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Chap 33 musculoskeletal


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Chap 33 musculoskeletal

  1. 1. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Chapter 33 Care of Patients with Musculoskeletal and Connective Tissue Disorders Theory Objectives State the factors to be assessed for the patient who has a connective tissue injury. Compare the assessment findings of a connective tissue injury with those of a fracture. State the care that is needed for the patient who has an external fixator in place. Identify the “do’s and don’ts” of cast care. Discuss the potential complications related to fractures. Identify the special problems of patients with arthritis and specific nursing interventions that can be helpful. Compare the preoperative and postoperative care of a patient with a total knee replacement with that of a patient with a total hip replacement. Explain the process by which osteoporosis occurs, ways to slow the process, and how the disorder is treated. Describe the care of the patient with a metastatic bone tumor. Identify important postoperative observations and nursing interventions in the care of the patient who has undergone an amputation. Clinical Practice Objectives Teach the patient going home with a cast about proper care of the cast and extremity. Provide pin care for a patient with external fixation. Observe a physical therapist who is teaching quadriceps exercise and then assist the patient to practice. Apply a sequential compression device for a patient as ordered. Sprain A sprain is a partial or complete tearing of the ligaments that hold various bones together to form a joint A sprain occurs when a joint may be forced, during trauma, past its normal range of motion, or there may be twisting The ankle, knee, and wrist are most commonly sprained Signs and Symptoms Grade I (mild): Tenderness at site; minimal swelling and loss of function; no abnormal motion Grade II (moderate): More severe pain, especially with weight-bearing; swelling and bleeding into joint; some loss of function Grade III (severe, complete tearing of fibers): Pain may be less severe, but swelling, loss of function, and bleeding into joint are more marked Diagnosis Physical examination X-ray to rule out a fracture or other pathology Treatment and Management RICE Rest Ice after injury and for 24-72 hours Compression—snug elastic bandage, careful to not to cut off circulation Elevation Grade II or III Rest the joint Crutches for lower extremity sprain NSAIDs around the clock for first couple of days Strain 1
  2. 2. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Signs, symptoms, and diagnosis History of overexertion Soft tissue swelling Pain Bleeding if muscle is torn Etiology and Pathophysiology A strain is a pulling or tearing of a muscle, a tendon, or both A strain occurs by trauma, overuse, or overextension of a joint The most common muscle strain occurs in the back muscles (back problems are discussed in Chapter 23, because they often have a neurologic component) Muscle strains do occur in other skeletal muscles—the most common sites are the hamstrings, quadriceps, and calf muscles Complementary and Alternative Therapies Soothing sore muscles Arnica purchased and applied topically as an essential oil is supposed to soothe sore, tired muscles after a long day’s work Valerian or kava brewed as a tea is also said to relax muscles Honey or apple juice will make the teas more palatable Treatment and Nursing Management Ice and compression should be immediately applied and the part should be rested The patient is taught to use ice for 20 minutes out of the hour only When compression is used, the distal parts of the extremity must be checked for sensation and adequate circulation Heat can be applied after 48 hours Anti-inflammatory medications are used for discomfort and, when spasm is present, a muscle relaxant may be prescribed Time is the greatest healer The patient is cautioned against reinjury and is taught proper ways to lift and move Surgical repair may be necessary Dislocation and Subluxation Etiology and pathophysiology Signs and symptoms History of outside force Severe pain aggravated by movement Muscle spasm Abnormal joint appearance X-ray Treatment Reduction of displacement under anesthesia Nursing management Rest Pain control 2
  3. 3. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Heat or cold applications Bursitis Etiology and pathophysiology Injury or overuse Signs, symptoms, and diagnosis Mild to moderate aching pain Swelling History of injury Physical examination Treatment Rest, ice, and massage Anti-inflammatory agents Compression wrap Bursa cortisone injection Nursing management Assess pain and perfusion Assist with mobilization Activity limitations Other Connective Tissue Disorders Rotator cuff tear Anterior cruciate ligament injury Meniscal injury Achilles tendon rupture Bunion (hallux valgus) Carpal Tunnel Syndrome Etiology and pathophysiology Compression of the median nerve Signs and symptoms Pain Numbness Tingling of the hand, particularly at night Repetitive movements of hands and wrists Diagnosis Physical examination Compression test Electromyography Treatment 3
