NCM104 5th Musculo II

7/30/2019 NCM104 5th Musculo II

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jcmendiola_Achievers2013

Care of Clients with Problems In Inflammatory

& Immunologic Response, Perception & Coordination

(NCM104)

Patients With Musculoskeletal Alterations II

Care of Clients with

Degenerative Disorders

Osteoarthritiso Definition: A joint disorder

characterized by degenerative

changes (aging process) of the

articular cartilage

(covering of the joint surface)

Classifications of Osteoarthritis1. Primary Type

o 65 years old and above (Aging process)o Associated with NO HISTORY of TRAUMA, INFLAMMATORY PROCESS,

and or JOINT DISORDER that affects the joints

o Incidence: Women are more affected Associated with hormones Post menopause

o Weight bearing joints are affected Hips and Ankles

2. Secondary Typeo More associated with maleso Brought about by certain JOINT DISORDER, TRAUMA and other

INFLAMMATORY DISEASE

Risk Factors1. Overweight (Obesity)

o Due to burden on the weight bearing jointso Bone may produce friction due to the weight

2. Traumao Due to a bad fall/infectious process

3. Genetic Factorso Studies show that Osteoarthritis can be given on a secondary generation from

grandparents

Clinical Manifestations1. Pain (Stiffness)

o MOST COMMON!!o Characteristics of pain:

Aggravated by any activity / walking BUT Relieved by rest

Only allow the client to rest if ACUTELY in PAIN

Because client is ENCOURAGED TO AMBULATE

2. Crepitus, Mild Tenderness, Deficit ROM (Due to inflamed joint), and Joint Enlargement3. Formation of NEW GROWTHS

o Bouchards Nodes LOCATED AT the Proximal Interphalangeal Joints

o Heberdens Joints LOCATED AT the Distal Interphalangeal Joints

Topics Discussed Here Are: Based sa Course Outline ni MAM

1. Degenerative Disordera. Osteoarthritis

2. Metabolic Disordersa. Osteoporosisb. Pagets Diseasec. Osteomalaciad. Gouty Arthritis

3. Spinal Column Deformitiesa. Scoliosisb. Kyphosisc. Lordosis

4. Bone Infections BOOKa. Osteomyelitis BOOK

5. Muscular Disorders BOOKa. Muscle Dystrophy BOOK

LOOKY

HERE

Note: Osteoarthritis can affect one joint,

but it can also affect more than one


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Diagnostic Test(s) X-Ray Only on the affected joint!

Management1. Medical

a. Relieve Pain

Rest If painful! Walking is encouraged if in the absence of severe painRationale: To improve the joint stability

Alternate Hot (Heat) and Cold compress BOOK BASEDHeat therapy only According to most clients

Drugs: NSAIDs

Mild GIT Irritation: Give on FULL STOMACH! Glucosamine

MOA: Stimulates the cartilage cells to produceproteoglycans (Substance responsible for reducing

the friction as the bones move)

Chondroitin

MOA: Prevents the breaking down of the enzymeproteoglycans

b. Functional Independence As much as possible let the client or give the client a chance to do all

the activities independently, if required, with the use of an assistive

device

c. Maintenance of Quality of Life Balance between rest and exercise DO NOT ALLOW the client to have a sedentary lifestyle It may

exacerbate the disease

Low impact exercise such as walking***As long as the client can keep on going do so!

2. Nursing Care Goal: To promote a healthy and positive adaptationa. Education Key to successful treatment

Pain management (Drugs) Rest Activity balance Nutrition:

As much as possible lessen the fats and red meat Give fruits and vegetables, milk and dairy products (Ca and

Vitamins)

REMINDER: Take everything, but in minimal! Weight loss Because putting on weight will put too much burden on

the joints

Self-Care Strategies Doing functional independence

b. Maintaining Independence Wheelchairs Crutches

3. Surgical Managementa. Osteotomy

Resection of a bone Then removal of the damaged cartilage but the functioning of the bone

can still be affected, so Arthrodesis is done

b. Arthrodesis / Joint Fusion Disadvantage: Client has an impaired mobility Advantage: Pain will be relieved

