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wvc musc/skel lect
wvc musc/skel lect. winter 2011
| Question | Answer |
|---|---|
| Muscular & skeletal Purpose and Function | Support; Protection; Movement; Blood cell production; Mineral storage |
| Effects of Aging on the musculoskeletal system | Osteoarthritis; Most common arthritis; Also known as “degenerative joint disease”; reduce ROM, |
| Assessment questions related to Musculoskeletal | History previous surgeries or trauma; level of activity; diet; fluid intake & output; job related factors; gender; ethnicity; medications (prednezone); ability to perform ADLs; level of pain. |
| Osteoarthritis | Most common arthritis; AKA “DJD”; Causes joint pain and loss of function; Age is the biggest risk factor for osteoarthritis, progressive erosion of cartilage & bone surface, narrowed joint spaces, bone spur, sinovitits, joint deformity. |
| Risk factors for osteoarthritis | Age (decreased muscle mass and bone density); Obesity (knees); Trauma (occupation related); Genetics (normally causes a secondary osteoarthritis) |
| Diagnostics for osteoarthritis | X-ray (shows joint deformity) ; MRI (inflammation, deformity, excess synovial fluid & damage to joint) ; ESR (measures inflammation in the body); High-sensitivity C-reactive protein (helps diagnosis of inflammation, produced by liver in acute inflamm.) |
| Sedimentation rate (ESR) | less than 20 |
| Pain management for osteoarthritis | Acetaminophen (Tylenol no more than 3 grams); Topical medications; NSAIDs; Opioids (some have acetaminophen in it/ resp. depresion/ constipation) ; Cortisone injection; Muscle relaxants; Heat/cold application |
| Complimentary/alternative therapies for osteoarthritis | Acupuncture; Tai chi; Imagery; Prayer; Meditation |
| Surgical intervention for osteoarthritis | Total joint arthroplasty; Total joint replacement; Total Hip Replacement (THR) ; Open reduction internal fixation (ORIF) |
| Criteria for THR | Pain (can it be managed by meds); Ability to participate in PT following surgery; Age (are they a good surgical risk); Medical history (other disease issues that will effect outcome) |
| Operative procedure | Pre-medication; Longitudinal incision on anteriolateral thigh; Acetabular cup;Femoral component |
| Post-surgical care | Prevention of dislocation; Positioning (don’t cross legs); Abduction wedge; Bending (don’t bend more than 90’); Abductor wedge, no more than 50 ml of drainage per 8 hrs, |
| Prevention of DVT/PE | Anti-embolism stockings; SCDs/foot pulsers; Anticoagulant therapy; Early ambulation |
| Total knee arthroplasty | Completed under general or spinal anesthesia; Central longitudinal incision, ~8 inches; Femoral and tibial components |
| Sign and symptoms of dislocation of hip | increased pain, shortening of effected leg & external leg rotation |
| Post operative care for Total Knee arthroplasty | Continuous passive motion (CPM); Increases flexibility; Increases mobility; Decreases recovery time; Increases ROM and function; Decreases pain |
| Nursing assessment After total hip replacement (THR), what are the signs of dislocation? | Hip pain, shortening of leg, and outward leg rotation |
| Rheumatoid Arthritis | chronic; Systemic; Inflammatory; Auto-immune process (auto antibodies attack the synovium & cartilage surrounding ligaments, tendons & bones); Joint deformity. Muscles & tendons on one side over power the joints on the other side causing the deformity |
| Assessment for RA | Joint stiffness & inflamation (bi-lateral), pain (ongoing pain throughout the day); Fatigue; Low-grade fever; Weakness; Paresthesias |
| Complications of RA | Baker’s cysts; Flares; Periungual lesions; Cardiac/Pulmonary complications (plerisey pneumonia, interstial fibrosis, pulmonary hypertension, pericadidis endocarditis ; Sjogren’s syndrome; Felty’s syndrome |
