Chapter 46

Linda S. Williams / Paula D. Hopper

Copyright © 2011. F.A. Davis Company

Understanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th Edition

Chapter 46

Nursing Care of Patients withMusculoskeletal and Connective Tissue

Disorders


Linda S. Williams / Paula D. HopperUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th EditionUnderstanding Medical Surgical Nursing, 4th Edition

Bone and Soft Tissue Disorders

Strain Sprain Dislocation Bursitis Rotator Cuff Injury



Carpal Tunnel Syndrome Median Nerve Compression in Wrist’s

Carpal Tunnel Occurs with Swelling in Tunnel Finger, Hand, Arm Pain/Numbness



Carpal Tunnel Syndrome (cont’d) Relieve Inflammation and Rest Wrist

Splint Anti-inflammatory Surgery

Teach Prevention



Fractures Break in a Bone Cause

Trauma Pathological (From Disease )

Open – Breaks Skin Closed – Does Not Break Skin



Types of Fractures



Signs and Symptoms Pain Decreased ROM Limb Rotation Deformity, Shortening of Limb Swelling Bruising



Diagnostic Tests X-Ray CT scan



Emergency Treatment Splint It As It Lies! Seek Medical Treatment



Fracture Management Goals

Realignment of Bone Ends Immobilization



Fracture Healing Phases



Closed Reduction Manual Realignment Bandages/Splints Casts Traction

Skin Skeletal



Types of Skin Traction



Balanced Suspension and Skeletal Traction



Fracture Management (cont’d) Open Reduction with Internal Fixation External Fixation



External Fixation



Complications of Fractures Nonunion Neurovascular compromise Hemorrhage Infection Thromboembolitic Complications Acute Compartment Syndrome Fat Embolism Syndrome



Compartment Syndrome



Bivalving Cast



Nursing Diagnoses Acute Pain Impaired Physical Mobility Impaired Walking Ineffective Health Maintenance Risk for Peripheral Neurovascular

Dysfunction



Nursing Diagnoses (cont’d) Risk for Ineffective Tissue Perfusion Risk for Ineffective Skin Integrity



Palming the Cast



Nursing Care Cast Care Traction Care Pain Control Neurovascular Checks Skin Care Nutrition



Nursing Care (cont’d) Self Care Deficits Psychosocial



Patient Education Cast Care Pin Care Nutrition



Osteomyelitis Infection of Bone Prevention is Key! Fever, Redness, Heat, Pain, Swelling, Pain Long-term Antibiotic Therapy Incision and Drainage Amputation



Osteomyelitis (cont’d)



Osteomyelitis (cont’d) Nursing Care

Medication Teaching Hand Hygiene Sterile Dressing Changes



Osteoporosis Low Bone Mass as Bone Loses Density Prone to Fractures Occur Spine, Wrist, Hip Most Common All Bones Affected



Osteoporosis Prevalence 10 Million People

8 Million Females 2 Million Males

Over Age 50 Fractures 1 in 2 Women 1 in 4 Men



Osteoporosis Fracture Effects Hip/Vertebral Fractures

Reduced Quality of Life Increased Disability Risk of Death (During Year After Fracture)



Osteoporosis Prevention Build Bone Through Age 30 Obtain Adequate Calcium and Vitamin D Exercise (Especially Childhood ) Avoid Alcohol and Smoking



Osteoporosis (cont’d) Imbalanced Remodeling Process



Osteoporosis Risk Factors Aging Female Caucasian/Asian Fracture History Family History Petite Body Build Postmenopausal Women



Osteoporosis Risk Factors (cont’d) Low Testosterone and Estrogen Low Calcium Intake Low Vitamin D Excessive Caffeine, Protein, Sodium Sedentary Lifestyle Excessive Alcohol Use Cigarette Smoking



Osteoporosis (cont’d) Signs and Symptoms

Dowager’s Hump Kyphosis Height Decreases Back Pain Fracture



Osteoporosis (cont’d) Body System Effects Functional Effects Emotional effects Socialization



Osteoporosis Diagnostic Tests

Dual-energy X-Ray Absorptiometry Serum Calcium, Vitamin D Decreased Serum Phosphorus Increased Serum Alkaline Phosphatase Increased