Note: Osteotomy and Arthrodesis

go HAND-in-HAND


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c. Total Hip Replacement (Arthroplasty) Repair of the hips Restores joint motion by replacing arthritic bones with metal

components

The synthetic material can either be plastic / metal on the joint Post Operative Care

1) Pain (Analgesics [Narcotics / Non-narcotics])2) Impaired mobility

Immediate ambulation, but affected extremity is IMMOBILIZED! Immobilization:

The affected extremity should have to be in an abductedposition

Makes use of an abduction wedge to preventADDUCTION and FLEXTION of the hip

Rationale:If in the Event the prosthesis is adducted, it willnot fit the site or dislodgement will occur!

DO NOT PUT CLIENT ON COMPLETE BED REST Be aware of the weight bearing limit In-Bed Exercise

Done during the 1st day If client goes out of the bed, do they need support?

Assist the client with at least 2 personnel3) Risk for peripheral neurovascular dysfunction

Neurological Assessment: q4 hours4) Risk for Injury Related to Prosthesis Dislocation

No bending Pedicure, tying of shoe laces

Use of Elevated Toilet Hips can only be up to 90 Can use instead a bed site commode

No Crossing of Legs Because one should maintain the 90 or it will promote

twisting of the affected leg No Inward Rotation of the Affected Extremity

Osteoporosiso Definition: Systemic skeletal disease characterized by bone mass and

microarchitectural deterioration of bone tissue that leads to fragility and susceptibility

to fracture

Enumeration: Bone Mass (Quality of bone) Microarchitectural deterioration of bone tissue (Parts of the bone are

damaged)

Leads to fragility Leads to susceptibility to fracture

o Fragility Fracture Results from low trauma as bending Example: Accidentally put weight on the palm

o Osteopenia / Osteopenic Bone with Low MINERAL DENSITYFactors that Influence Development of Osteoporosis

1. Bone Masso Quality of the boneo Measured by a Bone Densitometry

Note:

- Ask what type of vehiclewill bring the client home?

- If the right hip is affected,it should not be flexed

(only up to 90 only)


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Full Table DXA Report:

Report: (Reported as t-Score) BMC Bone Mineral Content BMD Bone Mineral Density

Normal:

Bone reaches its highest length until 20 y/o Peak mass is up until 30 y/o then will plateau untilmenopausal period

o Also present to males because it is influenced by hormoneso As one grows older, a person shortens due to bone mass

2. Heredity = 60 80%3. Low Body Weight Less than 127 lbs, because it can activate the Osteoblasts4. Prolonged premenopauseal amenorrhea / Early menopause5. Inadequate physical activity6. Low intake of dietary calcium7. Suboptimal level of Vitamin D8. Cigarette smoking9. Alcohol intake10. Drugs as Thyroid Hormone (Levothyroxine), Anti-convulsant (Phenobarbital), Furosemide

(Lasix), Steroids (Prednisone, Decadron)

Note:- t-Score = Difference between the

clients BMD/BMC and the

BMD/BMC of a young normal

adult having the same sex

- Standard Deviation =

BB-CC-D-VHAMP

Bone Mass

Body Weight

CalciumCigar

Drugs

Vit DHereditary

Alcohol

Menopause

Ph sical activit

Remodeling Bones are DYNAMIC

o They undergo continuous remodelingo Remodeling

Process of Changing old bones to have new boneso Phase I [Resorption]

(7 10 Days) Activated: Osteoclasts will try to absorb portions of the bones

considered old

o Phase II [Bone Formation] After removing of old cells, Osteoblasts come in


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Bone Resorption Old bone is replaced by new bone Functions:

o So as biochemical properties are not compromisedo For mineral homeostasis (Ca will be in-and-out)

Process:o Bone Resorption: Activation of OSTEOCLASTSo Bone Formation OSTEOBLASTS form an organic matrix

Controlled by 2 Important Factors1) Systemic Factors Exemplified by the need of Ca2) Local Cytokines Serves to coordinate the 1st and 2nd Phase

Clinical Manifestations1. Severe Back Pain

o May already be present, but client does not mind ito Only diagnosed after a history of fractures, compressed vertebrao Pain worsens on movemento Just like Osteoarthritis, relieved by resto Present for 1 1 weeks

2.

