Musculoskeletal Disorders Part II Osteoporosis Fractures Degenerative Joint Disease/Osteoarthritis Total Hip and Knee Prostheses Bone Infections / Osteomyelitis Gout Concept Map: Selected Topics in Musculo-Skeletal Nursing ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation “Neuro / Circ Checks” --”The 6 P’s” PATHOPHYSIOLOGY PHARMACOLOGY Fracture Osteoporosis Degenerative Joint Disease Osteoarthritis Osteomyelitis Gout Opioids NSAIDs Antibiotics Disease Specific Amputation Total Joint Replacement Lab Monitoring Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more…based On Nursing Process: A_D_O_P_I_E NURSING DIAGNOSES THAT APPLY…. Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary Nursing Diagnoses That (Might) Apply Pain, acute Comfort, impaired Mobility, altered Self-care deficit –feeding, grooming; bathing, hygeine; toileting Falls, risk for Skin breakdown, risk for Constipation, risk for Diversional activity, risk for Mobility, Physical, impaired Mobility, bed, risk for Walking, impaired, Tissue perfusion, impaired peripheral Peripheral neurovascular dysfunction, risk for Knowledge, deficient Body image, disturbed Grieving More…… Neurovascular Components: Early or Late Signs Assessment Parameters Client Teaching / Symptoms to Report Early Assess area involved using 0 to 10 rating scale: Increasing pain not relieved with elevation or pain medication “The 6 P’s” Pain 0 = no pain 10 = worst pain imaginable Paresthesia Early Assess for numbness/tingling, pins or needles sensation: Should be absent. Numbness or tingling, pins or needles sensation Pallor Early Assess capillary refill. Increased capillary refill time > 3 seconds, blue fingers or toes Brisk is < 3 seconds Polar Late Assess skin temperature by touch: Cool/cold fingers or toes Warm <or> Cool Paralysis Late Assess mobility: Moves fingers or toes Able to plantar dorsiflex the ankle area not involved or restricted by cast Unable to move fingers or toes Pulses Late Assess pulse(s) distal to injury: Pulse is palpable and strong Weak palpable pulses, unable to palpate pulses, pulse detected only with Musculoskeletal Disorders Degenerative Joint Disease (DJD) a degenerating arthritic condition that affects any joint in the body, including the spine (then it is called DDD – Degenerative Disc Disease) Risk Factors: Obesity (More in the weight – bearing joints) Poor nutrition, low in calcium or vitamin D Genetics – familial arthritis Overuse injuries or manual labor Sports injuries which affect the bursae or tendon - meniscal tissues that cushion the joint Smoking – as it dehydrates and constricts tissues Musculoskeletal Disorders Degenerative Joint Disease (DJD) Pathophysiology - the bone and supporting tissues start to degenerate, causing atrophy of tendons, and bone spurring, with degeneration of menisci and bursa which would normally protect the joint. Main symptoms are “stiffness in the morning” and pain. Eventually the bone spurring and breakdown will cause joint deformities. Musculoskeletal Disorders Degenerative Joint Disease (DJD) Also called OA – Osteoarthritis Diagnosis: Symptoms and history Arthroscopy X-rays MRI – for soft tissue visualization, i.e of menisci or bursae Bone scan if cancer has to be ruled out Musculoskeletal Disorders Degenerative Joint Disease (DJD) Note the loss of joint space with bone on bone Musculoskeletal Disorders Degenerative Joint Disease (DJD) Musculoskeletal Disorders Degenerative Joint Disease (DJD) Treatments – heat and cold therapy Preventative exercises – to strengthen supporting muscles Joint Injections – Hydralan, cortisone, etc. Analgesics/Anti-inflammatories – COX – 2 inhibitors i.e. Mobic, Celebrex Tylenol – contraindicated for liver patients Indocin - more risk for peptic ulcers Aspirin – more risk for peptic ulcers Partial or complete surgical repair Joint prosthesis Musculoskeletal Disorders Degenerative Joint Disease (DJD) – Musculoskeletal Disorders Hip Prosthesis Musculoskeletal Disorders knee prosthesis Musculoskeletal Disorders Care of Patients – Pain control Ambulation with assistance - only Prevent falls Exercise; usually has