Osteoporosis Therapeutic Interventions

Reduce Risk Factors Calcium Supplements Vitamin D Supplements Medications



Antiresorptive Medications Bisphosphonates

Alendronate (Fosamax) Ibandronate (Boniva) Risedronate (Actonel) Zoledronic acid (Reclast)

Calcitonin (Fortical, Miacalcin)



Antiresorptive Medications (cont’d)

Selective Estrogen Receptor Modulator Raloxifene (Evista)

Estrogen Therapy



Anabolic (Bone Forming) Teriparatide (Forteo)



Osteoporosis Nursing Care Pain Relief Symptom Management Education

Diet: Increase Calcium, Vitamin D Exercise Medication

Fall Prevention



Paget's Disease Increased Bone Loss Disorganized Bone Deposits No Obvious Symptoms Usually X-Ray, Bone Scan Calcitonin (Calcimar) Relieve Pain, Teach, Promote Life Quality



Bone Cancer Primary Malignant Tumors

Osteosarcoma Most Common 50% Occur in Distal Femur in Young Men Metastasizes to Lung Within 2 Years



Bone Cancer (cont’d) Primary Malignant Tumors

Ewing’s Sarcoma Most Malignant

Chrondrosarcoma Cancer of Cartilaginous Cells Better Prognosis



Primary Bone Cancer Therapeutic Interventions

Surgery, Chemotherapy, Radiation

Nursing Care Postoperative Care Supportive



Metastatic Bone Disease Bone-seeking Cancers

Prostate, Breast, Lung, Thyroid

Pathological Fractures Severe Pain Therapeutic Interventions

Radiation



Metastatic Bone Disease (cont’d) Nursing Care

Supportive Care as with Other Cancers



Gout Pathophysiology

Systemic Connective Tissue Disorder Uric Acid Build Up Urate Crystals Deposited in Joints/Connective

Tissues Severe Inflammation



Causes and Types Primary – Inherited Problem with Purine

Metabolism Secondary – Another Health Problem



Signs and Symptoms Acute

Swollen, Red, Hot, Painful Inflamed Joints Great Toe

Chronic Gout Urate Deposits Under Skin Renal Stones



Diagnostic Tests Serum Uric Acid Joint Fluid – Uric Acid Crystals



Therapeutic Interventions Medication

Colchicine NSAIDs Allopurinol (Zyloprim) Probenecid (Benemid)



Nursing Care Teaching

Diet: Avoid Foods High in Purines Avoid Aspirin, Diuretics, Alcohol Increase Fluids



Systemic Lupus Erythematosus

Autoimmune Disease Genetic Link Remissions and Exacerbations Systemic Type Skin Type – Discoid Lupus Erythematosus



Pathophysiology Abnormal Antibodies Immune Complex Formation Complement System Activation Affects Connective Tissue



Signs and Symptoms Butterfly Rash Photosensitive Fever Fatigue, Malaise Arthralgia, Myalgia Weight Loss



Signs and Symptoms (cont’d) Mucosal Ulcers Alopecia Skin Lesions



Diagnostic Tests Biopsy Erythrocyte Sedimentation Rate Immunological Tests

Antinuclear Antibody Titers Antibodies Against SR Proteins



Therapeutic Interventions NSAIDs Corticosteroids Antimalarials Immunomodulating Drugs Topical Cortisone Chloroquine (Aralen)



Nursing Diagnoses Acute Pain Chronic Sorrow Fatigue Disturbed Body Image



Nursing Diagnoses (cont’d) Ineffective Coping Ineffective Health Maintenance Powerlessness Risk for Impaired Skin Integrity Self-care Deficit



Patient Education Skin Care Avoid Prolonged Exposure to Sunlight Exercise Immunization Stress Reduction Community Support Groups



Scleroderma Inflammation Develops into Fibrosis and

Sclerosis of Tissues Autoimmune Response Progress Very Rapidly Remissions and Exacerbations Poor Prognosis