  4. 4. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Rest and splinting Changing the angle of the wrist during repetitive movements Steroid injections Surgery Nursing management Fractures Etiology and pathophysiology Definition Trauma Osteoporosis and metabolic problems Mechanism of injury Signs and symptoms Minimal to severe pain depending on the type of fracture, the bone(s) involved, and the amount of displacement Swelling and/or bleeding Tenderness, deformity of the bone, ecchymoses, crepitation with any movement, and loss of function Fractures (cont.) Diagnosis Physical examination X-ray Types of Fractures Complete ________________________________________________________________________________________________________________ Incomplete_______________________________________________________________________________________________________________ Comminuted _____________________________________________________________________________________________________________ Closed (simple) ___________________________________________________________________________________________________________ Open (compound) _________________________________________________________________________________________________________ Greenstick _______________________________________________________________________________________________________________ Elder Care Points The elderly are more at risk for fractures because of decreased reaction time, failing vision, lessened agility, alterations in balance, and decreased muscle tone Proton pump inhibitors (PPIs) increase the risk for fracture of the hip, wrist, and spine In epidemiologic studies, the risk was highest for people over age 50, who had used PPIs for more than a year Treatment of Fracture Emergency care Prevent shock and hemorrhage 4
  5. 5. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders “Splint as it lies” Tetanus immunization Prophylactic antibiotics Primary aim of treatment Establish union between broken ends to restore bone continuity Five Stages of Bone Healing and Repair 1. Blood oozes from the torn blood vessels in the area of the fracture; the blood clots and begins to form a hematoma between the two broken ends of bone (1 to 3 days) Five Stages of Bone Healing and Repair (cont.) 2. Other tissue cells enter the clot, and granulation tissue is formed. This tissue is interlaced with capillaries, and it gradually becomes firm and forms a bridge between the two ends of broken bone (3 days to 2 weeks) Five Stages of Bone Healing and Repair (cont.) 3. Young bone cells enter the area and form a tissue called “callus.” At this stage, the ends of the broken bone are beginning to “knit” together (2 to 6 weeks) Five Stages of Bone Healing and Repair (cont.) 4. The immature bone cells are gradually replaced by mature bone cells (ossification), and the tissue takes on the characteristics of typical bone structure (3 weeks to 6 months) Five Stages of Bone Healing and Repair (cont.) 5. Bone is resorbed and deposited, depending on the lines of stress. The medullary canal is reconstructed during consolidation and remodeling (6 weeks to 1 year) Reduction of Fractures Closed reduction Open reduction Stabilization Internal fixation External fixation Casts, splints, and braces Traction Internal Fixation Pins, nails, or metal plates Open reduction and internal fixation Prosthesis and autotransfusion IV antibiotics and risk for infection Nursing care Maintain good alignment of the affected leg Prevent complications of immobility Control pain Examples of Internal Fixation 5
  6. 6. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders External Fixation Indications Massive open fractures with extensive soft-tissue damage Infected fractures that do not heal properly Multiple trauma such as burns, chest injury, or head injury Nursing Management Pin site care and premedicate for pain Showering Physical therapy and ADLs Casts and Fractures Materials including plaster and synthetic casts Long-leg and short-leg casts, slings, and spicas Synthetic Limb Cast Braces and Splints Fracture boot, hinged brace, and slab Patient teaching Explain the procedure—feel warmth as cast sets and dries Never put a fresh cast on plastic Never cover a fresh plaster cast with a blanket Walking Boot Skeletal Traction Pins, wires, or tongs directly through the bone at a point distal to the fracture so that the force of pull from the weights is exerted directly on the bone Skeletal traction uses 10 or more pounds of weight and the body acts as the countertraction Skin Traction Bandage (moleskin or foam traction boot) is applied to the limb below the site of fracture and then pull is exerted on the limb No more than 7 to 10 lb of weight are used Continuous or intermittent Common Types of Traction Points of Care for the Patient in Traction Traction devices must be assessed to see that they are in correct position and that the weights are hanging free The patient’s body position should be assessed for proper alignment Complications of Fractures The sooner a fracture is fixed, the less likely the chance for complications. Healing can be impeded by improper alignment and inadequate immobilization Continued twisting, shearing, and abnormal stresses prohibit a strong, bony union. Fractures and Infection Open comminuted fractures and surgery 6