physical therapy from 6 - 8 weeks Non-smoking Encourage adequate intakes of vitamin C Post-op anti-coagulants, whether Lovenox, coumadin, heparin, or aspirin Musculoskeletal Disorders Hip prosthesis – NEVER adduct the leg (letting the hip and leg cross the other one will pop the prosthetic ball out of the pelvis) Only allow hip flexion to 90 degrees Turn patients using an adductor pillow while aligning the spine Musculoskeletal Disorders Adductor pillow between knees Musculoskeletal Disorders Bone infections Causes: Immunological problems Diabetes, nutritional problems Injury which allows pathogens into the bone fractures coral cuts trauma post-operative surgery Musculoskeletal Disorders Bone infections Chronic Osteomylitis in a diabetic Musculoskeletal Disorders Bone infections Diagnosis: Bone scan X-rays MRI for soft tissue view Blood cultures – need to be done 15 minutes apart from two different sites Wound cultures – if drainage is apparent Musculoskeletal Disorders Bone infection symptoms: Foul smelling drainage Fever Lethargy Swelling Redness Increased WBC’s on CBC with differential With increased neutrophils on the CBC, sometimes called PMN’s or polymorphic neutrophils. These cells in particular replicate to fight infection. If the WBC is not elevated with these symptoms, the patient is immunosuppressed and at risk for sepsis. Musculoskeletal Disorders Bone Infections Most common organisms: Staphlococci Aureus – MRSA in the hospital postoperatively (a drug resistant organism) Enterococci from wounds/trauma Clostridium Perfringens – gangrene E-Coli – fecal contamination Musculoskeletal Disorders Osteomylitis Treatments/Interventions #1 Pain control Monitor Vital signs every 4 hours and prn (Observe for signs of sepsis or drug reaction) Monitor skin integrity and site - intravenous antibiotics to get rid of infection (need a physician’s order) Surgical repair or debridement Removal of infected prostheses Sometimes it is necessary for amputation Musculoskeletal Disorders Ewing’s Sarcoma of the bone – usually malignant with mets, often treated with amputation Musculoskeletal Disorders Osteosarcoma – most common type of malignant bone tumor, most often in males between 10 and 30 y.o. or in older patients with Paget’s Disease osteosarcoma Chondrosarcoma This is a photograph of 70 year old woman who first presented like this with a massive chondrosarcoma of her right upper humerus of 8 months duration. She refused all treatment, and she died of a massive haemorrhage when the tumour burst the following week. http://worldortho.com/dev/index.php?option=com_content& task=view&id=1814&Itemid=328 Musculoskeletal Disorders Chondroma Musculoskeletal Disorders Types of amputations Simple Toe – uncomplicated, most often due to injury and diabetes Musculoskeletal Disorders Amputations – BKA Below the knee Treatments for amputations will be further covered in Adult Health Care II Musculoskeletal Disorders Types of Amputations AKA – above the knee – a surgical technique for saving a person’s life from an infected prosthesis or necrotic limb Musculoskeletal Disorders Amputations - facts and figures: More than 100,000 amputations are performed in the USA every year. The most common cause of amputations is diabetes & infection Of the 9,985 nonfatal workplace amputations in 1999, more than 1 in 3 cases required 31+ days away from work to recuperate (OSHA study) The third most common cause today is war-related. http://www.peglegbiker.com/index.html Musculoskeletal Disorders Assessment must include: Pain as a no. 1priority Proper patient assessment must include pain intensity, radiation, relief, medication side effects, and reassessment on a regular basis. Skin integrity Tissue Perfusion Prevention of infection Promotion of nutrition Exercise & ROM Body Image Musculoskeletal Disorders Gout – Pathophysiology Gout is a disease caused by the kidneys not clearing the uric acid out of the blood stream. Uric acid is the end product of purines in our diet (one of the amino acids in the body).This causes a hyperuricemia (high levels of uric acid in the blood) and initiates