Signs and Symptoms Arthritis, Fatigue Scleroderma

Pitting Edema, Tightening, Hardening, Thickening of Skin Tissue

Loss of ROM Contractures



Diagnosis History Physical



Therapeutic Interventions Steroids Immunosuppressant Antacids, Histamine Blockers Rehabilitative Therapy



Nursing Care Pain Control

Bed Cradle Sock/Gloves

Skin Protective Mild Soaps and Lotions



Nursing Care (cont’d) Small, Frequent, Bland Meals

Cut Food into Small Pieces Thicker Liquids



Osteogenesis Imperfecta Congenital Abnormality Characterized by

Skeletal Bone Fragility Brittle Bones Disease Pathological Fractures Collagen Synthesized Abnormally



Osteogenesis Imperfecta (cont’d) Signs and Symptoms

Fragile Bones Triangular Shaped Face Potential Hearing Loss Scoliosis Loose Joints



Osteogenesis Imperfecta (cont’d) Signs and Symptoms (cont’d)

Alterations in Muscle Tone or Development Blue, Purple, Grey Tint to Sclera Brittle or Discolored Teeth Smooth, Thin Skin



Osteogenesis Imperfecta (cont’d) Diagnosis

History of Fractures Physical Skin Biopsy



Osteogenesis Imperfecta (cont’d) Therapeutic Interventions

No Treatment Fracture Care



Osteogenesis Imperfecta (cont’d) Nursing Care

Careful Handling Teaching Support Groups

Osteogensis Imperfecta Foundation



Polymyositis Diffuse Inflammation of Skeletal Muscle Dermatomyositis – with Rash Progressive Remissions and Exacerbations Women Greater Than Men Treatment: Prednisone



Polymyositis (cont’d) Nursing Care

Supportive Care Education



Muscular Dystrophy Group of Nine Disorders Loss of Muscle Tissue Progressive Muscle Weakness Genetic Skeletal Muscle Fibers Degenerate,

Atrophy



Therapeutic Interventions Supportive Care Prevention of Complications Gene Therapy Research



Nursing Diagnoses Impaired Physical Mobility Ineffective Breathing Pattern Self-care Deficits Deficient Knowledge



Osteoarthritis Degenerative Joint Disease (DJD) Common



Pathophysiology Articular Cartilage/Joints Bone Ends

Deteriorate Joint Space Narrows, Bone Spurs Develop,

Joint Inflamed Joint Deformities, Pain, Immobility Weight-bearing Joints



Joints Affected by Osteoarthritis



Causes Unknown Risk Factors

Aging Obesity Excessive “Wear and Tear” on Synovial Joints



Signs and Symptoms Joint Pain

Intensifies After Physical Activity

Stiffness Heberden’s and Bouchard’s Nodes

Bony Nodes on Joints of Fingers



Diagnostic Tests X-Rays CT scan MRI Synovial Fluid Analysis



Therapeutic Interventions No Cure Medication

NSAIDs

Rest and Exercise Heat or Cold Weight Control



Therapeutic Interventions (cont’d) Complementary Therapies

Imagery, Music Therapy, Acupressure, Acupuncture

Surgery Total Joint Replacement



Nursing Diagnoses Chronic Pain Activity Intolerance Chronic Sorrow Disturbed Body Image Impaired Physical Mobility



Nursing Diagnoses (cont’d) Self-care Deficit Ineffective Health Maintenance



Patient Education Protect Joints Conserve Energy



Rheumatoid Arthritis Chronic, Progressive, Systemic

Inflammatory Disease Destroys Synovial Joints and Other

Connective Tissues Includes Major Organs



Rheumatoid Arthritis (cont’d)



Pathophysiology Synovitis Synovium Thickens, Fluid Accumulates Destructive Pannus Erodes Joint Cartilage,

Destroys Joint Bone Pannus Converted to Bony Tissue



Pathophysiology (cont’d) Joint Deformity Other Connective Tissue Affected



Etiology Unknown Genetic Predisposition Environmental Autoimmune Response – Antibodies

(Rheumatoid Factor) Local and Systemic Inflammation



Signs and Symptoms Remissions and Exacerbations Varies by Individual



Signs and Symptoms (cont’d) Early Symptoms

Bilateral, Symmetrical Joint Inflammation Reddened, Warm, Swollen, Stiff, Painful Stiffness After Resting Activity Decreases Pain and Stiffness Low Grade Fever, Weakness, Fatigue,

