Care of Patients with Musculoskeletal and Connective Tissue Disorders

1
Chapter 33

• Care of Patients with Musculoskeletal and
  Connective Tissue Disorders

2
Theory Objectives

• State the factors to be assessed for the patient
  who has a connective tissue injury.
• Compare the assessment findings of a connective
  tissue injury with those of a fracture.
• State the care that is needed for the patient who
  has an external fixator in place.
• Identify the dos and donts of cast care.

3
Theory Objectives (cont.)

• Discuss the potential complications related to
  fractures.
• Identify the special problems of patients with
  arthritis and specific nursing interventions that
  can be helpful.
• Compare the preoperative and postoperative care
  of a patient with a total knee replacement with
  that of a patient with a total hip replacement.

4
Theory Objectives (cont.)

• Explain the process by which osteoporosis occurs,
  ways to slow the process, and how the disorder is
  treated.
• Describe the care of the patient with a
  metastatic bone tumor.
• Identify important postoperative observations and
  nursing interventions in the care of the patient
  who has undergone an amputation.

5
Sprain

• A sprain is a partial or complete tearing of the
  ligaments that hold various bones together to
  form a joint
• A sprain occurs when a joint may be forced,
  during trauma, past its normal range of motion,
  or there may be twisting
• The ankle, knee, and wrist are most commonly
  sprained

6
Signs and Symptoms

• Grade I (mild) Tenderness at site minimal
  swelling and loss of function no abnormal motion
• Grade II (moderate) More severe pain, especially
  with weight-bearing swelling and bleeding into
  joint some loss of function
• Grade III (severe, complete tearing of fibers)
  Pain may be less severe, but swelling, loss of
  function, and bleeding into joint are more marked

7
Diagnosis

• Physical examination
• X-ray to rule out a fracture or other pathology

8
Treatment and Management

• RICE
• Rest
• Ice after injury and for 24-72 hours
• Compressionsnug elastic bandage, careful to not
  to cut off circulation
• Elevation

9
Sprains

• The Goal is to protect the ligament until it
  heals by scarring. Ligaments do not grow back
  together.
• If a joint is immobile too long, and muscles are
  not exercised muscle atrophy can begin within a
  matter of days- can cause permanent disability.

10
Treatment and Management (cont.)

• Grade II or III
• Rest the joint
• Crutches for lower extremity sprain
• NSAIDs around the clock for first couple of days

11
Etiology and Pathophysiology

• A strain is a pulling or tearing of a muscle, a
  tendon, or both
• A strain occurs by trauma, overuse, or
  overextension of a joint

12
Etiology and Pathophysiology (cont.)

• The most common muscle strain occurs in the back
  muscles (back problems are discussed in Chapter
  23, because they often have a neurologic
  component)
• Muscle strains do occur in other skeletal
  musclesthe most common sites are the hamstrings,
  quadriceps, and calf muscles

13
Strain

• Signs, symptoms, and diagnosis
• History of overexertion
• Soft tissue swelling
• Pain
• Bleeding if muscle is torn

14
Complementary and Alternative Therapies

• Soothing sore muscles
• Arnica purchased and applied topically as an
  essential oil is supposed to soothe sore, tired
  muscles after a long days work
• Valerian or kava brewed as a tea is also said to
  relax muscles
• Honey or apple juice will make the teas more
  palatable

15
Treatment and Nursing Management

• Ice and compression should be immediately applied
  and the part should be rested
• The patient is taught to use ice for 20 minutes
  out of the hour only
• When compression is used, the distal parts of the
  extremity must be checked for sensation and
  adequate circulation. Pallor (color) Pain
  Parasthesia (numbness or tingling) Pulse
  (Capillary Refill) Pressure (Swelling) Edema
• Paralysis (Movement)

16
Treatment and Nursing Management (cont.)

• Heat can be applied after 48 hours
• Anti-inflammatory medications are used for
  discomfort and, when spasm is present, a muscle
  relaxant may be prescribed
• Time is the greatest healer
• The patient is cautioned against reinjury and is
  taught proper ways to lift and move
• Surgical repair may be necessary

17
Dislocation and Subluxation

• Dislocation is the stretching and tearing of
• ligaments around a joint with complete
  displacement of a bone.
• Subluxation is a partial dislocation.
• Most common sites are the shoulder, knee, ankle,
  and temporomandibular joint.
•  

18
Dislocation cont.

• Dislocation often includes
• History of an outside force pushing from a
  certain direction
• Severe pain, aggravated by motion of the joint,
  muscle spasm, or abnormal appearance of the
  joint.
• Diagnosis
• Physical Exam
• X-ray
• Example dislocated shoulder.