an inflammatory response in the joints. The urate crystals deposit into a joint and/or subcutaneous tissues..This deposit and inflammation causes “gouty arthritis” and may appear the same as OA on X-ray.The deposits can also cause kidney stones, as deposits build up in the kidneys. Renal stones are `1000 times more common in people with gout. Musculoskeletal Disorders Gout Symptoms: Tophi - white crystalized deposits in the tissue, usually seen on the hands or toes. Heat & Redness Pain – Severe & sudden onset Swelling Inflammation – usually on one side of the body first, a ankle joint, knee, or toe May become an acute inflammation after an injury, i.e. stubbing your toe on the sprinkler Musculoskeletal Disorders Gout – Diagnosis: - X-ray of limb to rule out regular arthritis, osteomylitis/cellulitis - blood test for a uric acid level normal is 4.0-5.2 (lab values may differ the age of the patient) - Anything over 6.0 is consider high - An aspiration of the fluid in the joint will demonstrate crystalline deposits by microscope or based on Musculoskeletal Disorders Treatments Anti-inflammatories STAT – drugs of choice are colchicine and indocin – Patients need to be educated to side effects and dosing. Sometimes, doctors will give Toradol IM for immediate pain relief, as it acts like injectable aspirin and reacts quickly Pain control Maintenance on daily allopurinol – to allow the kidneys to secrete the acid Educate patient to avoid high purine foods Musculoskeletal Disorders gout Musculoskeletal Disorders Gout tophi Musculoskeletal Disorders Gouty tophi (in red) Pharmacology Associated with Musculoskeletal Patients--General Information Assess/monitor the client’s need for pain medication, and plan and provide care to meet the client’s needs for pain intervention. Assess/monitor the client for actual/potential specific food and medication interactions. Identify contraindications, Assess/monitor the effectiveness of pain intervention, and advocate for the client’s needs as indicated. Provide appropriate client education, and reinforce client teaching regarding the purposes and possible effects of pain medications. Assess/monitor the client for expected effects of medications. Assess/monitor the client for side/adverse effects of medications. actual/potential incompatibilities, and interactions between medications, and intervene appropriately. Identify symptoms/evidence of an allergic reaction, and respond appropriately. Evaluate/monitor and document the therapeutic and adverse/side effects of medications. Assess/collect data regarding the client’s medication use over time. Musculoskeletal Pharmacology : Medications for Pain & Inflammation NSAIDs—Non Steroidal Anti-Inflammatory Drugs Prototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®) Pharmacological Action Aspirin contraindications include: Inhibition of cyclooxygenase: Inhibition of COX-2 results in ↓ inflammation, pain, and fever. Inhibition of COX-1 results in the ↓ of platelet aggregation Peptic ulcer disease. Bleeding disorders (e.g., hemophilia, vitamin K deficiency) Hypersensitivity to aspirin and other NSAIDs. Pregnancy (Pregnancy Risk Category D). Children with chickenpox or influenza. Use NSAIDs cautiously in older adults, clients who smoke cigarettes, and in clients with H. pylori infection, hypovolemia, hay fever, chronic urticaria, and/or a history of alcoholism. Therapeutic Uses Inflammation suppression Analgesia for mild to moderate pain Fever reduction Dysmenorrhea Low level suppression of platelet aggregation Musculoskeletal Pharmacology : Medications for Pain & Inflammation NSAIDs—Non Steroidal Anti-Inflammatory Drugs Prototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®) Therapeutic Nursing Interventions and Client Education Advise the client to stop aspirin 1 week before an elective surgery or expected date of childbirth. Advise the client to take aspirin with food, milk, or a full glass of water to reduce gastric discomfort. Instruct the client not to chew or crush enteric-coated or sustained-release aspirin tablets. Advise the client to notify the primary care provider