| Periungual lesions | (ischemic skin legions commonly found around nail beds…small brownish spot) |
| Caplan’s syndrome RA | rheumatoid nodules found in the lungs |
| Felty’s syndrome RA | (enlarged liver and spleen) |
| Sjogren’s syndrome RA | (red around eyes, bloodshot & dryness of mucus memebranes) |
| Baker’s cysts RA | enlarge popletieal bursa behind the knee, which may cause tissue compression & pain with possible tendon rupture |
| Diagnostics for RA | Laboratory values looking at ANA (anti nuclear antibodies); CT scan; MRI; Arthrocentesis; rheumatoid factor (must be checked with other tests… can have a false negative) |
| Alternative/Complimentary Therapies for RA | Hypnosis; Acupuncture; Imagery; Music therapy |
| The RN is performing an assessment of the patient with RA. Which findings does the RN expect? | Early morning joint stiffness |
| Gout | Systemic disease; Most common inflammatory arthritis, Primary & Secondary |
| Primary gout | excess production of uric acid exceeds excretion capacity of kidneys |
| Secondary gout | Excessive uric acid in blood caused by some other process, such as renal insufficnciey, use of diuretics, crash diets and certain chemotherapeutic agents |
| Assessment of gout | Inflammation, assess Pain, Serum uric acid level (greater than 8.5 is abnormal) excretion of more than 750 ml Urinary uric acid level) |
| Medication interventions for gout | NSAIDs; Allopurinol (Zyloprim) treatment of gout (promotes uric acid excretion or reduces production) (side effects hypotension/ brady cardia, heart failure, drowsienss, N&V, diarhhera) |
| Systemic Lupus Erythematosus | Two main classifications (Discoid & Systemic ) |
| Discoid lupus | it is a skin rash that gets worse when in the sun (slightly raised) circular ‘discoid’ appearance |
| Systemic lupus | effects bone marrow ,heart failure, effects kidney function (assess creatinine & BUN) arthritis, lupus nephritis |
| Signs and symptoms of lupis | fatigue, stiff and swollen joints, fever, “Butterfly rash”, anemia, brain fog, |
| Diagnostics | Antinuclear Antibodies (ANA); Complete Blood Count (rbc/ wbc/ platelet count)(CBC); Erythrocyte sedimentation rate (ESR); Rheumatoid factor, Complete metabolic panel, Renal function, Electrolytes, c-reactive protein/ rule out RA. |
| Medication interventions for lupus | Antimalarial to decrease inflammation (N&V, abdominal pain), Steriods, Immunosuppresives, NSAIDs |
| Patient teaching for lupus | stress may trigger; fatigue is common; take care of your skin; exercise, get plenty of sleep, |
| The RN is teaching the patient about the common S/Es of chronic salicylate and NSAID therapy. Which body system S/Es does the nurse focus on in the teaching plan? | Gastrointestinal |
| SLE | systemic lupus Erythematosus |
| What can be expected for the patient with recently diagnosed SLE? | Spontaneous remission and exacerbations |
| What is the most common cause of death in patients with SLE? | Renal failure |
| Scleroderma | Chronic; Inflammatory; Auto-immune disease; Higher mortality rate than SLE |
| Two classifications of scleroderma | (diffuse & limited) Diffuse scleroderma -effects trunk, face, proximal & distal extremities …Limited scleroderma- distal to the elbow and knees and involves face and neck |
| Assessment of scleroderma | Joint pain and stiffness; Pitting edema; Taut, shiny skin; Tightening and hardening of the skin; Loss of elasticity of the skin; Joint contractures; major organ damage (GI tract, CV system, pulmonary system, renal system) |
| Interventions for scleroderma | Meds(predezone, immunosuppressants) slow progression/remission, Protective measures for skin (inspect skin daily for lesions),Bed foot cradle); Increase warmth in digits (may have raynaud’s syndrome.. keep stress low),Swallow study (upright after eating) |