Progressive Vertebral Deformitieso Client stoops forward to relieve paino Stooping progresseso As client becomes Kyphotic, rib cage compresses and client complains of abdominal

discomfort (Bloated abdomen)

o Restriction of lungs (DOB)3. Bone Loss

o Mandibles are affectedo Dentures loosen/tighten

4. Changes in appearanceCategories of Osteoporosis

1. Normalo

BMD of client is not more than 1 SD below the young adult individual2. Lowo If in the event it is 1 2.5 below the normal adult it is Low Bone Mass (Osteopenia)

3. Osteoporosiso A value for BMD / BMC that is greater than 2.5 SD below the young adult measure value

4. Severe Osteoarthritiso A value for BMD / BMC that is more than 2.5 SD below the young adult mean value and

the presence of 1 or more fragility of fractures

BMD is Done on the Following1. All Menopausal women under the age 65 y/o

(With one or more additional risk factors)

2. Women considering hormone replacement therapy (HRT)3. Individuals on prolonged steroid therapy

Management1. Prevention

a. Adequate intake of Ca and Vit D Women 25 50 y/o 1000 mg/day Post-menopausal

Taking Estrogen 1000 mg/day Not Taking 1500 mg/day

Women > 65 years 1000 mg/day


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Men < 65 years 1000 mg/day Men > 65 years 1500 mg/day

Sources of Calciumo Broccoli, milk, dairy, green leafy veggies, fish

Sources of Vitamin Do Sun (At least 50 minutes, do not use sunscreen), milk, fish

b. Regular weight bearing exercisec. Avoidance of tobacco and alcohol

2. Estrogen replacement Pagets Disease (Osteitis Deformans)

o Definition: Disorder of localized bone marrow turn over commonly affecting the Skull,Femur, Tibia, Pelvic Bone and Vertebra

o Enumeration Skull Femur Tibia Pelvic Bone Vertebra

o Incidence: 2% - 3% Occurs in adults 50 y/o and above More on maleso Cause - ?

Pathophysiology


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Clinical Manifestations1. Skull

o Thickenso Gives the face a SMALL and TRIANGULAR shapeo May have impaired hearing Due to compression of Cochlear Nerveo Hat / Bonnet cant fit 1st MANIFESTATION!o

Is insidious in nature!2. Long Boneo Femur and Tibia tend to bow, producing a waddling gaito Will form a bow-legged appearanceo As the client walks, there is a change in gait

3. Spineo Bent forwardo Slightly rigido Thorax is compressed Difficulty in breathing

4. Trunk is focused** on legso Worst scarring ***

5. Pain, tenderness, warmth over the bones6. Mild to moderate aching pain that in pain, due to weight bearing

Diagnostic Procedure1. Blood Tests: Calcium = Normal

o Serum Alkaline Phosphataseo Normal Serum Ca

2. Urine Testso Excretion of hydroxyproline

3. X-Ray of the boneso Shows area of demyelination

Management1. NSAIDs2. Walking Aids Done to move client around3. Reduce Weight4. Diet - in Ca and Vit D5. Anti-Osteoclastic Drugs

o Calcitonin Hormone Preparation (Thyroglobulin) MOA: Reduces bone resorption by reducing the number and

availability of osteoclasts

o Bisphosphonates Two Important Functions

1. To reduce number of osteoclasts to lessen boneresorption

2. Relieves paino Plicamycin

Cytotoxic Antibiotic To control the progression of Pagets Disease

Osteomalacia (Rickets)o Manage Problem: A deficiency with Vitamin D (Calcitriol)o Also known as Adult Ricketso Bones become abnormally soft because of disturbed Ca and Phosphate balance secondary

to Vitamin D deficiencyo Inadequate mineralization (demineralization) of the boneso Non absence and storage of Ca in bone


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Incidenceo Affects the pelvises, spine, and lower extremitieso More on women with multiple pregnancies and had breast fedo Common among Muslims (Clothing)

Causes:

1.