if signs and symptoms of gastric discomfort or ulceration occur. Clients unable to tolerate aspirin due to GI ulceration, risk of bleeding, or renal impairment should be prescribed a 2nd generation NSAID, such as celecoxib (Celebrex). CONTINUED… One 1st generation NSAID, ketorolac (Toradol), is used for short-term treatment of moderate to severe pain such as that associated with postoperative recovery. Ketorolac provides analgesia without antiinflammatory effect. When ketorolac is used concurrently with opioids, the analgesic effect of opioids is enhanced without the occurrence of adverse effects associated with opioids (e.g., respiratory depression, constipation). When ketorolac is used with other NSAIDs serious adverse effects can occur; therefore, ketorolac should be used no more than 5 days. Usually started as parenteral administration and then progresses to oral doses. Depending on therapeutic intent, effectiveness of NSAID USE may be evidenced by: Reduction in inflammation. Reduction of fever. Relief from mild to moderate pain or dysmenorrhea. Platelet aggregation suppression. Musculoskeletal Pharmacology : Medications for Pain & Inflammation Acetaminophen Prototypes: acetaminophen (Tylenol® ) Pharmacological Action Acetaminophen slows the production of prostaglandins in the central nervous system. Therapeutic Uses Analgesic (relief of pain) effect Antipyretic (reduction of fever) effects Side/Adverse Effects: Nursing Interventions and Client Education Acetaminophen is a component of multiple prescribed and over-the-counter medications. Keep a running total of daily acetaminophen intake and follow recommended dosages as prescribed by the primary care provider to prevent toxicity, not to exceed 4 g per day. In the event of an acetaminophen overdose, liver damage can be reduced by administering a weightbased dosage of the antidote acetylcysteine (Mucomyst) in a diluted form via an oroduodenal tube (has an unpleasant odor that ↑ risk of emesis). Nursing Interventions and Client Education Acute toxicity that results in liver damage with early symptoms of nausea, vomiting, diarrhea, sweating, and abdominal discomfort progressing to hepatic failure, coma, and death Advise the client to take acetaminophen as prescribed and not to exceed 4 g per day. Administer the antidote, Nursing Evaluation of Medication Effectiveness Depending on therapeutic intent, effectiveness may be evidenced by: Acetylcysteine (Mucomyst® ). Use cautiously in clients who consume three or more alcoholic drinks/day and those taking warfarin (interferes with metabolism). Relief of pain. Reduction of fever. Musculoskeletal Pharmacology : Medications for Pain & Inflammation Opioid Agonists Prototypes: Morphine sulfate Pharmacological Action Contraindications/Precautions Opioid agonists, such as morphine, codeine, meperidine, and other morphine-like medications (fentanyl), act on the mu receptors, and to a lesser degree on kappa receptors. Activation of mu receptors produces analgesia, respiratory depression, euphoria, and sedation, whereas kappa receptor activation produces analgesia, sedation, and ↓ GI motility. Contraindicated: Therapeutic Uses asthma, emphysema, and/or head injuries Relief of moderate to severe pain (e.g., postoperative pain, myocardial infarction pain, cancer pain) Infants and older adult clients Pregnant clients Sedation Clients in labor Reduction of bowel motility Clients with inflammatory bowel disease Codeine: cough suppression Clients with an enlarged prostate after biliary tract surgery. for premature infants (during and after deliverydue to respiratory depressant effects). Used Cautiously: because of respiratory depression Demerol ® -- meperidine Repeated use of meperidine (Demerol) can result in the accumulation of normeperidine, which can result in seizures and neurotoxicity. Do not administer meperidine more than 600 mg/24 hr, and limit its use to less than 48 hr. Morphine Sulfate Side Effects / Adverse Effects Nursing Interventions / Client Education Respiratory depression --Monitor the client’s vital signs. --Stop opioids if the client’s respiratory