19
Dislocation and Subluxation (cont.)

• Treatment
• Reduction of displacement under anesthesia
• Nursing management
• Rest the joint
• Pain control
• Heat or cold applications (Ice first 48 hours
  then heat.)

20
Rotator Cuff Tear

• Usually results from repetitive activity.
  Example Throwing or making overhead motions
  with the arm.
• Basketball, baseball players
• Signs and Symptoms
• Pain
• The patient will not be able to externally rotate
  the shoulder, or perform abduction

21
Rotator Cuff Injury

• Treatment
• Rest
• Sling will be applied to the affected shoulder
• Anti-inflammatory medications
• When acute episode is over
• Gentle progressive exercise is ordered. PT
• Prior to exercise Heat is recommended before the
  joint is exercised.

22
Rotator Cuff Tear

• If the tear does not heal
• Surgical repair usually by arthroscopy is
  indicated.
• Shoulder is immobilized
•  

23
Bursitis

• Etiology and pathophysiology
• Injury or overuse Usually repetitive motion
• Signs, symptoms, and diagnosis
• Mild to moderate aching pain
• Swelling
• History of injury
• Physical examination

24
Bursitis (cont.)

• Treatment
• Rest, ice, and massage
• Anti-inflammatory agents
• Compression wrap
• Bursa cortisone injection
• Nursing management
• Assess pain and perfusion
• Assist with mobilization
• Activity limitations

25
ACL Tear

• ACL (Anterior Cruciate Ligament
• Most commonly occurs from athletic injuries
• Falls and motor vehicle accidents may also cause
  injury

26
ACL Tear cont

• The ligament may be torn from the femur or tibia.
• Often the patient will tell you that they heard a
  loud pop the time of injury.
• Swelling will occur within hours
• The knee may feel unstable and feel like it can
  give way.
• Full extension of the leg is difficult

27
ACL Tear cont.

• Diagnosis
• Physical Exam and data collection how injury
  occurred
• MRI
• Arthroscopy is performed at which time the repair
  may be done. Grafting may be done if there is
  complete tearing.

28
ACL Tear

• According to the text some physicians order (CPM)
  continuous passive range of motion to promote
  full range of motion.
• Not so common today.
• Isometric exercises are prescribed in the
  recovery period including quadriceps bent knee
  exercises and foot exercises.
•  

29
Meniscal Injury

• The meniscus is the shock absorber of the knee
  and lies on top of the tibia, between tibia and
  the femur.
• A meniscus injury may accompany an ACL injury.

30
Mensical Injury

• Often occurs from a fixed foot rotation in weight
  bearing with the knees flexed, during sports
  activities such as basketball or skiing.
• Hear either a Popping, described like they feel
  like the knee is catching or buckling on them

31
Meniscal Injury cont

• Diagnosis
• Physical exam patient history. May hear a click
  with localized pain with movement of the joint.
  How did it happen, what activity was the patient
  doing?
• MRI is order to confirm
• Surgical repair is done arthroscopically

32
ACL Tear

• After injury the knee is
• immobilized usually with a long brace with fixed
  flexion
• Measures are instituted to decrease pain and
  reduce swelling.
• Ice dependent upon doctor
• Pain Management initial opiods, anti inflammatory
  medications

33
Achilles Tendon Rupture

• The Achilles attaches to the calcaneus (heel
  bone)
• If overstretched it can rupture.
• Sports injuries or a fall from a height are the
  usual ways that this injury occurs.
• Injury most often occurs with bursts of jumping,
  pivoting, and running such as tennis, and
  basketball.

34
Achilles Tendon Rupture

• Some predisposing factors that can increase risk
  include
• Diabetes
• Arthritis
• Some antibiotic use ( Cipro) Side effect can
  cause tendonitis.