  7. 7. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Antibiotics Inadequate calcium and phosphorus, vitamin deficiency, and atherosclerosis Temperature, white blood cells, and wound appearance (redness, swelling, heat, and purulent drainage) Osteomyelitis Osteomyelitis is a bacterial infection of the bone Staphylococcus aureus Sudden onset with severe pain and marked tenderness at the site, high fever with chills, swelling of adjacent soft parts, headache, and malaise Diagnosis The earlier osteomyelitis is diagnosed and treated, the better the prognosis History of injury to the part, open fracture, boils, furuncles, or other infections Sedimentation rate and WBC count X-rays Biopsy, in which the bone sample exhibits signs of necrosis Treatment Antibiotics are prescribed for 4 to 6 weeks, and the abscess is incised and drained Dead bone and debris are débrided from the site The affected limb is immobilized for complete rest Sometimes amputation is the only cure Nonunion of Fractures Electrical bone growth–stimulating device Surgery and bone grafting Fat Embolism Signs and symptoms Change in mental status Respiratory distress, tachypnea, crackles and wheezes Rapid pulse, fever, and petechiae (a measles-like rash over the chest, neck, upper arms, or abdomen) Nursing Management Stay with the patient High Fowler’s position Use a non-rebreather mask Establish a peripheral IV Summon the physician immediately Anticipate hydration with IV fluids and correction of acidosis Intubation and mechanical ventilation Venous Thrombosis The veins of the pelvis and lower extremities are very vulnerable to thrombus formation after fracture, especially hip fracture Immobility, traction, and casts may contribute to venous stasis 7
  8. 8. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Compression stockings, sequential compression devices, range-of-motion (ROM) exercises on the unaffected lower extremities are used to help prevent the problem Compartment Syndrome External or internal pressure that restricts circulation in one or more muscle compartments of the extremities Severe, unrelenting pain unrelieved by narcotics Assess for 6 “Ps”: pain, pallor, paresthesia, pulselessness, paralysis, and poikilothermia (cold to the touch) Treatment and Nursing Management Recognition and immediate notification of the physician can prevent permanent loss of function If a cast is in place, the cast can be bivalved (split through all layers of the material) Dressings will be cut or replaced Surgical fasciotomy (linear incisions in the fascia down the extremity) may be necessary to relieve the pressure on the nerves and blood vessels if other measures do not relieve the problem Elevation is the key to preventing compartment syndrome; toes and fingers should be higher than the trunk Fascial Compartments of the Calf Nursing Management of Fractures Assessment (data collection) Initial assessment (pretreatment) Mechanism of injury Physical assessment Special consideration of open fractures Daily assessment (posttreatment) Physical assessment of neurovascular status Thorough assessment of a patient in a cast Nutrition for immobile musculoskeletal patients Nursing Management of Fractures (cont.) Implementation Cast care—fiberglass and polyester cotton knit casts and plaster casts Comfort measures Positioning and repositioning Itching and skin care Nursing Management of Fractures (cont.) Evaluation Pain should be under control Progress toward independent ADLs No problems with immobility (skin breakdown, constipation, atelectasis, or DVT) No complications (infection, compartment syndrome) If the goals are not being met, the plan should be revised Inflammatory Disorders of the Musculoskeletal System 8
  9. 9. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Lyme disease Osteoarthritis Rheumatoid arthritis Gout Osteoporosis Paget’s disease Bone tumors Lyme Disease Cause Spirochete, Borrelia burgdorferi Signs and symptoms Flu-like symptoms Bull’s-eye rash Pain and stiffness in joints and muscles Carditis Meningitis, peripheral neuritis, or facial paralysis Fatigue, cognition problems, and arthralgia Treatment Osteoarthritis Etiology and pathophysiology A noninflammatory degenerative joint disease that can affect any weight-bearing joint Risk factors: Heredity, aging, female gender, obesity, previous joint injury, and recreational/occupational usage Healthy People 2020 Goals Related to Arthritis  Reducing the mean level of joint pain, activity limitations, care limitations, effect on