rate is less than 12/min, and then notify the primary care provider. --Avoid the use of opioids with CNS depressant medications (e.g., barbiturates, benzodiazepines, and consumption of alcohol). Constipation --↑ fluid intake and physical activity. --Administer a stimulant laxative, such as bisacodyl (Dulcolax), to counteract ↓ bowel motility, or a stool softener, such as docusate sodium (Colace), to prevent constipation. Orthostatic hypotension --Advise the client to sit or lie down if symptoms of lightheadedness or dizziness occur. --Avoid sudden changes in position by slowly moving the client from a lying to a sitting or standing position. --Provide assistance with ambulation as needed. Urinary retention --Advise the client to void every 4 hr. --Monitor I&O. --Assess the client’s bladder for distention by palpating the lower abdomen area every4 to 6 hr. Cough suppression --Advise the client to cough at regular intervals to prevent accumulation of secretions in the airway. --Auscultate the client’s lungs for crackles, and instruct the client to ↑ intake of fluid to liquefy secretions. Sedation --Advise the client to avoid hazardous activities such as driving or operating heavy machinery. Biliary colic --Avoid giving morphine to clients who have a history of biliary colic. Use meperidine as an alternative. Emesis --Administer an antiemetic such as promethazine (Phenergan). Opioid overdose triad of coma, respiratory depression, and pinpoint pupils --Monitor the client’s vital signs. --Place the client on a ventilator. --Administer opioid antagonists, such as naloxone (Narcan) or nalmefene (Revex). Musculoskeletal Pharmacology Medications for Pain & Inflammation Agonist – Antagonist Opioids Prototypes: pentazocine (Talwin ®) Pharmacological Action Compared to pure opioid agonists, agonistantagonists have: --A low potential for abuse causing little euphoria. In fact, high doses can cause adverse effects (e.g., anxiety, restlessness, mental confusion). --Less respiratory depression. Kappa receptors will cause a certain degree of respiratory depression and then no more (have a “ceiling”). Therapeutic Uses Agonists-antagonists opioids relieve mild to moderate pain; not used for treatment of severe pain. Contraindications/Precautions Use cautiously in clients with a history of myocardial infarction (↑ cardiac workload) and clients who are physically dependent on opioids. Nursing Interventions and Client Education Take the client’s baseline vital signs. If the client’s respiratory rate is less than 12/min, withhold the medication and notify the primary care provider. Warn the client not to ↑ dosage without consulting the primary care provider. Nursing Evaluation of Medication Effectiveness --Monitor for improvement of symptoms, such as relief of pain. Musculoskeletal Pharmacology Medications for Pain & Inflammation Opioid Antagonists Prototypes: naloxone (Narcan ®) Pharmacological Action Opioid antagonists interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no effect in the absence of opioids. Therapeutic Uses Treatment of opioid overdose Reversal of effects of opioids, such as respiratory depression Reversal of respiratory depression in an infant Contraindications/Precautions Hypersensitivity Opioid dependency Pregnancy Risk Category B Therapeutic Nursing Interventions and Client Education Naloxone has rapid first-pass inactivation and should be administered IV, IM, or SC. Do not administer orally. Observe the client for withdrawal symptoms and/or abrupt onset of pain. Be prepared to address the client’s need for analgesia (e.g., if given for postoperative opioid-related respiratory depression). Nursing Evaluation of Medication Effectiveness Reversal of respiratory depression (e.g., respirations are regular, client is without shortness of breath, respiratory rate is 16 to 20/min in adults and 40 to 60/min in newborns) Musculoskeletal Pharmacology Medications for Pain & Inflammation Adjuvant Pain Medications Prototypes:Tricyclic anti-depressants; anticonvulsants; CNS Stimulants; antihistamines; glucocorticoids; & biphosphonates Tricyclic antidepressants: