Musculoskeletal
Stressors
NUR240
JBorrero 10/08
Arthritis
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Degenerative Joint Disease
Arthritis= joint inflammation.
Arthralgia= joint pain
Different types of arthritis:
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Osteoarthritis
Rheumatoid arthritis
Gouty arthritis
Osteoarthritis
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Most common form of arthritis, noninflammatory,
nonsystemic disease
One or many joints undergo degenerative and
progressive changes, mainly wt. bearing joints.
Stiffness, tenderness, crepitus and enlargement
develop.
Deformity, incomplete dislocation and synovial
effusion may eventually occur.
Treatment: rest, heat, ice, anti inflammatory drugs,
decrease wt. if indicated, injectable corticosteroids,
surgery.
Osteoarthritis- Risk Factors
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Age
Decreased muscle strength
Obesity
Possible genetic risk
Early in disease process, OA is difficult to dx
from RA
Hx of Trauma to joint
OA- Signs and Symptoms
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Joint pain and stiffness that resolves with rest
or inactivity
Pain with joint palpation or ROJM
Crepitus in one or more joints
Enlarged joints
Heberden’s nodes enlarged at distal IP joints
Bouchard’s nodes located at proximal IP
joints
What to assess for:
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ESR, Xrays, CT acans
Pain
Degree of functional limitation
Levels of pain/fatigue after activity
Range of motion
Proper function/joint alignment
Home barriers and ability to perform ADLs
Osteoarthritis- Tx
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Pharmacotherapy- tylenol, NSAIDS, ASA, Cox-2
inhibitors
Intra-articular injections of corticosteroids
Glucosamine- acts as a lubricant and shock
absorbing fluid in joint, helps rebuild cartilage
Balance rest with activity
Use bracing or splints
Apply thermal therapies
Arthroplasty- joint replacement can relieve pain and
restore loss of function for patients with advanced
disease.
Auto-Immune Disease
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Inflammatory and immune response are normally
helpful
BUT these responses can fail to recognize self cells
and attack normal body tissues.
Called an auto-immune response
Can severly damage cells, tissues and organs
EG. RA, SLE, Progressive systemic sclerosis,
connective tissue disorders and other organ specific
disorders
Rheumatoid Arthritis
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Chronic, systemic, progressive inflammatory
disease of the synovial tissue, bilateral,
involving numerous joints.
Synovitis-warm, red, swollen joints resulting
from accumulation of fluid and inflammatory
cells.
Classified as autoimmune process
Exacerbations and remissions
Can cause severe deformities that restrict
function
RA- Risk Factors
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Female gender
Age 20-50 years
Genetic predisposition
Epstein Barr virus
Stress
Rheumatoid Arthritis- Dx
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Rheumatoid Factor antibody- High titers
correlate with severe disease, 80% pts.
Antinuclear Antibody (ANA) Titer- positive
titer is associated with RA.
C- reactive protein- 90% pts.
ESR: Elevated, moderate to severe elevation
Arthocentesis- synovial fluid aspirated by
needle
RA – Signs and Symptoms
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Joints- bilateral and symmetric stiffness, tenderness,
swelling and temp. changes in joint.
Pain at rest and with movement
Pulses- check peripheral pulses, use doppler if
necessary, check capillary refill.
Edema- observe, report and record amt. and location
of edema.
ROM, muscle strength, mobility, atrophy
Anorexia, weight loss
Fever- generally low grade
RA- Sign and Symptoms
1. Fatigue- unusual fatigue, generalized weakness
2. Morning stiffness lasting longer than 30 minutes
after rising, subsides with activity.
3. Red, warm, swollen, painful joints
4. Systemic S&S
5. Pain- at rest and with movement
What should we monitor?
Rheumatoid Arthritis- Tx
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Rest, during day- decrease wt. bearing stress.
ROM- maintain joint function, exercise –water.
Medication- analgesic and anti-inflammatory
(NSAIDS), steroids,Gold therapy, topical meds.
Immunosuppressive drugs- Imuran, Cytoxan,
methotrexate. Monitor for toxic effects
Biological response modifiers (BRM):Inhibit action of
tumor necrosis factor (Humira, Enbrel, Remicade)
Ultrasound, diathermy, hot and cold applications
Surgical- Synovectomy, Arthroplasty, Total hip
replacement.