35
Achilles Tendon Rupture

• Symptoms
• Sudden pain in the back of the ankle
• May hear a popping sound or a snapping sound

36
Achilles Tendon Rupture

• Physical Exam
• May see a depression 2 inches above the back of
  the heel
• Pain
• Swelling
• Stiffness
• Inability to point toes, or stand on tiptoe
• Bruising

37
Achilles Tendon Rupture

• Treatment Achilles Tendon Rupture
• Splinting
• Surgery followed by casting
• Recovery
• 6-8 weeks followed by PT

38
Meniscal Injury

• Pain Management is a priority
• PT is prescribed for muscle strengthening
•  

39
Carpal Tunnel Syndrome

• Etiology and pathophysiology
• Compression of the median nerve
• Signs and symptoms
• Pain
• Numbness
• Tingling of the hand, particularly at night
• Repetitive movements of hands and wrists

40
Carpal Tunnel Syndrome (cont.)

• Diagnosis
• Physical examination
• Compression test
• Electromyography
• Treatment
• Rest and splinting
• Changing the angle of the wrist during repetitive
  movements
• Steroid injections
• Surgery
• Nursing management

41
Bunion

• A bunion is the most common foot problem. It is
  a painful swelling of the bursa that occurs when
  the great toe, at the metatarsal joint.
• It may hereditary, or from ill fitting shoes
• More common in females than males

42
Bunion

• Wearing open toed shoes made of soft leather or
  athletic shoes that are wider in the toes area
  helps to reduce the pain.
• Shoes that have give.
• Properly fitting shoes.
• Metatarsal pads may provide some relief or
  pressure.

43
Bunion

• Corticosteroid injections are given into the
  joint if there is active bursitis and pain.
• Analgesics and anti-inflammatory medications may
  be prescribed.
• Surgical Intervention
• Bone realignment or bunionectomy may be done if
  becomes too painful. The key is too painful.
• Hammertoes often accompany bunions and they may
  be repaired at the same time.
•  

44
Fractures

• Etiology and pathophysiology
• Definition
• Trauma
• Osteoporosis and metabolic problems
• Mechanism of injury

45
Fractures (cont.)

• Signs and symptoms
• Minimal to severe pain depending on the type of
  fracture, the bone(s) involved, and the amount of
  displacement
• Swelling and/or bleeding
• Tenderness, deformity of the bone, ecchymoses,
  crepitation with any movement, and loss of
  function

46
Fractures (cont.)

• Diagnosis
• Physical examination
• X-ray

47
Types of Fractures

• Complete
• Incomplete
• Comminuted
• Closed (simple)
• Open (compound)
• Greenstick

48
Types of Fractures (cont.)
49
Types of Fractures (cont.)
50
Types of Fractures (cont.)
51
Elder Care Points

• The elderly are more at risk for fractures
  because of decreased reaction time, failing
  vision, lessened agility, alterations in balance,
  and decreased muscle tone
• Proton pump inhibitors (PPIs) increase the risk
  for fracture of the hip, wrist, and spine
• In epidemiologic studies, the risk was highest
  for people over age 50, who had used PPIs for
  more than a year

52
Treatment of Fracture

• Emergency care
• Prevent shock and hemorrhage
• Splint as it lies
• Tetanus immunization
• Prophylactic antibiotics
• Primary aim of treatment
• Establish union between broken ends to restore
  bone continuity

53
Five Stages of Bone Healing and Repair

1. Blood oozes from the torn blood vessels in the
   area of the fracture the blood clots and begins
   to form a hematoma between the two broken ends of
   bone (1 to 3 days)

54
Five Stages of Bone Healing and Repair (cont.)

1. Other tissue cells enter the clot, and
   granulation tissue is formed. This tissue is
   interlaced with capillaries, and it gradually
   becomes firm and forms a bridge between the two
   ends of broken bone (3 days to 2 weeks)

55
Five Stages of Bone Healing and Repair (cont.)

1. Young bone cells enter the area and form a tissue
   called callus. At this stage, the ends of the
   broken bone are beginning to knit together (2
   to 6 weeks)

56
Five Stages of Bone Healing and Repair (cont.)

1. The immature bone cells are gradually replaced by
   mature bone cells (ossification), and the tissue
   takes on the characteristics of typical bone
   structure (3 weeks to 6 months)

57
Five Stages of Bone Healing and Repair (cont.)

1. Bone is resorbed and deposited, depending on the
   lines of stress. The medullary canal is
   reconstructed during consolidation and remodeling
   (6 weeks to 1 year)

58
Reduction of Fractures

• Closed reduction
• Open reduction
• Stabilization
• Internal fixation
• External fixation
• Casts, splints, and braces
• Traction

59
Internal Fixation

• Pins, nails, or metal plates
• Open reduction and internal fixation
• Prosthesis and autotransfusion
• IV antibiotics and risk for infection
• Nursing care
• Maintain good alignment of the affected leg
• Prevent complications of immobility
• Control pain

60
Examples of Internal Fixation
61
External Fixation

• Indications
• Massive open fractures with extensive soft-tissue
  damage
• Infected fractures that do not heal properly
• Multiple trauma such as burns, chest injury, or
  head injury