employment and the proportion of those who find it very difficult to perform specific joint-related activities  Increasing health care provider counseling for weight and physical activity; the proportion of those seeing a health care provider for joint symptoms and effective evidence-based arthritis education as an integral part of managing the condition Osteoarthritis Signs, symptoms, and diagnosis Asymmetrical Typically affects only one or two joints Chief symptoms Aching pain with joint movement and stiffness and limitation of mobility Joints may be deformed and nodules may be present Treatment of Osteoarthritis Pain management—including salicylates, acetaminophen, or NSAIDs Strengthening and aerobic exercise Weight reduction if the patient is overweight 9
  10. 10. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Maintenance of joint function Complementary and alternative therapies Nursing Management of Osteoarthritis Balance exercise and rest Moist heat application Encourage to maintain weight within normal limits Imagery, relaxation, and diversion Quadriceps strengthening exercises may relieve pain and disability of the knee Rheumatoid Arthritis Etiology and pathophysiology Rheumatoid factor and small joints Remissions and exacerbations Pannus, ankylosis, and damage/atrophy of muscles Subcutaneous nodules in the pleura, heart valves, or eyes Rheumatoid Arthritis (cont.) Signs and symptoms Joint pain, warmth, edema, limitation of motion, and multiple joint stiffness Symmetrical—affects joints of the hands, wrists, and feet Limitations of ADLs Comparison of Rheumatoid Arthritis and Osteoarthritis Definition Pathology Etiology Rheumatoid factors (autoantibodies) Age at onset Weight General state of health Appearance of joints Muscles Other Rheumatoid Arthritis Diagnosis History of morning stiffness that lasts more than one hour or arthritis pain in 3 or more joints that lasts more than 6 weeks Blood tests for RF, C-reactive protein, and erythrocyte sedimentation rate X-rays confirm the cartilage destruction and bone deformities Treatment of Rheumatoid Arthritis Relieve pain Minimize joint destruction 10
  11. 11. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Promote joint function Preserve ability to perform self-care Medications for Rheumatoid Arthritis NSAIDs (i.e., ibuprofen) are the first-line agents used for arthritis pain Other medications include salicylates, corticosteroids, antimalarial drugs, methotrexate, gold compounds, sulfasalazine, d-penicillamine, and disease-modifying antirheumatic drugs (DMARDs) Tumor necrosis factor drugs (TNF inhibitors) Systemic corticosteroids DMARDs Medications for Rheumatoid Arthritis (cont.) The injection of steroids directly into a joint (intra-articular administration) has been used successfully in treating painful flare-ups, shortening the period of inflammation, and relieving pain and other symptoms When intra-articular steroid therapy is used, it is recommended that not more than two or three doses be injected into any joint within 1 year’s time Clinical Cues Monitor patients taking NSAIDs for GI intolerance Assess liver, kidney, and central nervous system function frequently Watch for signs of blood dyscrasias and check for tinnitus and hearing loss regularly The side effects of NSAIDs can be serious and sometimes permanent If early signs of toxicity appear, they should be reported promptly to the physician Elder Care Points Elderly arthritis patients must be taught to watch for side effects and promptly report to the physician or nurse Dizziness, which predisposes to falls, can occur with analgesics for arthritis pain, particularly if the medication contains codeine Advise patients to arise slowly, hold on to furniture until steady, and to wait until dizziness passes before trying to walk Assistive devices for ambulation can also prevent falls Surgical Intervention and Orthopedic Devices Casts/braces and splints Surgery Synovectomy Osteotomy Tendon reconstruction Joint replacement Total hip replacement including preoperative and postoperative care Total knee replacement Total Hip Replacement Discharge Teaching It is OK to lay on operated side For 3 months, you should not cross your legs Put a pillow between legs when rolling over or lie on your side in bed 11
  12. 12. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders It is OK to bend your hip but not beyond a right (90-degree) angle (demonstrate) Avoid sitting in low chairs Continue daily exercise program at home Nursing Management of Rheumatoid Arthritis Expected outcomes Patient’s pain will be controlled with medications, heat, and exercise within 2 weeks Patient’s mobility will improve with the use of assistive devices and physical therapy within 3 weeks Patient will demonstrate less disturbance of body image by partaking in more social activities within 1 month Implementation and Evaluation of Rheumatoid Arthritis Rest and exercise Instructions for joint protection Applications of heat and cold Safety considerations Patient teaching Diet Psychosocial care Resources for patient and family education Gout Etiology and pathophysiology Uric acid levels Possible factors Genetic increase in purine metabolism High-purine diets Big toe Diuretic therapy and secondary gout Gout (cont.) Signs and symptoms Tight reddened skin over an inflamed, edematous joint accompanied by elevated temperature and extreme pain in the joint Elevated serum uric acid Diagnosis History and physical examination Serum uric acid Gout (cont.) Treatment NSAIDs for 2-5 days Colchicine, allopurinol, and probenecid (Benemid) Febuxostat (Uloric) Nursing management 12