Nursing Interventions
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Assist with/encourage physical activity
Provide a safe environment
Utilize progressive muscle relaxation
Refer to support groups
Emotional support
Complications
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Sjogrens’s syndrome
Joint deformity
Vasculitis
Cervical subluxation
Gouty Arthritis
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Very painful joint inflammation, swollen and reddened
Primary-Inborn error of uric acid metabolism- increases production
and interferes with excretion of uric acid
Secondary- Hyperuricemia caused by another disease
Excess uric acid – converted to sodium urate crystals and
precipitate from blood and become deposited in joints- tophi or in
kidneys, renal calculi
Treatment:
Meds- colchicine, NSAIDS, Indocin (indomethacin), glucocorticoid
drugs,
Allopurinol, Probenecid-reduce uric acid levels
Diet- excludes purine rich foods, such as organ meats, anchovies,
sardines, lentils, sweetbreads,red wine
Avoid ASA and diuretics- may precipitate attacks
Systemic Lupus
Erythematosus
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SLE- Chronic Inflammatory disease affecting many
systems.
Women between 18-40, black>white, child bearing
years
Autoimmune process- antibodies react with DNA,
immune complexes form- damage organs and blood
vessels.
Includes: vasculitis; renal involvement; lesions of skin
and nervous system.
Initial manifestation- arthritis, butterfly rash,
weakness, fatigue, wt. loss
Symptoms and tx. depend on systems involved.
Systemic Lupus
Erythematosus
Pathologic changes-Autoimmune process
1. Vasculitis in arterioles and small arteries
2. Granulomatous growths on heart valves- non
bacterial endocarditis.
3. Fibrosis of the spleen, lymph node adenopathy
4. Thickening of the basement membrane of
glomerular capillaries.
5. 90% swelling and inflammatory infiltrates of synovial
membrane.
SLE
6. Renal- Lupus nephritis
7. Pleural effusion or PN
8. Raynaud’s phenomenon- about 15% cases
9. Neuro- psychosis, paresis, migraines, and
seizures
SLE Dx
ANA- hallmark test, + in 98% pts.
MedicationsNSAIDS
Antimalarial meds- hydroxychloroquine (Plaquenil)
Immunosuppressive agents- pt teaching
corticosteroids, methotrexate,
cyclophosphamide
Antidepressants
Resources:
http://www.lupus.org
http://www.arthritis.org
Systemic Lupus- Education
Encourage to avoid undue emotional/ physical
stress and to get enough rest
 Alternate exercise + planned rest periods.
 Teach how to recognize the symptoms of a flare
 Teach how to prevent and recognize infection
 Avoid sunlight, use sunscreen
 Eat a well balanced diet,vitamins and iron.
 Establish short term goals
 Teach re: meds.
 Meds avoid- Pronestyl, Hydralazine.
Charting Chuckles
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On the second day, the knee was better, and on
the third day, it had completely disappeared.
While in the emergency department, she was
examined, X-rated, and sent home
The patient will need disposition, and therefore,
we will get Dr. Blank to dispose of him.
Patient was admitted through the emergency
department. I examined her on the floor.
Joint Replacement Indications
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Rheumatoid arthritis
Trauma
Congenital deformity
Avascular necrosis
Total Hip Replacement
Indications for surgery:
 Arthritis
 Femoral neck fractures
 Congenital hip disease
 Failed prosthesis
Pre-op management
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Assess medication history.
Assess Respiratory, neurovascular,
nutritional and integumentary status.
Presence of other diseases- COPD, CAD,
Hx. Of DVT or pulmonary embolism.
Discuss surgical procedure, informed
consent.
Prepare for autologous blood donation.
Pre-op teaching
Presence of drains and hemovac
postoperatively.
 Pain management (epidural/PCA).
 Coughing and deep breathing.
 Use of incentive spirometer
 ROM exercises to unaffected extremities.
 Post-op restrictions:
Need to avoid bending beyond 90 degrees
Importance of leg abduction post-op.
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Post-op Management of THR
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Assess neurovascular status of involved
extremity.
Incision site, wound drains, hemovac.
Note excessive bleeding or drainage
Respiratory status- elderly population.
Position of affected joint and extremity
Mental alertness
Assess Hgb and Hct
Pain management
Total hip replacementComplications
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Dislocation of hip prosthesis
Thromboembolism
Infection
Avascular necrosis
Loosening of the prosthesis
Dislocation of prosthesis
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Increased pain, swelling
Acute groin pain
Shortening of the leg
Abnormal internal or external rotation
Restricted ability or inability to move leg
Reported popping sensation in hip.
