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Med-Surg Ch 40

Musculoskeletal Disorders

4 Metabolic Disorders of Musculoskeletal Osteoporosis, Paget’s Disease, Gout, Osteomalacia
Osteoporosis Risk Factors Remember ACCESS: alcohol, corticosteroids, calcium deficiency, estrogen low, smoking, and sedentary lifestyle. Age, Genetic predisposition, Female gender, Race: White or Asian, Endocrine disorders, Malabsorption disorders, Medications.
Osteoporosis Manifestations Loss of height, Progressive curvature of the spine, Low back pain, Fractures of forearm, hip, and spine, Dowager’s hump.
Osteoporosis Diagnostics Bone density (loss of 1-1.5 inches of height), X-rays, Quantitative computed tomography (QCT), Dual-energy X-ray Absorptiometry (DXA scan), Ultrasound
Estrogen Replacement Medications for Osteoporosis HRT (increased risk of cancer), Selective estrogen receptor modulators (SERMs): Raloxifene (Evista), Tamoxifen (Tamofen); Decreases risk of breast cancer; Estrogen related to bone loss, not reproduction; will still have hot flashes, irritability, etc.
Daily Calcium Needs 1000-1200 mg/day
Daily Vitamin D Needs 200-600 units/day
2 Kinds of Calcitonin for Osteoporosis Calcimar and Miacalcin (injection or nasal spray)
4 Kinds of Biphosphonates for Osteoporosis Alendronate (Fosamax) (once a week), Risedronate (Actonel), Ibandronate (Boniva) (once a month), and Reclast (once a year). Drug of choice. Preserves bone density.
Foods High in Calcium Green leafy veggies (Broccoli, collard greens, bok choy, spinach), Clams, oysters, sardines, salmon.
Paget's Disease Osteitis deformans, > calcium, 2nd common bone disease in US, Abnormal/excess bone resorption and formation, Chronic remodeling = Bones are larger and softer (Remind you of chalk, thick, but break easy), Affects the axial skeleton. Initially asymptomatic.
Musculoskeletal effects from Paget's Disease Pain aggravated with pressure, Deformity, Fractures, Muscle weakness.
Neurologic effects from Paget's Disease Scull abnormal thickening presses on the brain = Hearing loss, decreased level of consciousness, migraines, speech problems, ataxia (< coordination).
Cardiovascular Effects from Paget's Disease Increased vascularity (and skin temp) of the affected bones.
Metabolic Effects from Paget's Disease Hypercalcimia and Hypercalcimauria
Paget's Disease Diagnostics X-ray, CT, MRI, Alkaline Phosphatase. May be treated with surgery.
Medications for Paget's Disease Pain Relief (NSAID’s: Motrin or Indomethicin) and Suppress bone cell activity: Calcitonin and Biphosphonates.
Gout Hyperuricemia (> uric acid in blood). Urate crystals deposits in joints. Abrupt onset usually at night. Usually great toe joint initially. Increased risk for urate kidney stones.
Normal Uric Acid Levels 2.8 – 6.8 in women. 3.5 – 7.0 in men.
Gout Risk Factors Male, Diet rich in red meat/seafood, ETOH consumption, Soft drink with corn syrup, sweetener consumption, Dehydration, Aspirin.
5 things correlated to Gout Obesity, metabolic syndrome, hyperlipidemia, HTN, insulin resistance.
Primary Gout Error in purine metabolism=uric acid. Inherited as X-linked trait (momma gave it to me). Middle aged to older men. Post menopausal women.
Secondary Gout Hyperuricemia. Caused from another disease/diets. Some drugs: Lasix, PZA, cyclosporin, salicylates. All ages.
Stages of Gout Stage 1-Asymptomatic hyperuricemia: Uric acid levels 9-10 mg/dL. Stage 2-Acute Gouty Arthritis: Excruciating pain, inflamed joint, > WBC, Sed rate, triggered by the RF. Stage 3-Advanced gout: Chronic or tophaceus gout, Kidney disease.
Gout Collaborative Care Terminate acute attacks. Prevent recurrent attacks (Lifestyle changes, Refer back to RF). Reverse/prevent complications.
Acute Gout Drug Therapy Does not get rid of gout. Indomethicin (Indocin): Can be used for other pain relief. Colchicine (Colsalide): Only for gout (SE: abd cramping, n/v).
