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Med-Surg Ch 40
Musculoskeletal Disorders
| Question | Answer |
|---|---|
| 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. |
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