Strict Vegetarianism (Not ENOUGH with VEGGIES

)2. Very low fat diet3. Malabsorption syndrome4. Excessive loss of Calcium5. GIT Disturbances as biliary tract obstruction6. Liver and Kidney Disease (Site of Vit D conversion to active form)7. Renal insufficiency8. Hyperparathyroidism9. Decreased intake of food HIGH in Ca and Vit D

Assessment1. Easy fatigability, body malaise and bone pain

o Cant PINPOINT where the pain is2. Physical Assessment

a. Skeletal Deformities Bow-leggednessb. Waddling/Limping Gaitc. Muscle Weakness

3. Laboratory Testa. Serum Cab. Moderate increased alkaline Phosphatasec. Urine excretion of Ca and Creatinine

4. Biopsyo amount of Osteoid (Pre-bone)o A picture of deminerlizing of bone

Management1. Gentle handling of clients

o Assist when changing positiono Use of pillows to relieve pressure / pain

2. Ca and Vit D Supplement3. Protein4. Expose to sunlight (50 minutes)5. Use of braces (Assistive Devices)

Gouty Arthritiso Brought about by deposition of URIC ACIDo A metabolic disorder in which Purine (CHONE) metabolism is altered, there is

accumulation of uric acid usually on the BIG TOE

Classifications of Gouty Arthritis

1. Primaryo Inherited defect of Purine metabolismo About 85%; 95% are maleso Occurs on 3rd or 4th Decade of life

2. Secondaryo Acquired condition as in:

a) Hematopoietic Disorders Any disorders of the blood (Bleeding Loss of Globulin/Albumin)

b) Rapid Induction of Chemotherapy Radiation

Pathophysiology


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Destruction of surrounding tissue Cells has protein inside, if destroyed, then no more protein

c) Renal disorders Can no longer have conversion of AMMONIA to UREAd) Drugs as aspirin, thiazide and anti-TB Drugse) Alcoholismf) Starvation

Clinical Manifestations1. Asymptomatic Hyperuricemia

o Elevated URIC ACID (> 7.0 mg/dL)o No signso Requires no treatmento Fluid Intake To pass out URIC ACID easily

2. Acute Gouto Has deposited uric acid in the joint spaces leading to:

Sudden onset of pain

3. Interval / Intercriticalo Period between acute attackso No signso Normal joint function

4. Chronic Tophaceous Gout / Advanced Gouto

Most disabling; develops over a long period

o Has caused permanent damage to joints and times to the kidneyso With proper treatment, wont progress to this stage

Diagnosis1. Persistent *** - >7.0 mg/dL2. Presence of uric acid in aspirated synovial fluid

o To determine level of uric acid at synovial spaceManagement

Tophi

- Deposition of uric acid atthe big toe

- Appears at the LASTSTAGE

Pain is known as the Thief of

the Night Because pain

appears during the night


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1. Management of Acute Attack Reduce paina. Cold compressb. Rest until pain subsides Splint to immobilized footc. Use of Drugs

Colchicine 1st Antigout Drug NSAIDs / Steroids To the inflammatory process and Pain Allopurinol Blocks formation of Uric Acid Probenecid Promotes resorption and excretion of uric acid by the kidney

