Musculoskeletal System Part 2

This is the second part of Musculoskeletal System lecture. More nursing lectures about this system at
  1. Below the knee amputation
  2. Nursing Intervention
    • Preoperative
      • Offer support/encouragement
      • Discuss:
        • Rehabilitation program & use of prosthesis
        • Upper extremity exercise such as push ups in bed
        • Crutch walking
        • Amputation dressing/cast
        • Phantom limb sensation as a normal occurrence
      • Observe stump dressing for signs of hemorrhage and mark outside of dressing so rate of bleeding can be assessed (tourniquet at bedside)
  3. Post-operative Care
    • Prevent edema
      • Raise extremity with pillow support for first 24 h
    • Prevent hip/knee contractures
      • Avoid letting patient sit in chair with hips flexed for long periods of time
      • Have patient assume prone position several times a day and position hip on extension
      • Avoid elevation of stump after 24 hrs
      • For BKA: hip & knee exercises
      • For AKA: hip exercises
    • Pain medication as ordered (phantom limb pain)
    • Ensure that stump bandages fit tightly and are applied properly to enhance prosthesis fitting
  4. Inflammatory Disorders of the Musculoskeletal System
    • Rheumatoid arthritis
    • chronic systemic inflammatory disease
    • destruction of connective tissue and synovial membrane within the joints
    • weakens and leads to dislocation of the joint and permanent deformity
    • Risk Factors
    • exposure to infectious agents
    • fatigue
    • stress
  5. Rheumatoid Arthritis
    • Signs and Symptoms
    • Morning stiffness
    • Fatigue
    • Weight loss
    • Joints are warm, tender, and swollen
    • Swan neck deformity-late
    • Diagnostic Studies
    • X-ray
    • Elevated WBC, platelet count, ESR*, and positive RF
    • Treatment
    • No cure for RA
    Swan neck deformity
  6. Rheumatoid Arthritis
  7. Pharmacotherapy
    • Aspirin- mainstay of treatment, has both analgesic and anti-inflammatory effects
    • Nonsteroidal anti-inflammatory drugs (NSAIDs):
      • Indomethacin (Indocin)
      • Phenylbutazone (Butazoldin)
      • Ibuprofen (Motrin)
      • Fenoprofen (Nalfon)
      • Naproxen (Naprosyn)
      • Sulindac (Clinoril)
    • I mmunosuppressives : Methotrexate
      • Gold Standard for RA treatment
      • Teratogenic
  8. Pharmacotherapy
    • Gold compounds
    • Injectable form: sodium thiomalate, aurothioglucose; given IM once a week; takes 3-6 months to become effective
    • Oral form: auranofin- smaller doses are effective; diarrhea is a common side effect
    • Corticosteroids
    • Intra-articular injections
  9. Rheumatoid Arthritis
    • Treatment
    • Surgical Procedures: synovectomy, arthrotomy, arthrodesis, arthroplasty
    • Nursing Management
    • Advised bed rest during acute pain
    • Passive ROM exercise of joints
    • Splint painful joints
    • Heat & Cold application
    • Advised warm bath in the morning
    • Protect from infection
    • Advised well-balanced diet
  10. Arthrotomy Arthrodesis Arthroplasty
  11. Osteoarthritis (Degenerative Joint Disease)
    • Progressive degeneration of the joints as a result of wear and tear
    • affects weight-bearing joints and joints that receive the greatest stress, such as the knees, toes, and lower spine .