62
External Fixation (cont.)
63
Nursing Management

• Pin site care and premedicate for pain
• Showering
• Physical therapy and ADLs

64
Casts and Fractures

• Materials including plaster and synthetic casts
• Long-leg and short-leg casts, slings, and spicas

65
Synthetic Limb Cast
66
Braces and Splints

• Fracture boot, hinged brace, and slab
• Patient teaching
• Explain the procedurefeel warmth as cast sets
  and dries
• Never put a fresh cast on plastic
• Never cover a fresh plaster cast with a blanket

67
Walking Boot
68
Skeletal Traction

• Pins, wires, or tongs directly through the bone
  at a point distal to the fracture so that the
  force of pull from the weights is exerted
  directly on the bone
• Skeletal traction uses 10 or more pounds of
  weight and the body acts as the countertraction

69
Skin Traction

• Bandage (moleskin or foam traction boot) is
  applied to the limb below the site of fracture
  and then pull is exerted on the limb
• No more than 7 to 10 lb of weight are used
• Continuous or intermittent

70
Common Types of Traction
71
Common Types of Traction (cont.)
72
Points of Care for the Patient in Traction

• Traction devices must be assessed to see that
  they are in correct position and that the weights
  are hanging free
• The patients body position should be assessed
  for proper alignment

73
Complications of Fractures

• The sooner a fracture is fixed, the less likely
  the chance for complications.
• Healing can be impeded by improper alignment and
  inadequate immobilization
• Continued twisting, shearing, and abnormal
  stresses prohibit a strong, bony union.

74
Fractures and Infection

• Open comminuted fractures and surgery
• Antibiotics
• Inadequate calcium and phosphorus, vitamin
  deficiency, and atherosclerosis
• Temperature, white blood cells, and wound
  appearance (redness, swelling, heat, and purulent
  drainage)

75
Osteomyelitis

• Osteomyelitis is a bacterial infection of the
  bone
• Staphylococcus aureus
• Sudden onset with severe pain and marked
  tenderness at the site, high fever with chills,
  swelling of adjacent soft parts, headache, and
  malaise

76
Diagnosis

• The earlier osteomyelitis is diagnosed and
  treated, the better the prognosis
• History of injury to the part, open fracture,
  boils, furuncles, or other infections
• Sedimentation rate and WBC count
• X-rays
• Biopsy, in which the bone sample exhibits signs
  of necrosis

77
Treatment

• Antibiotics are prescribed for 4 to 6 weeks, and
  the abscess is incised and drained
• Dead bone and debris are débrided from the site
• The affected limb is immobilized for complete
  rest
• Sometimes amputation is the only cure

78
Nonunion of Fractures

• Electrical bone growthstimulating device
• Surgery and bone grafting

79
Fat Embolism

• Signs and symptoms
• Change in mental status
• Respiratory distress, tachypnea, crackles and
  wheezes
• Rapid pulse, fever, and petechiae (a measles-like
  rash over the chest, neck, upper arms, or abdomen)

80
Nursing Management

• Stay with the patient
• High Fowlers position
• Use a non-rebreather mask
• Establish a peripheral IV
• Summon the physician immediately
• Anticipate hydration with IV fluids and
  correction of acidosis
• Intubation and mechanical ventilation

81
Venous Thrombosis

• The veins of the pelvis and lower extremities are
  very vulnerable to thrombus formation after
  fracture, especially hip fracture
• Immobility, traction, and casts may contribute to
  venous stasis
• Compression stockings, sequential compression
  devices, range-of-motion (ROM) exercises on the
  unaffected lower extremities are used to help
  prevent the problem

82
Compartment Syndrome

• External or internal pressure that restricts
  circulation in one or more muscle compartments of
  the extremities
• Severe, unrelenting pain unrelieved by narcotics
• Assess for 6 Ps pain, pallor, paresthesia,
  pulselessness, paralysis, and poikilothermia
  (cold to the touch)

83
Treatment and Nursing Management

• Recognition and immediate notification of the
  physician can prevent permanent loss of function
• If a cast is in place, the cast can be bivalved
  (split through all layers of the material)
• Dressings will be cut or replaced

84
Treatment and Nursing Management (cont.)

• Surgical fasciotomy (linear incisions in the
  fascia down the extremity) may be necessary to
  relieve the pressure on the nerves and blood
  vessels if other measures do not relieve the
  problem
• Elevation is the key to preventing compartment
  syndrome toes and fingers should be higher than
  the trunk