Impaired physical mobility r/t joint
replacement and pain
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Maintain bed rest with affected joint abducted
with wedge pillow.
Perform passive and teach active ROM to
unaffected joints, quad, isometric, gluteal
exercises.
Ambulate with assistance, WB restrictions
Turn pt. as ordered, monitor skin for
breakdown
Altered Tissue perfusion r/t
reduced flow and immobilization
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Administer parenteral fluids with electrolytes
to increase tissue perfusion.
Monitor VS q4h and prn, I and O.
Assess NV status q1h for first 12 hrs., then
q4h. Color, temp., pulse, sensation.
Ambulation and exercises
Monitor CBC, electrolytes, PT/INR
Administer anticoagulants - phlebitis
Pain r/t surgical intervention and
impaired mobility
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Assess location, intensity, quality pain.
Administer analgesics, sedatives, antiinflammatories, assess effectiveness,
Monitor PCA or continuous epidural
Change position frequently, back rubs.
Provide diversional activities- reduce
attention on pain.
Monitor - severe chest, affected joint pain.
Knowlwdge deficit R/T…
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Stress importance of rehab program and
exercises, no flexion greater than 90
degrees.
Discuss and demonstrate incision care
Medication teaching- especially
anticoagulants, instruct pt to be checked,
observe for bleeding, etc.
High protein, high fiber and increased fluid to
prevent constipation.
Pain Management
Discharge/home care
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Safety: stairs with hand rails, no scatter rugs,
grab bars tub and toilet, good light.
Height of bed and chair for easy transfer.
Elevated toilet seat, fracture pan, urinal
Ability to care for wound, correct supplies and
hand washing technique.
Correct transfer techniques, ability to follow
rehab plan and exercises.
Arthroscopy
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Pre-op: lab work- Hgb, Hct, Pt/PTT, urine,
PT,exercises
History of underlying problem, meds.
Post-op- N/V assessment, pulses distal to
Joint.
Teach: ROM to unaffected extremities,
limitations post-op, crutch walking prn, pain
management, reinforce explanation of
procedure.
Total Knee Replacement
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Indications:Osteoarthritis, rheumatoid
arthritis, posttraumatic arthritis, bleeding into
joint.
Post-op compression bandage and ice.
Assess N/V status of leg, active flexion q1h.
While awake, CPM machine.
Wound suction drain
OOB within24 hrs., knee immobilizer and
elevated while sitting.
Care of the patient undergoing an
amputation
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Pre-op monitor N/V status both extremities
Observe for ulceration, edema, necrosis.
Baseline VS and lab data, doppler studies,
angiography, ECG, chest x-ray.
Time for verbalization fears, anxieties.
Teach re; overhead trapeze, C and DB,
incentive spirometer.
http://www.diabetesresource.com/
Post-op: amputation
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Stump dressing, amt. and color of drainage,
hemovac drain.
Respiratory status and VS.
Presence of phantom limb pain.
Monitor for complications; infection, hemorrhage,
phantom pain, contractures, scar formation,
abduction deformity.
PT, diet, rest, activity, wound care
Pain management
Phantom limb pain
Immobility complications
Body image disturbance r/t loss
body part
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Allow time for pt. to grieve, assess need for
counseling.
Encourage pt. to discuss and view stump
Assist in identifying positive coping strategies, praise
strengths observed.
Provide a supportive environment.
Demonstrate positive regard for pt. and acceptance
of personal appearance.
Assess religious beliefs re: care of amputated limb
Verbalize feelings re: change in role, job, family,
sexual perosn
Discharge/ Home care
planning
Environmental/safety status:
 Hand rails- tub toilet, stairs, no scatter rugs.
 Wide doorway to accommodate wheelchair,
walker, Ht. of bed, chair ok.
 Ability to care for wound and has correct
supplies.
 Ability and desire to follow prescribed rehab
plan and exercises.
 Prosthesis fitting with orthotist
Osteoporosis
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Primary or Secondary
Metabolic bone disorder- progressively porous,
brittle, fragile bones, low bone density, susceptible
to fractures
Occurs in postmenopausal women
Bone resorption (osteoclast) > bone formation
(osteoblast) activity
Dowager’s hump – progressive kyphosis – gradual
collapse of vertebrae.
Post menopausal lose height, c/o fatigue.
Osteopenia, precursor to osteoporosis
Dx tests: Radiographs, Dexa scans
Osteoporosis- Risk Factors
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Gerontologic- over 80 yrs. old, 84% have
osteoporosis.