Gout Prevention Drug Therapy Allopurinal (Zyloprim): Prevents conversion of ziathem to uric acid, decreased serum uric acid. Probenecid (Benemid): Drink at least 3L/day, 2500 ml is normal/non gout intake.
Gout Nutritional Needs/Concerns Low purine diet, Increase fluids (>2L/day), Avoid: red meats, shellfish, excessive ETOH, yeast, beans, peas, spinach, aspargus, cauliflower, mushrooms, fad diets.
Gout Diagnostic Tests Serum uric acid, WBC, ESR or sed rate, 24-hour urine, Analysis of fluid aspirated from inflamed joint.
Osteomalacia Adult Rickets (bowing of legs)
What causes Osteomalacia Inadequate intake/absorption of calcium, Vitamin D deficiency, and/or Phosphate depletion.
3 Manifestations of Osteomalacia Muscle fatigue/weakness, Bone pain/tenderness, Marked deformities.
Treat/Educate Osteomalacia Give calcium/vitamin D supplement. Safety/prevent falls. 15-20 min sun exposure for vitamin D absorption. Use assistive devices properly.
Osteoarthritis (OA) Degenerative JOINT. Most common form of arthritis. Leading cause of Pain/Disability. Loss of joint cartilage, synovitis, loss of joint motion. Most affected joints: Hands, Neck, Lower back, Hip, Knee.
OA Risk Factors Aging (uncommon under 40)(men earlier than women). Genetic changes. Obesity. Smoking. Trauma. Repetitive use. Inactivity.
OA Manifestations Deep aching PAIN. Paresthesias (numbness/tingling). Decreased ROM. Stiffness of joints. Crepitus. Joint enlargement.
Physical Assessment of OA Unilateral (one side affected). Pain, stiffness. Crepitus. Enlarged joint. Herberden’s nodes (top knuckle) and Bouchard’s nodes (middle knuckle). Joint Effusions. Atrophy of skeletal muscle. Loss of function. OA of spine: Nerve issues, Spasms.
OA Medications Analgesics: Acetaminophen (4g/day max), Topicals (capsasin), NSAIDS, COX2 Inhibitor, Opioids. Joint injections: Gel/Cortisone, every 4-6 weeks, more frequently can accelerate OA. Muscle relaxants: Helps with spasms, Flexareal, Glucosamine/Chondroitin.
OA non-Pharmalogical Treatment Rest, Heat/Ice, Positioning, Regular exercise, Assistive Devices, paraffin dips, Diathermy, Ultrasound, Weight control.
OA Surgeries Arthroscopy. Osteostomy. Joint arthroplasty.
Osteostomy Incision into or transaction of the bone, realign an affected joint.
Joint Arthroplasy Reconstruction, Replacement (Hip, knee, shoulder, elbow, ankle, wrist, fingers, toes).
Muscular Dystrophy Inherited. Muscle degeneration and wasting. Fat and connective tissue replace muscle fibers. < ambulation, eventually wheelchair bound. May see cardiac, endocrine, and mental retardation (Duchenne’s, Myotonic, Becker’s, Facioscapulohumeral, Limb-girdle)
Muscular Dystrophy Labs CK-MM- creatine kinase, isoenzyme found in skeletal muscle. Muscle biopsy- identify fibrous connective tissue and fatty deposits that displace functional muscle fibers. EMG- Electromyogram, shows a decrease in amplitude MD.
Rheumatoid Arthritis Chronic, systemic, autoimmune disease. Inflammation of connective tissue. 3x as many women as men. Onset: usually between 30-50. Course and severity variable. Shortened life span. Unknown cause: genetic, virus, environmental.
RA Etiology Combo of genetics and environmental: HLA and DR4, Female reproductive hormones, Epstein-Barr virus, Physical and emotional stress.
Early Manifestations of RA Joint stiffness (especially in morning), Swelling, Pain, Fatigue, Low grade fever, Generalized Weakness, Anorexia, Paresthesia (Bilateral, systemic)
Late Manifestations of RA Gel phenomen – stiff, harder to use. Joints of feet/hands puffy, spindle like. Deformities. Moderate to severe pain. Osteoporosis. Carpal tunnel. Spinal column. Life threatening. Baker’s cyst (Bursars sac behind knee, cyst, Tendon Rupture). Anemia.