  13. 13. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Patient teaching and medications Diet management—weight control and restriction of high-purine foods Fluid intake Audience Response Question 1 Dietary management of gout includes which measure(s)? (Select all that apply.) 1. Weight reduction 2. Salt restriction 3. High caloric intake 4. Avoiding foods high in purine 5. High-carbohydrate diet Osteoporosis Etiology and pathophysiology Osteopenia Risk factors: Age, chronic disease (i.e., liver, lung, kidney), medications (i.e., steroids, anticonvulsants, anticoagulants, proton pump inhibitors, selective serotonin inhibitors), long-term calcium deficiency, vitamin D deficiency, smoking, excessive caffeine or alcohol intake, and sedentary lifestyle Osteoporosis (cont.) Signs and symptoms No early signs and symptoms Height loss, kyphosis, and compression of the spine Diagnosis Bone x-rays Dual energy x-ray absorptiometry (DXA or DEXA); reported as a T score Treatment Goals Stop bone density loss Increase bone formation Prevent fractures Estrogen replacement therapy Adequate dietary and supplemental calcium and vitamin D Weight-bearing exercise Bisphosphonates Parathyroid hormones Osteoporosis and Vertebral Fracture Pain medication, activity limitation, physical therapy, and bracing Vertebroplasty Kyphoplasty Nursing Management 13
  14. 14. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Promote screening for osteoporosis Teach the benefits of healthy lifestyle, need for calcium supplement, and weight-bearing exercise Medications, cautions, and side effects Upright position for 1 hour after taking bisphosphonate-type drugs to prevent esophageal irritation and erosion Paget’s Disease Etiology Abnormal weak bones Signs and symptoms Pain Diagnosis X-ray 24-hour urine collection Serum alkaline phosphatase Paget’s Disease (cont.) Nursing management Firm mattress Light brace or corset Avoid lifting and twisting Bone Tumors Etiology and pathophysiology Benign and malignant tumors Primary and secondary tumors Osteosarcoma and Paget’s disease Bone Tumors (cont.) Signs and Symptoms Pain, warmth, and swelling Diagnosis X-ray, bone scan, and biopsy Treatment Surgery, radiation, and chemotherapy Amputation Lower-limb amputations are related to peripheral vascular disease, diabetes mellitus and resultant gangrene, severe trauma, malignancy, congenital defects, and military injuries from shrapnel and land mines Upper-extremity amputations are brought on by crushing blows, thermal and electric burns, severe lacerations, vasospastic disease, malignancy, and infection Care After Accidental Amputation Rinse the detached part only enough to remove visible debris Wrap the part in a clean, damp cloth 14
  15. 15. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders Place the part in a sealed plastic bag or in a dry water-tight container Immerse the bag or container in a mixture of water and ice (3 parts water to 1 part ice). Do not let the part get wet or freeze Care After Accidental Amputation (cont.) Alternatively, place the container in an insulated cooler filled with ice If no ice is available, keep the part cool; do not expose it to heat Tag the bag or container with the person’s name and the name of the body part and take it to the hospital with the person Amputation: Preoperative Care Patient participation in decision-making Stages of loss and grieving Phantom sensations Physical preparation Muscle strengthening exercises Amputation: Postoperative Care Hemorrhage and edema of residual limb Elevation for 24 hours Monitoring for excessive bleeding Dressing care Phantom limb sensations Miacalcin IV infusion Transcutaneous electrical nerve stimulator Stump stocking Amputation: Postoperative Care (cont.) Alternative modes for managing stump after amputation Soft dressing with delayed prosthetic fitting Rigid plaster dressing and early prosthetic fitting Rigid plaster dressing and immediate prosthetic fitting Amputation: Postoperative Care (cont.) Adequate healing and weight-bearing Below-the-knee amputation is better to begin walking and weight-bearing than above-the-knee amputation Abduction contractures and proper positioning Adjusting to the new center of gravity Patient teaching: stump care, activity and weight-bearing, and exercise Rehabilitation Community care 15
  16. 16. Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders C-Leg Prosthesis in Action 16