| Fibromyalgia | Diagnosed through “trigger points” (specific sites: back of neck, upper chest, trunk, low back & extremities);Pain syndrome; Possible dysfunction in the brain; Pain increases with stress, increased activity, and weather changes; H/A and jaw pain common |
| Fibromyalgia May be diagnosed as | chronic fatigue syndrome (patients can become frustrated by difficulty with getting a diagnosis) |
| Scleroderma CREST | Calcinosis (calcium deposits on skin) / Raynauds/ Esophageal dysfunction/ sclerodactyly (tightening of skin on hands & fingers)/ Telangiectasias (dilation of capillaries on the skin causing red marks) |
| Interventions for Fibromyalgia | Pregabalin (Lyrica)first drug approved, NSAIDs, Muscle relaxants, Antidepressant medication, Regular exercise |
| Musculoskeletal Trauma | Fractures; Amputation; Carpel Tunnel; Sprain/Strain |
| Types of Fractures | Pathologic fracture; Stress fracture; Compression fracture; Please review Figure 54-1, page 1179 for common types of fractures |
| Complications of bone fractures | Acute compartment syndrome; SERIOUS CONDITION; Compression causes decreased circulation; Most common sites: lower leg and forearm; Ischemia-edema cycle |
| 6 P’s | PAIN; Pressure; Paralysis; Pulseless; Pallor; Paresthesia |
| Emergency care of acute compartment syndrome | “Within 4-6 hours after the onset of compartment syndrome, neurovascular and muscle damage are irreversible. The limb can become useless in 24 to 48 hours.”Ignativicius & Workman, 6th edition, pg 1181 |
| Pathophysiology of acute compartment syndrome | Capillaries in muscles diaillate> capillaries become more permeable > fluid moves out of space and causes edema> pressure increases which decreases circulation and increases pain> tissue becomes ischemic and could become necrotic (numb/ weak pulse/ cold) |
| acute compartment syndrome is verified: | Fasciotomy ; Open wound packing; Debridement of wound; Skin graft |
| Nursing Interventions in ACS | Notify MD STAT; elevate limb above heart; isometric exercises; monitor CMS closely. |
| Fasciotomy | is a surgical procedure where the fascia is cut to relieve tension (& treat the resulting loss of circulation to an area of tissue/muscle) Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. |
| Myoglobinuric renal failure (Potentially fatal complication of ACS) | Occurs when large or multiple compartments are involved; Injured muscle tissue releases myoglobulin; Clogs the renal tubules; Myoglobulin has a direct toxic effect on kidney; Increased serum K+ r/t inability of kidney to secrete K+ |
| Fat Embolism | Release of fat globules into bloodstream; Fat globules clog small blood vessels that supply vital organs; Usually results from a long bone fracture; May also occur in patients who have a total joint replacement, comes from yellow marrow of the bone. |
| Fat embolism | Impairs profusion 12-48 hours after surgery. Results normally from a long bone fracture or TJA |
| fat embolism first sign is | change of mentation d/t reduction in oxygen to the brain. |
| Assessment of Fat Embolism | early s/s is altered mental status; Monitor for petechiae over the neck, upper arms, or chest and abdomen; Monitor lab changes (increased SED rate); decreased RBC & platelet decreased Ca level; increased serum lipase level |
| Risk factors for DVT (deep vein thrombosis): | Prolonged immobility; Cancer; Smoking; Obesity; heart disease; oral contraceptives or hormones; age (older); history of VTE. |
| Assessment of DVT | Severe pain below the level of the occlusion; Extremity is cool/cold; Pulseless & mottled…With onset of PE:SOB; Pallor; Cyanosis; Chest/back pain ; More common in the lower extremities |
| Diagnostics for DVT/ PE | D-Dimer -A global (throughout body) marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis |
| Treatment DVT | Anticoagulant therapy; Heparin, Lovenox, Fragmin (Q12 hrs; subQ; Coumadin (PO, based on PT & INR, SE= bleeding, highly interactive with herbs St. Johns Wart, Chamomile, dong quai, garlic, ginger, ginko, licorice,); ASA (aspirin, GI bleeds, heart burn) |
| PT & INR | PT (11-16 sec) & international normalized ratio (2.0-3.0)(2.5-3.5 with mechanical valve) |
| Nonsurgical management of fractures | Splint (non weight bearing); Cast (weight bearing); Immobilization; |
| Splint | For scapula and clavicle—elastic bandage or commercial immobilizer; Splints used on upper extremity bones |
| Casts | Used on complex fractures or fractures of the lower extremities; Immobilizes affected body part |
| Plaster of Paris cast | Takes 24-72 hours to dry; Cutting a window (observe skin and palpate pulses); Measures if cast becomes too tight; Fiberglass casts (lighter material and requires less drying time) |
| Cast care | monitor CMS every hour for first 24 hours; cover cast to protect from urine & feces. |
| Patient teaching casted patients | When lying down, elevate extremity above the heart; Utilize crutches when ambulating; Crutches need to measured accurately; Do not put body weight on arm pits; Report if cast becomes too tight/loose; Report if drainage occurs |
| Traction | Provides reduction,alignment & rest; Will assist w/ decreasing muscle spasm; five types: Skin traction, Skeletal traction, Plaster traction Circumferential traction, Brace traction |
| Skin traction | (buck’s traction) |
| Brace traction | (used for correction of alignment deformities) |
| Circumferential traction | (uses a belt around body for low back problems) |
| Plaster traction | (combination of skeletal traction & plaster cast), |
| Skeletal traction | (surgically insertion of pins, wires or tongs), |
| TRACTION | Temperature, ropes hang freely, alignment, circulation check (5 p’s); type & location of traction; increase fluid intake; overhead trapeze; no weights on bed or floor. |
| Traction Nursing care | Maintain traction; Skin inspection q 8 hours; Pin care; Monitor CMS q 4 hours |
| Medications used for soft tissue and skeletal injury | NSAIDs; Patient controlled anesthesia (PCA)Opioids (Most common side effect = constipation watch for resp. depression) |
| Amputation | Removal of a part of the body; May be elective or traumatic |
| Goal of amputation | To persevere extremity length and function while removing the dead tissue |
| Levels of amputation | Below the knee (BKA); Above the knee (AKA); Upper extremity (UE) (Fewer than 10% of amputations are UE ) |
| amputation Complications of amputation | Hemorrhage (hypovolemic shock); Infection; Phantom limb pain; Neuroma; Flexion contractures (often in hip or knee); Psychological aspects: Grief response, Altered self concept, Family’s reaction, Coping abilities |
| amputation Assess for: | Tissue perfusion; Pain management; Mobility; Phantom pain |
| Carpal Tunnel Syndrome | Common condition; Usually a chronic problem; Most common type of repetitive stress injury; Jobs with repetitive hand activities; Computer use, jackhammer use, etc.; Overuse in sports: Golf, tennis, racquetball |
| Carpal tunnel pathophysiology | Caused by compression of the medium nerve, compression caused by swelling through the carpal tunnel. |
| Care of stump | elevate for 1st 24 hours; compression dressing; clean area; discourage semi fowlers position. |
| Assessment for carpal tunnel syndrome: | work/activity history; Report of pain (opqrs); Report of numbness; Phalen’s maneuver; Tinel’s sign; Motor changes; Muscle atrophy; The importance of ergonomics |
| Phalen’s maneuver | (patient relaxes wrist in flexion or to place the back of hands together and flex both hands at same time, if that causes parastethia on palm side, it is positive for carpel tunnel syndrome) |
| Tinel’s sign | (parastheia on palm side when you tap lightly over medium nerve on wrist) |