Family hx, thin, lean body build
Postmenopausal estrogen deficiency
Hyperparathyroidism – increases bone
resorption
Hx of low Ca intake and low levels of Vit D
Long tem corticosteroid use
Lack of physical activity/ prolonged immobility
Hx of smoking, high alcohol intake
Osteoporosis
Diagnosis:
Physical assessment:
Psychosocial assessment:
Pt. teaching- osteoporosis
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Adequate dietary calcium- 1200mg/day with
fluids
Exercise, wt. bearing beneficial.
Walking outdoors- vitamin D absorption.
Good body mechanics
Safe home environment, fall prevention
Balanced diet- protein, Mg, Vit K & D, Ca
Modify lifestyle choices- smoking, alcohol and
caffeine intake and sedentary lifestyle.
Patient teaching- Meds
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HRT-Raloxifene (Evista)
PTH- Forteo Subcut
Bisphosphonates- Fosamax,Boniva, Actonal
Reclast, Zometia
Calcitonin, Vit D
NSAIDs
Osteomyelitis
Infection of the bone
Endogenous:
 Extension of soft tissue infection- infected pressure
ulcers or incision.
 Blood borne (spread from other body sites)
 At risk- poorly nourished, elderly, obese, impaired
immune systems, corticosteroid therapy, chronic
illnesses.
 Prevention- proper tx. of infections, aseptic post op
wound care
Exogenous:
 Organism enters from outside the body. Eg. Open fx
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Osteomyelitis
Signs and symptoms High fever, chills, increased HR, general
malaise, swelling, tenderness, heat and
erythema, painful movement.
 Draining ulcers, bone pain
 Dx- increased WBCs, elevated ESR, positive
blood cultures, X-rays, bone scan, MRI.
Osteomyelitis Tx
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Long term IV antibiotics
Hickman or other CVAD catheter
Strict sterile technique for tx
Hyperbaric oxygen tx
Surgery- bone exposed and necrotic tissue
removed, debridement, bone grafts,
amputation
Contusions, Strains, Sprains
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Contusion-soft tissue injury, hematoma,
ecchymosis.
Strain- “muscle pull” over use over stretching.
Sprain – an injury to ligaments surrounding
joint, caused by twisting.
Management- RICE = rest, ice, compression,
elevation.
Orthopedic Injuries
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Joint dislocation- out of joint. If not treated
promptly, avascular necrosis can occur.
Reduced- put back in place = closed
reduction. Neurovascular status- check.
Rotator cuff injury/tear
Tennis elbow
Ligament injuries
Fractures (Fx)
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Complete- a break across the entire cross- section
and is frequently displaced.
Incomplete (Greenstick)-break occurs through only
part of the cross-section of the bone.
Closed Fracture (simple)- doesn’t break through the
skin.
Open fracture (compound) - extends through the skin
Comminuted- splintered into fragments
Depressed- fragment(s) is(are) indriven
Pathologic- through an area of diseased bone
FracturesSigns and Symptoms
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Pain- continuous and increases in severity
after injury.
Swelling- usually over affected area, but can
also occur in adjacent structures.
Reduction- open or closed
Treatment- Casting and/or traction
Fracture complications
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Shock
Fat embolism
Compartment syndrome
DVT, thromboembolism or pulmonary
embolism.
DIC
Infection
Avascular necrosis
Casts
Used to immobilize a body part so that a
fracture of a bone or dislocation can heal.
Pressure from hard casting materials can
produce complications such as:
 Pain
 Decreased sensation
 Skin breakdown
Casting materials- plaster or fiberglass.
Casts-Indications
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Provide protection and healing of fractures
Maintain therapeutic alignment- body parts
Protect soft tissue injuries
Provide support after orthopedic surgery
Correct skeletal malformations.
Casts
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While cast is drying, check C/M/S or NV status
hourly and then q4-8h
Circulation/ vascular checks- Warmth, color, pulses,
capillary refill, swelling.
Motion checks- ask pt. to wiggle fingers or toes.
Sensation checks- can pt. feel pressure, ask about
pain, this may detects if cast is too tight.
Check for odor and drainage
Electrical Bone Stimulation
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Application of electrical current at fracture
site, invasive or non-invasive.
Stimulates osteogenesis to fracture site.
Invasive- inserts cathode to site.
Non-invasive- Coil encircles cast or skin,
attached to external generator, used 3-10
hrs. per day.
Contraindicated in presence of infection.