amitriptyline (Elavil) Anticonvulsants: carbamazepine (Tegretol), gabapentin (Neurontin), phenytoin (Dilantin CNS stimulants: methylphenidate (Ritalin), dextroamphetamine (Dexedrine) Antihistamines: hydroxyzine (Vistaril) Glucocorticoids: dexamethasone (Decadron), prednisone (Deltasone) Bisphosphonates: etidronate (Didronel), pamidronate (Aredia) Pharmacological Actions Adjuvant medications for pain enhance the effects of opioids. Therapeutic Uses Used in combination with opioids – cannot be used as a substitute for opioids Treating pain with an adjuvant medication allows for lower dosages of opioids, and thereby ↓ the adverse effects experienced with opioids (e.g., sedation and constipation). Help alleviate other symptoms that aggravate pain (e.g., depression, seizures, dysrhythmias) Used in the treatment of neuropathic pain (e.g., cramping, aching, burning, darting and lancinating pain). Used in cancer-related conditions (e.g., ↑ intracranial pressure, spinal cord compression, bone pain). Musculoskeletal Pharmacology Medications for Pain & Inflammation Antigout Medication Prototypes: colchicine Pharmacological Action Colchicine and indomethacin ↓ inflammation in clients with gout by possibly preventing infiltration of leukocytes. These medications do not effect uric acid production or excretion. Allopurinol inhibits uric acid production. Probenecid inhibits uric acid reabsorption by the renal tubules. Contraindications/Precautions Avoid use of colchicine during pregnancy (FDA Pregnancy Risk Category C, if used orally; Category D, if used intravenously). Use colchicine cautiously in older adults, debilitated clients, and clients with renal, cardiac, and gastrointestinal dysfunction. Therapeutic Nursing Interventions and Client Education Instruct the client to concurrently take preventive measures such as avoiding alcohol and foods high in purine (e.g., red meat, scallops, cream sauces). The client should ensure an adequate intake of water, exercise regularly, and maintain an appropriate body weight. Nursing Evaluation of Medication Effectiveness Depending on the therapeutic intent, effectiveness may be evidenced by: --Improvement of pain caused by a gout attack (e.g., ↓ in joint swelling, redness, and uric acid levels). Therapeutic Uses Colchicine and indomethacin: --Treatment of acute gout attacks. --If given in response to precursor symptoms of an acute gout attack, can abort the attack. --↓ in the incidence of acute attacks for clients with chronic gout. Allopurinol and probenecid: --Hyperuricemia (chronic gout secondary to cancer chemotherapy). Probenecid: --Prolongs the effects of penicillins and cephalosporins by delaying their elimination. --↓ in number of gout attacks. --↓ in uric acid levels. Musculoskeletal Disorders Case Study Exercise Group I John is a 34 y.o. skier with a spiral fracture of the right tibia. He has pins set to traction below his knee to continue with 5 pounds of pressure to hold the ones in place. Create a nursing care plan, that you will present to the class. Complete with two references: Research articles on Traction, pins, and spiral fractures. Musculoskeletal Disorders Case Study Exercise Group II Maria is a 48 y.o. with osteomyelitis and MRSA of the (R) tibia. Medical history includes Diabetes Mellitus, Type 2. She is returning from the operating room, S/P Right BKA Create a nursing care plan, that you will present to the class. Complete with two references: Research articles on amputation. Musculoskeletal Disorders Case Study Exercise Group III Franklin is a 64 y.o. male who is returning from the operating room, S/P (R) Total knee replacement. He is otherwise “healthy,” on no home medications other than NSAIDs. Create a nursing care plan, that you will present to the class. Complete with two references: Research articles on TJR. Musculoskeletal Disorders Case Study Exercise Group IV Johnna is a 48 y.o. with severe pain to her right ankle. Has just been diagnosed with gout. Create a nursing care plan, that you will present to the class. Complete with two references: Research articles on Gout and its treatment.