Week 7: Muculoskeletal Disorders Flashcards
What can cause a shortening of the trunk in older adults?
Vertebral disks become thinner as a result of gravity and dehydration, spontaneous and unknown spinal fractures may occur as the result of osteoporosis (OP) causing a shortening of the trunk.
What causes postural and structural changes to occur?
Primarily because of age-related bone calcium loss and atrophic cartilage and muscle.
Aging of the Musculoskeletal System: Bones
Bone renewal cannot keep pace with resorption -> results in reduced bone mineral density -> bones become brittle and fracture more easily.
What are factors that affect bone loss in older adults?
- Genetics
- Hormonal factors (estrogen and testosterone levels)
- Decreased bone development
- Nutritional deficiencies (especially calcium, magnesium and vitamin D)
- Underlying conditions (i.e immune disorders, thyroid disease)
- Lifestyle choices (i.e physical inactivity, smoking and alcohol intake)
Excessive loss of bone mineral density can lead to what?
Osteopenia or osteoporosis
What can cause age related deterioration in articular cartilage?
Biochemical changes
The aging of the musculoskeletal system: Joints
As joints dry, movement is less fluid and pain may result if changes progress to the extent where bone rubs bone.
The aging of the musculoskeletal system
- Approximately 1% of the bulk and strength of skeletal muscle decline for each year after the age of 50.
- Accelerated loss occurs with disuse and deconditioning
Sarcopenia
..
What are the most common musculoskeletal disorders?
Osteoarthritis
Rheumatoid Arthritis
Gout
Psuedogout
Form of arthritis in which calcium crystals deposit in the joints causing pain
Polymyalgia Rheumatica
Inflammatory disorder causing muscle pain and stiffness around the shoulders and hips
Osteoporosis: Major Risk Factors
- Caucasians and Asians at highest risk
- Low body weight
- Family history of osteoporosis
- Estrogen deficiency
- Inadequate calcium and vitamin D intake
- Lack of weight-bearing activities
- Excess alcohol use (>1 drink daily for women and >2 for men)
- Smoking/exposure to tobacco smoke
- Eating disorders
DEXA Scan
Determines the presence of reduced bone mineral
Osteoporosis: Etiology
-Results from gradual loss of cortical and trabecular bone and micro architectural deterioration.
Primary osteoporosis
is likely a normal change of aging, particularly in postmenopausal women who do not take hormone replacement therapy.
Secondary Osteoporosis
can be caused by a number of factors including dietary deficiencies of calcium and vitamin D, medications such as steroids, and autoimmune disorders.
What are complications of osteoporosis?
Morbidity and mortality resulting from an osteoporosis related fall (hip fractures leads to high degree of morbidity and premature mortality)
Where are the most common sites for fractures?
- Hips
- Vertebra
- Wrist
- Pelvis
FRAX Tool
A computerized calculator for determining 10-year probability of fracture.
Osteoarthritis
- Slow, progressive, non-inflammatory disorder of the diarthrodial (synovial) joints
- Involves the entire joint including the cartilage, joint lining, ligaments and underlying bones.
Is osteoarthritis a part of the aging process?
NOT a normal part of aging process (aging is only a risk factor)
Joints commonly affected by osteoarthritis include
- Knees
- Hips
- Hands
- Spine
What are causes of osteoarthritis?
- The specific causes are unknown; however, it is believed to be a combination of mechanical forces and molecular events in the affected joint.
- Idiopathic
- Conditions that directly damage the cartilage or causes joint instability (trauma, mechanical stress, inflammation, skeletal deformities, hematological disorders, endocrine disorders, and medications such as steroids)
What are modifiable risk factors for osteoarthritis?
- Obesity
- Joint injury
- Knee pain
- Occupation requiring excessive or repeated mechanical stress
- Muscle weakness
What are non-modifiable risk factors for osteoarthritis?
- Gender (female)
- Age (increases until about 75)
- Race (Asians with lowest risk)
- Genetic predisposition
- Poor proprioception
Diagnostics Criteria for osteoarthritis include
- Stiffness in a joint when getting in and out of bed or sitting for a long time.
- Swelling or tenderness in one or more joints.
- Crepitus in the joint (feeling of ‘crunching’ as bones rub together).
- May or may not include x-rays of the joint, which may show narrowed space within the joint.