Factors inhibit fracture healing
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Extensive local trauma
Bone loss- demineralization, osteoporosis
Inadequate immobilzation
Space/tissue between bone fragment
Infection, malignancy, bone disease
Irradiated bone (radiation necrosis)
Avascular necrosis
Age- impaired healing process
Corticosteroids inhibit repair rate
Traction- Indications
Used to minimize muscle spasm
2. Used to reduce, align, and immobilize fractures
3. Used to correct/prevent deformity
4. Tx of dislocated, degenerated, rutured
intravetebral discs and sc compression
Nursing goals:
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Maintain line of pull.
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Pt. is in center of bed, with good alignment
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Weights hanging freely.
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Prevent complications
1.
Types of traction
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2.
3.
4.
Skin traction (straight) - Buck’s, Bryant’s,
pelvic girdle. The pull is transmitted to
muscle structure, indirect traction.
Skeletal traction – pins or wires inserted in
bone and attached to traction, may be used
to treat fractures of humerus, tibia, fibula
Continuous- for fractures
Intermittent- for back muscle sprains
Traction
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Ropes unobstructed and in straight alignment.
Skin care- check skin traction for intact skin, pin care
for skeletal traction.
Circulation- fat emboli, thromboembolism.
Respiratory- pneumonia, exercise, ROM.
GI- high fiber diet, increased fluids.
Renal- to prevent stones- increase fluids.
MS- isometric exercises
Pain management
Diversion activities
5P’s Assessment for
Orthopedic Patients
Symmetric comparison:
 Pain- location, severity
 Pulse- distal to injury, check bilaterally.
 Parasthesias- numbness, tingling, compare
bilaterally. Sensaton check
 Pallor- check skin color and temp.
 Paralysis- Assess mobility, watch for foot
drop, compartment syndrome.
Documentation
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Amt traction, type, weight, changes in tx
Pt tolerance and pain
Pt assessment of NV checks, skin condition,
respiratory status, elimination pattern
Note condition of any pin sites and any care
given
Hip fractures
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High incidence in elderly due to risk for falls,
osteoporosis.
Intracapsular- fx. Neck of femur, may
damage blood supply, aseptic necrosis.
Extracapsular- base of neck and lesser
tronchanter of femur- heals more easily.
ORIF- open reduction with internal fixation.
Symptoms of Fractures
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Deformity
Swelling
Bruising
Muscle spasms
Tenderness
Pain
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Impaired sensation
Loss of normal
function
Abnormal mobility
Crepitus
Shock
Abnormal Xrays
Nursing Diagnoses
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Risk for injury r/t subluxation or dislocation
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Pain related to surgical incision
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Risk for infection r/t impaired skin integrity
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Impaired physical mobility
Risk for Peripheral Neurovascular
Dysfunction
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Back Pain
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Review of anatomy
Cervical Disc
Low back pain
Signs and Symptoms
Etiology
Back Pain- Assessment and
Dx Evaluation
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Posture and gait
Cervical Disc Pain and stiffness
Loss of muscle strength
Assess bowel and bladder control
MRI, CT scan, Neuro exam
Electromyelography and Nerve conduction
studies
Back Pain
Conservative Management
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Positioning
Firm mattress and back board
Exercise and physical therapy
Pharmacology
Heat and Ice
Diet Therapy
PT with manipulation, shoes insoles, back
braces
Complementary and alternative therapies
Operative Procedures
Conventional open Procedures:
 Diskectomy
 Laminectomy
 Diskectomy with fusion
Minimally Invasive Surgeries:
 Percutaneous lumbar diskectomy
 Microdiskectomy
 Laser assisted laparoscopic lumbar diskectomy
 Interbody cage fusion
 Direct current stimulation for bone fusion
Postoperative Care
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Body mechanics
Neurovascular assessment
CSF leakage
Fluid volume deficit
Acute urinary retention
Paralytic ileus
Fat embolism
Infection
Persistant or progressive lumbar radiculopathy
Back Surgery- Patient
Education
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Takes 6 weeks for ligaments to heal
Schedule rest periods
Avoid heavy labor 2-3mos postop
Back exercises
Cervical Disc Herniation or
Rupture
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Usually occurs at C5, C6, or C7 interspaces
Surgical tx is MIS cervical diskectomy with or
without fusion using an anterior or posterior
approach
Complications:
Postop CareCervical Diskectomy
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ABC
Check dsg for CSF
Check for hoarseness and inability to cough
Check for swallowing ability
Assess pt ability to void
Assist with ambulation
Manage pain
Assess for complications