More Late Manifestations of RA > Weight. Subcutaneous nodules (Round/movable/non-tender, Watch for infection = severely progressed RA). Peripheral neuropathy. Vasculitis (inflammation of the vascular system). Pericarditis/myocarditis (inflammation of pericardial sac). Iritis/scleritis.
Diagnostic Criteria for RA Morning stiffness (>1 hr., lasting > 6 weeks). Swelling/effusion (3 or more joints, > 6 wks). Arthritis of wrist (Metacarpal Pharengyl, PIP joints > 6wks). Joints move as one not seperate. Nodules. ^ Rheumatoid factor. ^ C-reactive protein. ^ ESR.
5 Kinds of RA Drug Therapies NSAIDS, Corticosteroids, Disease Modifying Antirheumatics, Biological Response modifiers, and Tumor Necrosis Factor inhibitors.
RA Corticosteroids Prednisone (Deltasone), Cortisone injections. Anti-inflammatory, immunosuppressive effects. Side Effects: Buffalo hump, wt gain, acne, moon face, < immune. Complications: DM, Infection, Fluid/electrolyte imbalances, HTN, Osteoporosis, Glaucoma.
4 Disease Modifying Antirheumtics for RA Methotrexate, Sulfasalazine (Azulfide), Leflunomide (Arara), and Hydroxycholorquine (Plaquenil).
Methotrexate Immunosuppressive of bone marrow. Low, one time week dose. Slow acting 4-6 weeks. SE: Decrease WBC, Decrease LFT, creatinine (damaging to kidney), N/V, Stomatitis. Can’t take while pregnant. Strict birth control. Avoid crowds.
Sulfasalazine (Azulfide) Mild to moderate inflammatory arthritis. Do NOT take if allergy to sulfa drugs or ASA. 3-6 months therapy. SE: Yellow/orange skin/urine, Sulfa taste, Decreased WBC, platelet counts, Teratogenic (can damage fetus, decrease sperm count).
Leflunomide (Arara) Slow acting immune modulating med. Decreased inflammation, stiffness 4-6 week before benefits, possibly 3 months. Antidote: Cholestryramine (Questran). SE: Hair loss, Diarrhea, Decreased WBC/platelets/LFT.
Hydroxycholorquine (Plaquenil) Anti-malarial. Decreased joint and muscle pain. SE: Alopecia, Pruritis, Retinal damage, Eye exam every 6-12 months!
Biological Response Modifiers (RA drug) Newest on market. Neutralize biological activity of tumor necrosis factor (TNF). Inhibits receptor binding. >$, Ins may not pay. NOT for TB or MS pt. Must have neg PPD. Etanercept (Enbrel). SQ injection. 1-2/week. Monitor: CBC, creatinine, LFT q4-8 weeks.
Tumor Necrosis Factor inhibitors (RA Drug) Infliximab (Remicade), Adalimumab (Humira), Abatacept (Orencia), and Rituxmib (Rituxan)
Infliximab (Remicade) IV infusion. S/S of reaction: Chest discomfort, Tachycardia, SOA, Lightheadedness. 2, 4, then 6 weeks.
Adalimumab (Humira) Decreased joint stiffness, swelling = ^ movement. Monitor: Injection site and labs (same as Enbrel).
Abatacept (Orencia) and Rituxmib (Rituxan) IV infusions. Used with high level progression. Monitor for: Cough, Dizziness, Dyspnea, wheezing, Flushing, itching.
Other Treatments for Clients with RA Rest and exercise. PT and OT. Heat and cold. Assistive devices and splints. Diet. Surgery (Synovectomy, Arthrodesis, Arthroplasty).
Teaching for RA Stop activity immediately when needed. PAIN—warning signal. Use strongest joints available. Avoid stress toward a position of deformity. Avoid activities that need a tight grip (writing, wringing, unscrewing).
Ankylosing Spondylitis (AS) Affects vertebral column. Stiffening and fusion of the spine. Onset age: 17-35.
Complications of Ankylosing Spondylitis Intermittent back pain. Loss of lumbar curve. Uvetits (inflammation of iris). Bowel and cardiopulmonary dysfunction.
Treating Ankylosing Spondylitis Pain control. Disease modifying drugs. Exercises.