  12. Osteoarthritis
    • Risk Factors
    • aging (>50 yr)
    • rheumatoid arthritis
    • arteriosclerosis
    • obesity
    • trauma
    • family history
    • Signs and Symptoms
    • Dull, aching pain,* tender joints
    • fatigability, malaise
    • crepitus
    • cold intolerance*
    • joint enlargement
    • presence of Heberden’s nodes or Bouchard’s nodes
    • weight loss
  13. Medications
    • Aspirin
    • inhibits cyclooxygenase enzyme, diminishes the formation of prostaglandins
    • anti-inflammatory, analgesic, antipyretic action
    • inhibit platelet aggregation in cardiac disorders
    • Adverse effects
    • Epigastric distress, nausea, and vomiting
    • In toxic doses, can cause respiratory depression
    • Hypersensitivity
    • Reye’s syndrome
    • Ibuprofen
    • use for chronic treatment of rheumatoid and osteoarthritis
    • less GI effects than aspirin
    • Adverse effects
    • dyspepsia to bleeding
    • headache, tinnitus and dizziness
  14. Medications
    • Indomethacin
    • inhibits cyclooxygenase enzyme
    • more potent than aspirin as an anti-inflammatory agent
    • Adverse effects:
    • nausea, vomiting, anorexia, diarrhea
    • headache, dizziness, vertigo, light-headedness, and mental confusion
    • Hypersensitivity reaction
  15. Osteoarthritis
    • Nursing Intervention
    • Promote comfort: reduce pain, spasms, inflammation, swelling
      • Heat to reduce muscle spasm
      • Cold to reduce swelling and pain
    • Prevent contractures: exercise, bed rest on firm mattress, splints to maintain proper alignment
    • Weight reduction
    • Isometric and postural exercises
    • Nursing Diagnosis
    • Pain related to friction of bones in joints
    • Risk for injury related to fatigue
    • Impaired physical mobility related to stiff, limited movement
  16. Gouty Arthritis
    • Metabolic disorder that develops as a result of prolonged hyperuricemia
    • Caused by problems in synthesizing purines or by poor renal excretion of uric acid.
    • Acute onset, typically nocturnal and usually monarticular, often involving the first metatarsophalangeal joint
    • Risk Factors
    • Men
    • Age (>50 years)
    • Genetic/familial tendency
  17. Gouty Arthritis
    • Signs and Symptoms
    • extreme pain
    • swelling
    • erythema of the involved joints
    • fever
    • Tophi
    • Laboratory Findings
    • elevated serum uric acid (>7.0 mg/dl)*
    • urinary uric acid
    • elevated ESR and WBC
    • crystals of sodium urate aspirated from a tophus confirms the diagnosis*
  18. Treatment
    • Allopurinol
    • - a purine analog
    • - reduces the production of uric acid by competitively inhibiting uric acid biosynthesis which are catalyzed by xanthine oxidase.
    • Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies).
    • Adverse effects : hypersensitivity reactions, nausea and diarrhea
    • Colchicine
    • Effective for acute attacks
    • Anti-inflammatory activity alleviating pain within 12 hours
    • Adverse effects : nausea, vomiting, abdominal pain, diarrhea, agranulocytosis, aplastic anemia, alopecia
    • Probenecid/Sulfinpyrazone
    • uricosuric agents
    • increases the renal excretion of uric acid
    • Sulfinpyrazone used as a preventive agent.
    • Adverse effects: nausea, rash & constipation
  19. Nursing Implementation
    • Maintain a fluid intake of at least 2000 to 3000 ml a day to avoid kidney stone.
    • Avoid foods high in purine such as wine, alcohol, organ meats, sardines, salmon, anchovies, shellfish and gravy.
    • Take medication with food.
    • Have a yearly eye examination because visual changes can occur from prolonged use of allopurinol
    • Caution client not to take aspirin with these medication because it may trigger a gout attack and may cause an elevated uric acid levels.
    • Encourage rest and immobilize the inflamed joints during acute attacks
    • Avoid excessive alcohol intake
    • Notify physician if rash, sore throat, fever or bleeding develops.
  20. Osteomyelitis
    • Infection of the bone
    • Staphylococcus aureus is the most common pathogen.