| Diagnostics for carpal tunnel syndrome | Routine x-ray; Electromyography (EMG) (records electrical activity in the muscle); Nerve conduction studies (NCS) ; MRI(shows compression) |
| Non-surgical interventions for carpal tunnel syndrome | Drug therapy; Immobilization (splinting); |
| Surgery is necessary in about ½ of patients with Carpal Tunnel Syndrome | Relieves pressure on the median nerve; Major surgical complications rare. |
| nueroma | (sensitive tumor consisting of damaged nerve cells) |
| nerve conduction study (NCS) | (placing an electrical stimulator over a nerve & measuring the time required for an impulse to travel over measured segment of that nerve) |
| Strain: | “excessive stretching of a muscle or tendon when it is weak or unstable.” |
| Management of a strain: | Cold/Heat application; Activity limitations RICE (rest, ice, compression, elevation) |
| Sprain: | “excessive stretching of a ligament.” |
| Management of a sprain | Rest; Use of ice; Compression bandage; Elevation; |
| Osteoporosis | Chronic metabolic disease; “silent disease” rapid bone loss will normally begin in meta-pause |
| Osteopenia versus osteoporosis | due to the measuring of the density of the bone, with a dexus scan (DXA scan), Osteopenia will/ can lead to osteoporosis. |
| Assessment for osteoporosis | Dowager’s hump (kyphosis); Decreased height; Back pain; Fractures; Assess risk for falls |
| Diagnostics for osteoporosis | Serum calcium, vitamin D, phosphorous; DXA scan; QCT |
| Generalized osteoporosis vs. regionalized osteoporosis | throughout the body in generalized when compared to regionalized which is in one area (e. hip joint) |
| Patient education for osteoporosis | Fall risk; Nutrition; Protein; Magnesium; Calcium; Vitamin D; Iron; * Exercise |
| Risk factor for osteoporoses | Small stature, early metapause, late onset of menses; never had a pregnancy; smoking, dietary (calcium, vit-d, phosphorus), sedentary, alcohol users |
| Medication for osteoporosis | Ca; Alendronate (Fosamax),Risedronate (Actonel), Ibandronate sodium (Boniva) (reflux)Raloxifene (Evista) (selective estrogen receptor modulator, V bone loss/ ^’s density, bonds to estrogen receptor sites on bone, watch for DVT) ; Calcitonin miacalcin |
| Osteomyelitis (can be chronic or acute) | Infection caused by virus, bacteria, or fungi; Invasion by the pathogen; Inflammatory response; Increases vascular leak and edema; Exudate is released into the bony tissue; Bone necrosis |
| Assessment for osteomyelitis | Bone pain; Fever; Possible skin ulcerations; Erythema; Elevated WBC count; Elevated ESR (can cause death to the bone) |
| Nonsurgical intervention for osteomyelitis | Antimicrobial therapy; Wound irrigation; Standard precautions unless MRSA is present |
| Vancomycin & Gentamicin | main side effects autotoxicity/ hearing loss and nephrotoxicity |
| Surgical intervention for osteomyelitis | Debridement; Grafting; Nursing Assessment following surgery; Assess for infection; Assess circulation; Elevate involved extremity |
| Treatment for RA | NSAIDs , Antimalarial agent to decrease inflammation, (hydroxychloriquim); imunosuppressive agents (methotrexate) |
| Pathologic fracture | spontaneous fracture due to other disease factors |
| Stress fracture | Excessive stress or strain on a bone |
| PT & INR | pro time (11-16 sec) & international normalized ratio (2.0-3.0) |
| Antimalarial | to decrease inflammation (N&V, abdominal pain, seizures, aplastic anemia, agranulocytosis, leukopenia) |
| Compression fracture | From a loading force |
| Complications with lupus | renal fail, pericarditis, plurisey, vasculitis, seizure, raynaud’s, Sjogren’s, nephritis; Arthritis; Peripheral neuropathy; ;Paralysis; Stroke; Pul-hypertension; Glomerulonephritis; Leukopenia; Thrombocytopenia; Myocarditis; clots; Anemia; |
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