Signs and Symptoms of Osteoarthritis include
- Stiffness with inactivity (greater in the morning but usually resolves within 20-30 minutes after movement begins)
- Pain with activity that is relieved at rest
- Subluxation and joint instability may be found
- Crepitus is common
- Spinal stenosis develops in the lumbar region
- Osteophytes develop in the joints of the fingers
Complications of Osteoarthritis include
- Degenerative changes on function
- Side effects of the treatment RT pain
Nursing Care for Osteoarthritis: Focus is on
1) Managing pain and inflammation
2) Preventing disability
3) Maintaining and improving joint function
Nursing Care for Osteoarthritis: Interventions include
- Rest and joint protection (immobilization should not exceed 1 week) with the use of assistive device.
- Ice for inflammation
- Heat for stiffness
- Nutritional therapy and exercise
- Complementary and alternative therapies include acupuncture, yoga and glucosamine and Chondroitin.
Pharmacological Interventions for Osteoarthritis
Based on severity of patient symptoms:
- Acetaminophen (1000 mg every 6 hours)
- Topical agent (e.g capsaicin cream [Zostrix])
- Topical salicylates (e.g Aspercreme)
- Other OTC (Bengay)
- NSAIDs: Ibuprofen 200 mg up to 4x daily
Rheumatoid Arthritis
A systemic inflammatory autoimmune disorder affecting primarily the joints, where it causes pain, swelling, stiffness and los of function.
Infalmmation of the synovium causes
Destruction of the surrounding cartilage and bone.
Why is rapid diagnosis of rheumatoid arthritis necessary?
So treatment can begin as early as possible, providing greatest chance the joints can be preserved
Signs and Symptoms of RA include
- Tender, warm, swollen joints
- Symmetrical pattern of affected joints
- Joint inflammation often affecting the wrist and finger joints closest to the hand
- Joint inflammation sometimes affecting other joints, including the neck, shoulders, elbows, hips, knees, ankles and feet.
- Fatigue, occasional fevers and loss of energy
- Pain and stiffness lasting >30 minutes in the morning or after a long rest**
- Symptoms last for many years
What are the causes of RA?
- Etiology unknown, but now believed to be the result of interaction between environmental exposures, genetic factors and age-related increased autoimmunity.
- Single nucleotide polymorphism
What are the three variations of RA?
- Monocyclic
- Polycyclic
- Progressive
Monocyclic RA
One episode lasting 3-5 years
Polycyclic RA
Intensity of symptoms varies over time
Progressive RA
Increase in severity and present all the time
What are complications of RA?
- Boutonnière Deformity or flexion of the distal inter phalange always (DIP) joint with flexion of the proximal interphalangeal (PIP) joint
- More likely to die to heart disease at a higher rate than general population
What are the most common co-morbidities of RA?
- Cardiovascular disease
- Infections such as TB
- Depression
- Anxiety
- Lymphoproliferative malignancies
Gout
An inflammatory arthritis characterized by the deposition of uric acid crystals in the tissue and fluid in the body.
Where is the most common site for gout?
The joint of the great toe, however it may occur in the ankle, knee, wrist or elbow.
Etiology: Gout
- Cytokine-mediated inflammatory response to the accumulation of uric acid in the blood and other body fluids, such as synovial fluid of a joint or joints.
- Clinical manifestation of either overproduction of uric acid or inadequate excretion of uric acid.
- Excessive alcohol consumption, lead toxicity and a high purine diet can also cause gout.
Signs and Symptoms of Gout
- Pain in the affected joint or joints, often starting in the middle of the night awakening one from sleep.
- Joint is bright red, hot and too painful to touch.
Complications of Gout include
Crystallization of uric acid, forming insoluble precipitates that gather in the SQ tissue.
- Seen as small, white tophi that may be quite painful.
- Can collect in the kidneys and form irate renal stones and cause renal failure.
Osteoporosis education and preventative strategies:
- Nutrition: Calcium and Vitamin D
- Exercise
- Education
- Pharmacological approaches
What are goals when treating OA and RA?
The goals are to minimize disability by preventing further damage and assuring adequate pain relief.
Pharmacological treatment of OA and RA
NSAIDs or COX-2 inhibitors
DMARDs
The first goal of treatment during an acute attack of gout is to
Stop it as promptly as possible.
Pharmacological treatment for gout includes
- NSAIDs
- Colchicine
- Long-acting steroids into joint
After an acute attack of gout, the goal is to
- Prevent another attack
- Prevent systemic spread of the disease
- Prevent the development of chronic gout
Nursing Care for Gout: Nutrition
Foods high in purines
- Meat, poultry and fish (limit 4-6 oz daily)
- Organ meats such as hearing, anchovies and mackerel
- Alcohol (limit or avoid)
- Foods sweetened with high-fructose corn syrup (limit or avoid)