    • Other organisms include Proteus, Pseudomonas and E. Coli
  21. Osteomyeliti s
    • Risk Factors
    • poorly nourished, elderly or obese
    • impaired immune systems
    • chronic illnesses
    • long term corticosteroid therapy
    • Clinical Manifestation
    • area appears warm, swollen and extremely painful
    • systemic manifestations (fever, chills, tachycardia)
    • Diagnostic Studies
    • X-ray
    • Bone Scan
    • Blood and wound culture
  22. Nursing Management
    • Promote comfort
    • Immobilized affected bone by maintaining splinting.
    • Elevate affected leg
    • Administer analgesics as needed.
    • Control infectious process
    • Apply warm, wet soaks 20 min. several times a day.
    • Administer antibiotics as prescribed.
    • Use aseptic technique when dressing the wound.
    • Encourage participation in ADL within the physical limitations of the patient.
  23. Osteoporosis
    • reduction of total bone mass
    • change in bone structure, which increases susceptibility to fracture
    • bone becomes porous, brittle, and fragile
  24. Risk Factors
    • Menopause
    • aging
    • long term corticosteroid therapy
    • high caffeine intake
    • smoking
    • high alcohol intake
    • sedentary lifestyle or immobility
    • insufficient calcium intake or absorption
    • hereditary predisposition
    • coexisting medical conditions (hyperparathyroidism, hyperthyroidism)
  25. Osteoporosis
    • Clinical Findings
    • loss of height
    • fractures of the wrist, vertebral column and hip
    • lower back pain
    • kyphosis
    • Respiratory impairment
    • Diagnostic Findings
    • X-rays
    • Dual-energy x-ray absorptiometry (DEXA)
    • Serum calcium
    • Serum phosphatase
    • Urine calcium excretion
  26. Medical Management
    • Pharmacologic Therapy
    • Hormone replacement therapy
    • Alendronate (Fosamax)
    • Calcitonin- ↓ plasma levels of Ca, ↑ deposition of Ca in the bone
  27. Nursing Management
    • Prevention
    • Adequate dietary or supplemental calcium
    • Regular weight bearing exercise
    • Modification of lifestyle
    • Calcium with vitamin D supplements
    • Administer HRT, as prescribed
    • Relieving pain
    • Improving bowel elimination
    • Preventing injury
    • Nursing Activities
    • Encourage use of assistive devices when gait is unstable
    • Protect from injury (side rails, walker)
    • Encourage active/passive ROM
    • Promote pain relief
    • Encourage good posture and body mechanics
  28. Bone Tumors
    • Osteosarcoma
    • Most common primary bone tumor
    • Occurs between 10-25 years of age, with Paget's disease and exposure to radiation
    • Exhibits a moth-eaten pattern of bone destruction.
    • Most common sites: metaphysis of long bones especially the distal femur, proximal tibia and proximal humerus
  29. Osteosarcoma
    • Clinical Manifestation
    • local signs – pain ( dull, aching and intermittent in nature), swelling, limitation of motion
    • palpable mass near the end of a long bone
    • systemic symptoms: malaise, anorexia, and weight loss
    • Diagnostic Findings
    • Biopsy- confirms the diagnosis
    • X-ray
    • MRI
    • Bone Scan
    • Increase alkaline phosphatase
  30. Medical Management
    • Radiation
    • Chemotherapy
    • Surgical management
      • amputation
      • limb salvage procedures
    • Prognosis: poor prognosis (rapid growth rate)
  31. Nursing Management
    • Promote understanding of the disease process and treatment regimen
    • Promote pain relief
    • Prevent pathologic fracture
    • Assess for potential complications (infection, complications of immobility).
    • Encourage exercise as soon as possible (1st or 2nd post-op day)
  32. Total Hip Replacement
    • a plastic surgery that involves removal of the head of the femur followed by placement of a prosthetic implant
  33. Nursing Management
    • Teach client how to use crutches
    • Teach client mechanics of transferring.
    • Discuss importance of turning and positioning post-op.