Collaborative Care of Ankylosing Spondylitis HLA-B27, confirmed by x-rays. PT, daily exercises to prevent stiffness. Medications: NSAID’s (usually Indocin), Sulfasalazine, Corticosteroids. May require hip arthroplasty. Supportive nursing care and education.
Systemic Lupus Erythematosus (SLE) Chronic/progressive/Inflammatory/Autoimmune. Major body systems fail. Butterfly rash. > in Women. > in African American. Child-bearing age. Genetic/environment. Cell DNA affected by ANA. Invades organs = vasculitis. Blood/oxygen cell death. Likes kidneys.
Systemic Lupus Erythematosus Assessment Remissions client looks/acts healthy. Skin: Butterfly rash, Alopecia, Mouth ulcers, Photosensivity, Discoid lesions. Other: Polyarthritis, Fever and fatigue, Nephritis, Pleural Effusions, Pericarditis, Raynaud’s, Cognitive dysfuction.
Systemic Lupus Erythematosus Diagnostics ANA testing. Anti-DNA antibody testing. ESR (>100mm/hr). Serum complement levels decreased. CBC. Urinalysis and renal function tests. Kidney biopsy.
Systemic Lupus Erythematosus Medications NSAID’s. Anti-malarial drugs such as Plaquenil. Corticosteroids. Immunosuppressive therapy.
Systemic Lupus Erythematosus Skin Protection Avoid exposure to sunlight, UV. Long sleeves. Wide brim hat. SPF 30 or >. Mild soaps. Inspect skin daily.
Lyme Disease Spirochete Borrelia burgdafei. Transmitted primarily by infected deer tick in Summer months and early Fall. Prevalent in Northeast, Mid Atlantic states, and Midwest.
Stages of Lyme Disease 1: Flu-like, migrans, bulls-eye, 3-30/d, Doxycycline/Amoxicillian/Erythromycin/Cefuroxime/NSAIDS. 2: 1-2/wks, Carditis/dysrhythmias/palpations/Dyspnea/dizziness/CNS. Late stage: mo-yrs, < memory, Permanent damage to joints/CNS, IV antibiotics x30/d.
How to Prevent Lyme Disease Avoid wood areas. Walk in center of trail. Avoid dark clothing. Insect repellant. Long sleeves, pants and tuck. Closed shoes. Bath immediately. Check pets. Remove a tick with fine tip tweezers, flush or keep for testing.
Osteomyelitis Infection of the bone. Acute, subacute, or chronic. Any age. More common after age 50. Causes: bacterial, fungal, parasitic or viral, most common, Staph aureus, Open wound, complication of surgery.
Osteomyelitis Complications Tachycardia. N/V, anorexia. Lymph node involvement. Localized tenderness. Drainage/ulceration at site. Swelling, erythemia, warmth at site. Increased temp, abrupt onset of pain, malaise. Decrease use of extremity.
Osteomyelitis Diagnostics MRI or CT. Ultrasound. Bone scan. Biopsy. ESR, WBC elevated with acute infection. Blood and tissue cultures identify organism.
Osteomyelitis Treatments Antibiotic therapy. Surgery: Debris/amputate.
Septic Arthritis Joint space is invaded by a pathogen. Persistent bacteremia. Previous joint damage. Use of contaminated needles. STI’s.
Septic Arthritis Manifestations Sudden onset. Pain and stiffness around joint. Red, hot, swollen, tender joint. Systemic manifestations.
Septic Arthritis = Medical Emergency Gram stain & culture of aspirated joint fluid. Cultures obtained from likely sources of infection: blood, sputum, or wounds. Treatment: rest, immobilization, elevation, antibiotic therapy, Physical therapy, AROM, Monitoring of temperatures.
2 Types of Bone Tumors Primary (most common) and Metastatic.
Manifestations of a Bone Tumor Bone pain: Increased at night, Continuous or intermittent. Mass: Firm, Tender, May be palable, Injury often brings attention to.
Bone Tumor Diagnostic Tests X-ray. CT scan. MRI. Needle biopsy. Serum: Alkaline phosphate, Calcium.
Bone Tumor Treatment Chemotherapy. Radiation. Surgery.
Scleroderma Systemic sclerosis, progressive, chronic, inflammatory, autoimmune. Hardening of skin and connective tissue: like stone. Localized or systemic. Symptoms similar to lupus. Mortality rate compared to SLE. Cause unknown, all races, 25-55 y/o female.