Anorexia



Signs and Symptoms (cont’d) Late Symptoms

Joint Deformity Secondary Osteoporosis



Joint Abnormalities in Rheumatoid Arthritis



Diagnosis Rheumatoid Factor (RF) Red Blood Cell (RBC) C4 Complement Decreased

Erythrocyte Sedimentation Rate (ESR) Antinuclear Antibody (ANA) C-reactive Protein (CRP)



Therapeutic Interventions Medication

Disease-modifying Antirheumatic Drugs Leflunomide (Arava) Etanercept (Enbrel)



Therapeutic Interventions (cont’d) Medication (cont’d)

Methotrexate Gold Prednisone NSAIDs



Therapeutic Interventions (cont’d) Heat/Cold Balanced Rest and Activity Surgery – Total Joint Replacement



Nursing Diagnoses Acute Pain Disturbed Body Image Fatigue Self-care Deficit Impaired Physical Mobility Deficient Knowledge



Patient Education Disease Process Medication Management Rest and Exercise Vocational Counselor Community Resources



Total Hip Replacement Acetabular Cup Inserted Into Pelvic

Acetabulum Femoral Component Inserted Into Femur



Total Hip Replacement (cont’d) Preoperative Care

Total Joint Education Programs Autologous Blood Donation



Total Hip Replacement (cont’d) Postoperative Care to Prevent

Complications Hip Dislocation

Prevent Adduction or Hyperflexion

Skin Breakdown Prevent Pressure Ulcers



Abductor Pillow

Harjeet

Note to Pub:Per the author, this slide with the abductor pillow must be deleted as it was taken out of the book. Please verify that it is ok to delete.Thank you



Hip Flexion After Total Hip Replacement

jkohl

Per author the photo showing the person sitting and the 90 degree angle is still the figure that is incorrect. She noted that she has informed FAD that there was a correction to be made to the figure.



Total Hip Replacement (cont’d) Pain

Provide Pain Relief

Infection Prophylactic Antibiotics

Coughing and Deep Breathing Incisional Care



Total Hip Replacement (cont’d) Bleeding

Monitor Incision/Drainage from Drain

Neurovascular Compromise Neurovascular Checks



Total Hip Replacement (cont’d) Ambulation

Physical Therapy Use Walker/Crutches



Total Hip Replacement (cont’d) Thromboembolitic Complications

Compression Devices Leg Exercises

Enoxaparin (Lovenox)



Total Hip Replacement (cont’d) Self-care

Assistive Dressing Devices Raised Toilet Seat Rehabilitation



Total Knee Replacement Femoral Component, Tibial Component,

Patellar Button Dislocation Not a Concern Care like Total Hip Replacement Continuous Passive Motion Machine

(CPM)



Continuous Passive Motion Machine



AmputationRemoval of a body part



Amputation (cont’d) Surgical Amputations

Ischemia from Peripheral Vascular Disease Bone Tumor, Frostbite, Congenital Problems,

Infections



Amputation (cont’d) Traumatic Amputations

Accidents



Amputation (cont’d) Replantation

Wrap Severed Body Part in Cool, Slightly Moist Cloth

Place in Sealed Plastic Bag Submerged in Cold Water

Transported to Hospital



Amputation (cont’d) Levels of Amputation

Below-the-knee (BKA) Above-the-knee (AKA) Below-the-elbow (BEA) Above-the-elbow (AEA)



Amputation Nursing Care Preoperative Nursing Diagnoses

Deficient Knowledge Teach Preoperative Procedures

Disturbed Body Image Begin Support Services



Amputation Nursing Care (cont’d)

Postoperative Hemorrhage Prevention Infection Pain Control

Phantom Pain

Mobility and Ambulation



Bandaging for Above-the-Knee Amputation



Amputation Nursing Care (cont’d)

Postoperative Nursing Diagnoses Prosthesis Lifestyle Adaptation

Chapter 46

Documents

Transcript of Chapter 46