2. Long Term Managementa. Diet AVOID

RED MEAT SEA FOODS As long as kidney is normal, OKAY! Organ Meat

b. Fluid intakec. Weight

Management of Clients with Spinal Column DisordersScoliosis

o Definition: The lateral curvature of the spine May occur at the cervical, thoracic, thoracolumbar / lumbar area

o Incidence: Curve less than 10 = 1.5% - 3% Less than 20 - Affects both Male and Female Most common Over 10 years; more on female

ETIOLOGY1. Congenital

o Results from (Intrauterine) malformation of body segments of the spine dueto failure of:

Formation Absence of portion of vertebra Segmentation Absence of normal separations between vertebra

2. Neuromuscularo Associated with spinal deformities as Poliomyelitis (1 leg is shorter),

Cerebral Palsy

o Born with a NORMAL spineTYPES

1. Congenital Associated with a GENE called CHD72. Idiopathic According to onset

a. Infantile


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5. Degenerativeo Occurs in agedo Caused by changes in spine as arthritis

6. Structural Does not correct itself on forced bending7. Non-structural

Easily corrected No vertebral rotation (DO EXERCISE if diagnosed early)

8. Types According to Vertebra Affected (Scoliosis) Thoracic Lumbar

ASSESSMENT Assess for the symmetry of the shoulder Assess also for appearance of hips The Gluteal folds must be equal Paraspinal muscles Adams Forward Test (Bend FORWARD)

Diagnosis1. Adams Forward Test

o Ask client to bendo Used as a screening testo WOF: Deformation of the Paraspinal muscles

2. X-Ray3. Cobb Angle

o To assess the curvature quantitativelyo Upper end plate, uppermost vertebra involved and lower end plate of the

lowest vertebra

Management1. Less then 20 - Exercise

o Turning of body Towards the oppositeo Stretching of the body Towards the oppositeo SWIMMING!o MONKEY BARS!

2. Between 20-40 - Milwaukee Brace3. Surgery - >45

o Spinal Fusion WITH Instrumentation Insertion of a Harrington Rod

o Lessen discomfort, movement, by use of HIPS, the spine should not bemoved!

Kyphosiso Abnormal convex angulation in the curvature of the THORACIC spineo Posterior rounding of the thoracic spineCauses

1. Poor posture Most common among females, early breast tissue formation2. Secondary to Disease Ex. TB Of Spine (Infection of Spine)3. Degenerative Process4. Developmental Problems5. Trauma

Types of Kyphosis1. Congenital

Spinal Fusion- Spinal Fusion- Steel rods help support the

fusion of the vertebra

- Bone grafts are placed togrow into the bone and

fuse the vertebra


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o Spinal column not fully developed in the wombo Vertebra may be malformed / fused together

2. Posturalo Most commono Attributed to SLOUCHINGo Among Younger Slouching Kyphosiso Adult Dowagers Hump / Hyperkyphosis

3. Nutritional Occurs in childhood with Vitamin D Deficiency4. Associated with children with Rickets5. Scheuermanns Kyphosis

o Among femaleso Worst COSMETICALLYo Causes pain at apex aggravated by physical activity and prolonged standing

or sitting

o Apex at curve Thoracic vertebra rigid (Compression of lungs) Poorexpansion (DOB)

Managment1. Orthosis Use of Milwaukee Brace2. Surgery or Kyphoplasty Repair of Kyphotic Vertebra

Lordosiso Excessive inward curvature of lumbar spine / vertebrao Cervical and Lumbar Vertebra Lordotic; convex anteriorly, concave posteriorlyo Excessive Saddle back, Sway Back / Hollow Back

Causes1. Tight low back muscles (Muscles at Lumbar area)2. Excessive visceral fats3. Pregnancy4. Secondary to disease as Flexion Contracture of hip5. Associated with congenital hip dislocation

Manifestations1. May lead to Sway Back Lumbosacral spinal curves sharply and

Thoracolumbar Spine exhibits Kyphosis

2. Sagging shoulder3. Exaggerated pelvic angle4. Medial rotation of legs

Management1. Loss of weight2. Use of brace3. Surgery Spinal Fusion!

NCM104 5th Musculo II

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