    • Place affected leg in an abducted position and straight alignment following surgery
    • Prevent hip flexion of more than 90 degrees.
    • Apply support stockings
    • Advise client to avoid external/internal rotation of affected extremity for 6 months to 1 year after surgery
    • Instruct client to avoid excessive bending, heavy lifting, jogging, jumping
    • Encourage intake of foods rich in Vitamin C, protein, and iron.
    • Administer prescribed medications.
    Metallic implant
  34. Complications
    • Infection
    • Hemorrhage
    • Thrombophlebitis
    • Pulmonary embolism
    • Prosthesis dislocation
    • Prosthesis loosening
  35. Dysplasia of the Hip
    • condition in which the head of the femur is improperly seated in the acetabulum, or hip socket, of the pelvis.
    • Congenital or develop after birth
  36. Assessment
    • Neonates: laxity of the ligaments around the hip, allowing the femoral head to be displaced from the acetabulum upon manipulation.
    • Implementation:
    • Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation (neonatal period)
    Pavlik harness
  37. Assessment
    • Infants
    • Asymmetry of the gluteal and thigh skin folds when the child is placed prone and the legs are extended against the examining table.
    • Limited range of motion in the affected hip.
    • Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed.
    • apparent short femur on the affected side
  38. Congenital Hip Dysplasia
    • Implementation
    • Traction and/or surgery to release muscles and tendons
    • Following surgery, positioning and immobilization in a spica cast until healing is achieved.
  39. Assessment
    • The walking child
    • minimal to pronounced variation in gait with lurching toward the affected side; positive Trendelenburg sign
    • Positive Barlow or Ortolani’s maneuver
    Ortolani’s maneuver Barlow maneuver
  40. Scoliosis
    • Lateral curvature of the spine
    • Surgical and nonsurgical interventions are employed
    • The type of treatment depends on the degree of curvature, the age of the child, and the amount of growth that is anticipated.
  41. Assessment
    • visible curve fails to straighten when the child bends forward and hangs arms down toward feet.
    • asymmetry of hip height
    • pelvic obliquity
    • inequalities of shoulder height
    • scapular prominence
    • rib prominence and rib humps
    • severe cases, cardiopulmonary and digestive function may be affected because of compression or displacement of internal organs.
  42. Nursing Intervention
    • Monitor progression of the curvature
    • Prepare the child and parents for the use of a brace if prescribed
    • Worn from 23 hours a day
    • Inspect the skin for signs of redness or breakdown
    • Keep the skin clean and dry, avoiding lotions and powders
    • Advise the child to wear soft nonirritating clothing under the brace
    • Scoliosis screening: 8 years old*
  43. Nursing Implementation
    • Prepare the child and parents for surgery if prescribed.
    • Postoperative
    • maintain proper alignment; avoid twisting movements
    • logroll the child when turning, to maintain alignment
    • instruct in activity restrictions
    • instruct the child to roll from a side-lying position to a sitting position, and assist with ambulation
  44. Laminectomy
    • Surgical incision of part of posterior arch of vertebrae and removal of protruded disc
    • Nursing Intervention
    • Preoperative
      • Teach patient log rolling and use of bedpan
    • Postoperative
    • Position as ordered
    • Lower spinal surgery- flat
    • Cervical spine surgery: slight elevation of head of bed
    • Proper body alignment- cervical spinal surgery: avoid flexion of neck and apply cervical collar
  45. Laminectomy: Postoperative Care
    • Avoid:
      • Acute hip flexion (bending, stooping, crossing the legs
      • Prolonged sitting/standing
      • Running, jogging, horseback riding
    • Back- strengthening exercises
      • Prone position
      • Walk in seawater
    • Lie in side- lying with hip flexion
  46. Laminectomy: Postoperative Care
    • Patient teaching and Discharge Planning
      • Wound care
      • Good posture and proper body mechanics
      • Activity level as ordered
      • Recognition and reporting of complications such as wound infection, sensory or motor deficits

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