85
Fascial Compartments of the Calf
86
Fasciotomy
87
Nursing Management of Fractures

• Assessment (data collection)
• Initial assessment (pretreatment)
• Mechanism of injury
• Physical assessment
• Special consideration of open fractures
• Daily assessment (posttreatment)
• Physical assessment of neurovascular status
• Thorough assessment of a patient in a cast
• Nutrition for immobile musculoskeletal patients

88
Nursing Management of Fractures (cont.)

• Implementation
• Cast carefiberglass and polyester cotton knit
  casts and plaster casts
• Comfort measures
• Positioning and repositioning
• Itching and skin care

89
Nursing Management of Fractures (cont.)

• Evaluation
• Pain should be under control
• Progress toward independent ADLs
• No problems with immobility (skin breakdown,
  constipation, atelectasis, or DVT)
• No complications (infection, compartment
  syndrome)
• If the goals are not being met, the plan should
  be revised

90
Inflammatory Disorders of the Musculoskeletal
System

• Lyme disease
• Osteoarthritis
• Rheumatoid arthritis
• Gout
• Osteoporosis
• Pagets disease
• Bone tumors

91
Lyme Disease

• Cause
• Transmitted by the bite of a deer tick. A
  systemic infection occurs from a bacteria called
  Spirochete, Borrelia burgdorferi.
• Signs and symptoms 1-2 weeks
• Flu-like symptoms
• Bulls-eye rash
• Pain and stiffness in joints and muscles
• Progresses to Stage II if untreated 2-12 weeks
• Carditis
• Meningitis, peripheral neuritis, or facial
  paralysis similar to Bells Palsy
• Fatigue, cognition problems, and arthralgias

92
Lyme Disease Rash
93
Deer Tick
94
Lyme Disease cont.

• Treatment
• Oral antibiotics such as doxicycline, amoxicillin
  by mouth for 10-21 days.
• Later stages are treated with IV antibiotics
• Steps to prevent Lyme disease include using
  insect repellent, wearing long sleeve clothing
  when in woods. Removing ticks promptly from
  clothing.

95
Osteoarthritis

• Etiology and pathophysiology
• A non inflammatory degenerative joint disease
  that can affect any weight-bearing joint
• The exact cause is not known
• Risk factors Heredity, aging, female gender,
  obesity, previous joint injury, and
  recreational/occupational usage
• People with osteoarthritis seem to produce less
  collagen to strengthen and protect the joints
• With time joints become thickened and withstand
  weight poorly causing more damage to cartilage.

96
Osteoarthritis

• Signs, symptoms, and diagnosis
• Usually occurs Asymmetrically
• Typically affects only one or two joints
• Chief symptoms
• Aching pain with joint movement and stiffness and
  limitation of mobility
• Joints may be deformed and nodules may be present 

97
Treatment of Osteoarthritis

• Pain managementincluding salicylates,
  acetaminophen, or NSAIDs
• Strengthening and aerobic exercise,
• Weight reduction if the patient is overweight
• Maintenance of joint function
• Complementary and alternative therapies

98
Nursing Management of Osteoarthritis

• Balance exercise and rest,
• Walking, knitting, and swimming improve mobility
• Moist heat application
• Encourage to maintain weight within normal limits
  decreases stress on the joints.
• Imagery, relaxation, and diversion
• Quadriceps strengthening exercises may relieve
  pain and disability of the knee
• Yoga and massage may help to manage the pain

99
Rheumatoid Arthritis

• Etiology and pathophysiology
• Is an Inflammatory Disease of the joints
• Rheumatoid factor will appear in the blood and in
  the synovial fluid of the joints.
• Remissions and exacerbations
• As the disease progresses Pannus is formed which
  is granulated tissue this can lead to ankylosis,
  and damage/atrophy of muscles
• Subcutaneous nodules may form in the pleura,
  heart valves, or eyes

100
Rheumatoid cont.

• Cause is unknown
• Can occur at any age.
• More common in older women
• Maybe hormonal, genetic, environmental
• An infectious agent may trigger an autoimmune
  response

101
Rheumatoid Arthritis (cont.)

• Signs and symptoms
• Joint pain, warmth, edema, limitation of motion,
  and multiple joint stiffness lasting more than 1
  hour, worse in the morning.
• Symmetricalaffects joints of the hands, wrists,
  and feet. Nodules may form on the joints.
• Limitations of ADLs due to joint deformity, and
  pain.
• Systemic symptoms
• Low grade fever, anorexia, weight loss, anemia
  resistant to iron.

