 6 weeks.
Total knee replacement?
Patients with progressive arthritis, trauma, rare diseases that damage joint
Most common in United States: severe osteoarthritis
Progressively increasing pain and stiffness
Diagnostic test: MRI
Total knee replacement nursing management
Early obilization
Continuous passive motion (CPM) device
Pain controlled with medication
Hospital stay 3 to 7 days
Discharge goals: bend
knee 90 degrees,
walk with crutches or
walker
Mobility Assistive devices:
Crutches
Wheelchairs
Walkers
Canes
Reachers
Traction
Application of a pulling force to the body to provide reduction, alignment, and rest at that site
Types of traction: skin, skeletal
Traction care:
Maintain correct balance between traction pull and countertraction force
Care of weights
Skin inspection
Pin care
Assessment of neurovascular status
External fixations systems:
Unilateral fixators
Taylor spatial frame fixator
The earliest signs and symptoms of FES are
a low arterial oxygen level (hypoxemia),
dyspnea, and tachypnea (increased respirations).
Headache, lethargy, agitation,
confusion, decreased level of consciousness, seizures, and vision changes may
follow
Nonpalpable, red-brown petechiae—a macular, measles-like rash—may
appear over the neck, upper arms, and/or chest. This rash is a classic
manifestation but is usually the last sign to develop (