Crest Memory Tool For Scleroderma Calcinosis. Raynauds. Esophageal dysmotility. Sclerodactyly. Telangiectasia.
Manifestations of Scleroderma Arthralgia. Stiffness. Non-Pitting edema. Taut, shiny, wrinkle free. “Sausage like” fingers. elasticity, ROM.
Scleroderma Organ Involvement GI: < motility, malabsorption. CV: Raynauds, Disarythmias. Lung: Avioli fybros, Pulmonary artery HTN (serious, leads to death). Renal: HTN, < output.
Scleroderma Diagnostic Tests ESR (inflammatory process). CBC (anemia of chronic disease. Gammaglobulin levels. ANA. RF. Skin biopsy (to confirm diagnosis).
Scleroderma Interventions Aim for remission to slow progression. ID organ involvement, treat. Use mild soaps, lotions, gentle cleaning. Prevent chilling-gloves, socks. Avoid smoking. ST, HOB. Histamine antagonist/antacids. NSAIDS.
Marfan Syndrome Autosomial dominant. Skeletal, ocular, cardiopulmonary, CNS. Connective tissue issue. S/S: VERY tall, elongated bones, scoliosis, funnel-chest, < cervical curvature, hyperextendable joints, lens subluxation. Main cause of death is heart problems.
Sjogren’s Syndrome Autoimmune disorder. Exocrine gland inflammation & dysfunction. Primarily women. Ages 40-60. Associated with other rheumatic disease.
Sjogren's Syndrome Manifestations Xerophthalmia (dry gritty eyes). Xerostomia (altered swallowing/chewing). > risk of malignant lymphoma.
Sjogren's Syndrome Diagnostic Tests Schirmer’s test and Biopsy of lip
Sjogren's Syndrome Treatment Artificial tears. Drink fluids. Saliva substitute. Sugarless gum. Avoid : antihistamines, decongestants, atropine. Good oral hygiene.
Fibromyalgia Widespread musculoskeletal pain. All ethnic groups, almost every country. Women 9x more than men. Between 20-50 years of age. Unknown cause. Related to physical or emotional trauma. Trigger points. Tender Points.
Fibromyalgia Manifestations Fatigue, sleep disturbances. Tender points. Sensitivity to odors, noises, lights. Headache, jaw pain, morning stiffness, diarreha, constipation, chest pain, disrythmias, blurred visual.
Fibromyalgia Diagnostics H & P, physical exam. Widespread pain for 3 months. Pain at 11 or more tender points. Tests to rule out: RA, SLE.
Fibromyalgia Treatment Exercise. Hypnotherapy. Antidepressants. Pregabalin (Lyrica).
Scoliosis Lateral curvature of the spine. Posterior view is S-shaped. One shoulder higher than the other. Prominent hip. Projecting scapula. Pain. Shortness of breath from diminished chest expansion. Crowded abdominal organs.
Kyphosis Excessive angulation of the normal posterior curve of the thoracic spine. Slumping/slouching/hunchback. Impaired mobility. Respiratory problems.
Treatment of Scoliosis and Kyphosis Diagnose early and treat to prevent deformity in adult. Conservative: Braces, electrical stimulation, traction in adolescent, Wt. loss, active and passive ROM. Surgery: stabilization with metal reinforcing rods to correct deformity.
Lower Back Pain Most commonly due to muscle strain. May be caused by degenerative disc disease or herniated vertebral discs. Mild to debilitating pain. Manifestations: Alterations in gait and flexion, Neurologic involvement, PAIN.
Treat Lowe Back Pain With NSAID’s. Muscle relaxants (Flexeril, Robaxin, Soma). Steroid injections. Conservative: Braces, Electrical stimulation, alternating hot/cold, PT for ultrasound, exercises.
Common Foot Disorders Hallux Valgus, “bunion”: caused by pointed/narrow-toe shoes, high heels. Hammertoe “claw toe”: dorsiflexion with plantar flexion. Morton’s Neuroma: from repeated compression, S/S: burning pain, >weight = >pain, palpable mass, better massage or no shoe.
Treatment of Foot Disorders Conservative: Corrective shoes, Orthotic devices, NSAIDs, Corticosteroid injections. Surgery: Bunionectomy, Cast.
Created by: nimeggs