102
Comparison of Rheumatoid Arthritis and
Osteoarthritis

• Definition
• Pathology
• Etiology
• Rheumatoid factors (autoantibodies)
• Age at onset

• Weight
• General state of health
• Appearance of joints
• Muscles
• Other

103
Rheumatoid Arthritis

• Diagnosis
• History of morning stiffness that lasts more than
  one hour or arthritis pain in 3 or more joints
  that lasts more than 6 weeks for greater than 1
  hour
• Blood tests for RF, C-reactive protein, and
  erythrocyte sedimentation rate, synovial fluid
  will
• be positive for RA
• X-rays confirm the cartilage destruction and bone
  deformities

104
Treatment of Rheumatoid Arthritis

• Aimed at Relieving pain
• Minimizing joint destruction
• Promote joint function Rest exercise, and
  medication.
• Preserve ability to perform self-care
• Immobilization and use of splints and other
  supportive devices during periods of severe
  inflammation
• Hot and Cold Treatments

105
Medications for Rheumatoid Arthritis

• NSAIDs (i.e., ibuprofen) are the first-line
  agents used for arthritis pain
• Other medications include salicylates,
  corticosteroids, antimalarial drugs,
  methotrexate, gold compounds, sulfasalazine,
  d-penicillamine, and disease-modifying
  antirheumatic drugs (DMARDs)
• Tumor necrosis factor drugs (TNF inhibitors)
• Humeria, Prolia

106
Rheumatoid Treatment cont.

• Systemic corticosteroids (Once thought to be
  miracle drugs) Long term affects diminish over
  time requiring and increase in the dose to obtain
  the same results.
• Long term steroids increase the risk for diabetes
  mellitus, osteoporosis, hypertension, acne,
  cataracts, and weight gain.
• Reserved for patient who do not get relief with
  the other drugs.

107
Medications for Rheumatoid Arthritis (cont.)

• The injection of steroids directly into a joint
  (intra-articular administration) has been used
  successfully in treating painful flare-ups,
  shortening the period of inflammation, and
  relieving pain and other symptoms
• When intra-articular steroid therapy is used, it
  is recommended that not more than two or three
  doses be injected into any joint within 1 years
  time

108
Clinical Cues

• Monitor patients taking NSAIDs for GI intolerance
• Assess liver, kidney, and central nervous system
  function frequently
• Watch for signs of blood dyscrasias and check for
  tinnitus and hearing loss regularly
• The side effects of NSAIDs can be serious and
  sometimes permanent
• If early signs of toxicity appear, they should be
  reported promptly to the physician

109
Elder Care Points

• Elderly arthritic patients must be taught to
  watch for side effects and promptly report to the
  physician or nurse
• Dizziness, which predisposes to falls, can occur
  with analgesics for arthritis pain, particularly
  if the medication contains codeine
• Advise patients to arise slowly, hold on to
  furniture until steady, and to wait until
  dizziness passes before trying to walk
• Assistive devices for ambulation can also prevent
  falls

110
Surgical Intervention and Orthopedic Devices

• Casts/braces and splints may be used to
  immobilize an affected part so that it can rest
  during an active phase of the arthritic disease
• Surgery
• Synovectomy -Excision of synovial membrane.
• Osteotomy - Excision of a wedge of bone to allow
  realignment
• Tendon reconstruction
• Joint replacement

111
Nursing Management of Rheumatoid Arthritis

• Expected outcomes
• Patients pain will be controlled with
  medications, heat, and exercise within 2 weeks
• Patients mobility will improve with the use of
  assistive devices and physical therapy within 3
  weeks
• Patient will demonstrate less disturbance of body
  image by partaking in more social activities
  within 1 month

112
Implementation and Evaluation of Rheumatoid
Arthritis

• Rest and exercise
• Instructions for joint protection
• Applications of heat and cold
• Safety considerations
• Patient teaching
• Diet
• Psychosocial care
• Resources for patient and family education

113
Total Joint Replacement

• May be done for a knee, shoulder, hip, elbow or
  finger
• Hip and Knee the most common
• Non cemented press fit prosthesis usually used
  for a younger, heavier, or active patient.
• Cement used in the prosthetic usually lasts about
  10 years
• Primary purpose is the relieve pain

114
Joint Replacement cont.

• Most joints are elective surgery
• Patient will come in for PAT work
• Data collection will begin
• An appointment will be scheduled for pre op
  teaching usually 3 weeks ahead of time
• Many centers coordinating all the above on one
  day

115
Joint Replacement

• Expectations discussed
• Pain management
• Routine and expectations foley, IV activity
• Rehab and PT
• Pre op exercises, Isometric
• Blood collection post op
• Patient will receive instructions to complete
  chlorahexidine showers pre op or scrubs to the
  affected leg

116
Joint Replacement cont

• Patient transported to OR in bed
• Returned in bed
• Ice for pain
• Abductor pillows for Hip prosthesis to prevent
  dislocation
• Pillow needs to be in place when turning the
  patient from side to side
• Dislocation is the concern.

117
Joint Replacement cont.

• Post Op
• Patient may have a blood salvage unit . It is
  then filtered and retuned to the patient
• Drain in surgical site, DVT prophalxsis
  important. Heparin, lovenox or counmadin
• Weight bearing staus PT

118
Total Hip Replacement Discharge Teaching

• It is OK to lay on operated side
• For 3 months, you should not cross your legs
• Put a pillow between legs when rolling over or
  lie on your side in bed
• It is OK to bend your hip but not beyond a right
  (90-degree) angle
• Avoid sitting in low chairs
• Continue daily exercise program at home

119
Gout

• Etiology and pathophysiology
• Arthritis of a joint caused by high Uric acid
  levels
• Possible factors
• Genetic increase in purine metabolism
• More common in patient populations that consume
  increase protein and high purine diets.
• Big toe most common but can occur in other
  joints.
• Diuretic therapy and secondary gout because of
  the loss of fluids

120
Gout (cont.)

• Signs and symptoms
• Tight reddened skin over an inflamed, edematous
  joint accompanied by elevated temperature and
  extreme pain in the joint
• Elevated serum uric acid
• Diagnosis
• History and physical examination
• Serum uric acid

121
Gout
122
Gout (cont.)

• Treatment
• NSAIDs for 2-5 days
• Colchicine, allopurinol, and probenecid (Benemid)
  given orally with drastic relief within 24-48
  hours
• Febuxostat (Uloric)
• Nursing management
• Patient teaching and medications
• Diet managementweight control and restriction of
  high-purine foods
• Fluid intake Increase to 2000-3000cc per day to
  protect the kidney from crystal formation and
  stones.

123
Gout cont.

• Alcohol should be restricted
• Patients who are placed on allopurinol require
  periodic liver function tests
• Dietary restriction high purine diets.
• Examples Red meat, organ meat, sardines,
  anchovies, sweetbreads.

124
Elder Care Points

• Elderly patients with decrease creatine clearance
  should not take allopurinol.
• If patient has elevate BP Cozar is a good choice.
  ARB controls BP and promotes dieresis

125
Audience Response Question 1

• Dietary management of gout includes which
  measure(s)? (Select all that apply.)
• Weight reduction
• Salt restriction
• High caloric intake
• Avoiding foods high in purine
• High-carbohydrate diet

126
Osteoporosis

• Etiology and pathophysiology
• Makes the patient more prone to fractures
• Decrease in bone mass
• Risk factors Age, chronic disease (i.e., liver,
  lung, kidney), medications (i.e., steroids,
  anticonvulsants, anticoagulants, proton pump
  inhibitors, selective serotonin inhibitors),
  long-term calcium deficiency, vitamin D
  deficiency, smoking, excessive caffeine or
  alcohol intake, and sedentary lifestyle
• Premenopausal age of 35 women loose 1 bone mass
  a year. Post menopausal 2 per year

127
Osteoporosis (cont.)

• Signs and symptoms
• No early signs and symptoms
• Height loss, kyphosis, and compression of the
  spine
• Diagnosis
• Bone x-rays Bones appear porous
• Dual energy x-ray absorptiometry (DXA or DEXA)
  reported as a T score
• 1.5 to 2.0 standard deviations osteopenia
• 2.5 to 3.0 standard deviations osteoporosis

128
Treatment

• Goals
• Stop bone density loss
• Increase bone formation
• Prevent fractures
• Estrogen replacement therapy
• Adequate dietary and supplemental calcium and
  vitamin D
• Weight-bearing exercise
• Bisphosphonates (Fosamax, Actinol)

129
Treatment of Osteoporosis and Vertebral Fracture

• Vertebral fractures are common in patients with
  osteoporosis.
• This are two new minimally invasive spine
  procedures for those who do not repond to
  tradtional therapy
• Vertebroplasty
• Kyphoplasty
• These are often treated with pain medication,
  activity limitation, physical therapy, and
  bracing

130
Osteoporosis

• Parathyroid hormones are alternative treatment
  for post menopausal women who cant take
  estrogen. Miacalcin or Fortical
• Contains calcitonin.
• Diary Products are the best source of calcium
  cheese, yogurt, are better choices.
• Sardines and anchovies are also sources of
  calcium

131
Nursing Management

• Promote screening for osteoporosis
• Teach the benefits of healthy lifestyle, need for
  calcium supplement, and weight-bearing exercise
• Medications, cautions, and side effects
• Upright position for 1 hour after taking
  bisphosphonate-type drugs to prevent esophageal
  irritation and erosion

132
Pagets Disease

• Etiology
• More common in men
• Cause unknown
• Abnormal weak bones
• Problem with bone reabsorbtion followed by
  replacement of normal marrow with fibrous
  connective tissue. Prone to fracture
• Signs and symptoms
• Pain main problem

133
Pagets Disease (cont.)

• Diagnosis
• X-Ray Usually diagnosed at time of fracture
• 24 hour urine presence of hydroxyproline presence
  indicates osteoclasic activity
• Serum alkaline phospatase is elevated in disease
• Nursing management
• Firm mattress may relieve back pain
• Light brace or corset
• Avoid lifting and twisting proper body mechanics

134
Bone Tumors

• Etiology and pathophysiology
• Bone is subject to both benign and malignant
  tumors
• Bone tumors are often seen in people 10-25 years
  of age ( Osteosarcoma)
• Primary and secondary tumors
• Arise from several types of tissues including
  cartilage, bone, and fibrous tissue

135
Bone Tumors (cont.)

• Signs and Symptoms
• Pain, warmth, and swelling
• Diagnosis
• X-ray, bone scan, and biopsy
• Metastatic Disease is seen more than a primary
  bone cancer
• Malignancies of the prostate, kidney, breast,
  thyroid, and lung spread to the bone. Vertebrae,
  pelvis, and femur
• Treatment
• Surgery, radiation, and chemotherapy

136
Amputation

• Lower-limb amputations are related to peripheral
  vascular disease, diabetes mellitus and resultant
  gangrene, severe trauma, malignancy, congenital
  defects, and military injuries from shrapnel and
  land mines
• Upper-extremity amputations are brought on by
  crushing blows, thermal and electric burns,
  severe lacerations, vasospastic disease,
  malignancy, and infection

137
Amputation Preoperative Care

• Patient participation in decision-making
• May have preference of how to dispose of limb.
• Stages of loss and grieving (Denial, anger,
  grieving)
• Phantom sensations Patient remembers pain before
  surgery, brain still receiving signals
• Physical preparation
• Muscle strengthening exercises to prepare for
  post op rehabilitaion

138
Amputation Postoperative Care

• Two most important post op concerns
• Hemorrhage and edema of residual limb
• Elevation for 24 hours after 24 hours hip
  contractures may develop
• Monitoring for excessive bleeding
• VS
• IV fluids
• Dressing care The initial dressing is usually
  removed by the surgeon 48 to 72 hours later.

139
Amputation Post Op Care

• Assess the skin for inflammation or breakdown ,
  warmth, drainage
• Assess pain
• Phantom limb sensations
• Miacalcin IV infusion during the week after
  surgery.
• Transcutaneous electrical nerve stimulator
• Stump stocking

140
Amputation Postoperative Care (cont.)

• Alternative modes for managing stump after
  amputation
• Soft dressing with delayed prosthetic fitting
• Rigid plaster dressing and early prosthetic
  fitting
• Rigid plaster dressing and immediate prosthetic
  fitting

141
Amputation Postoperative Care (cont.)

• Adequate healing and weight-bearing
• Below-the-knee amputation is better to begin
  walking and weight-bearing than above-the-knee
  amputation
• Abduction contractures and proper positioning
• Adjusting to the new center of gravity
• Patient teaching stump care, activity and
  weight-bearing, and exercise
• Rehabilitation
• Community care

142
C-Leg Prosthesis in Action
143
Care After Accidental Amputation

• Rinse the detached part only enough to remove
  visible debris
• Wrap the part in a clean, damp cloth
• Place the part in a sealed plastic bag or in a
  dry water-tight container
• Immerse the bag or container in a mixture of
  water and ice (3 parts water to 1 part ice). Do
  not let the part get wet or freeze

144
Care After Accidental Amputation (cont.)

• Alternatively, place the container in an
  insulated cooler filled with ice
• If no ice is available, keep the part cool do
  not expose it to heat
• Tag the bag or container with the persons name
  and the name of the body part and take it to the
  hospital with the person