Chap 76 Musculoskeletal Disorders

Front 1

(2) In relationship to a client with a muscoloskeletal disorder, discuss the diagnostic benefits of the following tests: laboratory tests incluidng ESR, CBC, RF, URIC ACID, CK, CALCUIM

Back 1

CBC complete blood cell count, uric acid levels, and blood levels of calcium (8.5 to 10.5) and phosphorus (2.4 to 4.1) held indicate the overall condtion of the musculoskeletal system; ESR erythrocyte sedimentation rate, rheumatoid factor RF, creatine kinase CK these blood test may show inflammation related to an infection or inflammatory condition of bones or muscles.

Front 2

(2) In relationship to a client with a muscoloskeletal disorder, discuss the diagnostic benefits of the following tests:x-ray, arthrogram, myelogram, CT scan, MRI

Back 2

radiography "x-ray" is most common method of assessing the general state of bones, non-invasive visualization of bones and other internal structures to diagnose abnormalties and monitor the effectiveness of treatments. Some require dye to visualize the cavities within bony parts. CONFIRM NO ALLERGIES to shellfish and dye and pregnancy. ARTHROGRAM x-ray study of a joint (knee or shoulder) radiopaque/radiolucent substance is injected and x-rays taken to determine the join'ts condition.

MYELOGRAM (myel/o=spinal cord) is an x-ray exam of the spinal cord and vertebral canal after injection of a contrast medium or air into the spinal subarachnoid space to evaluate spinal cord abnormalities caused by tumor, herniated disks or lesions.
CT scan provides 3-dimensional view of body parts, painless, done with and w/o contract dye, useful to diagnosis bone, tendon, ligament, soft tissue disorders and tumors.

MRI safer and less expensive than those that use dyes or surgery. A magnetic field enables a scanning ma

Front 3

(2)(c) In relationship to a client with a muscoloskeletal disorder, discuss the diagnostic benefits of the following tests: MRI, Bone Scan, Ultrasound, Arthroscopy, Bone Biospy and EMG "electromyogram"

Back 3

BONE SCAN used to detect primary bone tumors, metastatic bone disease, osteomyelitis, osteoporosis, inflammation, bone or joint infections and stress fractures; requires IV injection of radioisotope, technetium 99m, which enhances the visualization of abnormal tissue areas. Client lies down during bone scan and NURSE encourages extra fluids after for excretion of the isotope.
ULTRASOUND uses sound waves and echos to display images to evaluate soft tissue masses, osteomyelitis, infection, congenital, acquired pediatric disorders, bone mineral density, sports injuries.
ARTHROSCOPY invasive procedure using arthroscope (lens and light source that transmits pictures to video monitor) to view joints. Allowing the surgeon to view and operate on the inside of the joint interior via a cut called a "stab wound"; same day surgery, local anesthesia. A rough or worn joint can be made smoother or tissue samples can be obtained or torn meniscus or ligament can be diagnosed or repaired.
Bone BISOPY is uses

Front 4

(2) In relationship to a client with a muscoloskeletal disorder, discuss the diagnostic benefits of the following tests: bone biospy and EMB

Back 4

Bone Biopsy of bone tissue or muscle may be performed using local anesthesia to diagnose tumors, infections, muscle inflammation or atrophy and various other problems. AFTER monitor the biopsy site for bleeding, swelling, infection or hematoma.

EMG "electromyogram" test of electrical conductivity. The provider places fine needles into the client's muscles (my/o=muscle) and measures the electrical impulses within the muscle both at rest and during actvity so the provider can determine if the client's muscle respond appropriatel to stimuli.

Front 5

(3) Describe at least six components of data collection for a client with a musculoskeletal disorder

Back 5

Data collection should include (1) baseline vitals for future comparison and repot any changes from baseline (2) observe skeletal deformity (3) observe posture, coordination and body build noting any asymmetry or deformity (4) palpate soft tissue, joints, muscles (5) measure muscle mass (6) palpate the skin temp for warmth and document any swelling, crepitation, tenderness, skin discoloration or other abnormality.

Perform range of motion exercises; check for bilateral muscle strength and balance and gait. Observe emotion responsse to disorder and evaluate if client needs assistance with ADL or social or physcological.

Front 6

(4) Identify at least four major components of nursing care necessary to protect the client from the hazards of immobilization.

Back 6

Complication of PRESSURE: edema, skin color, numbness, cool temperature, severe pain, lack of distal pulse, slow capillary refill.

Wound INFECTION evidenced by signs of elevated temperature, pulse and respirations; odor of decaying tissue; elevated leukocyte count; draingae of blood or serous fluid; redness or swelling in surrounding tissues, pain and swelling.

Infection -BONE INFECTION:(osteomyelitis) s/s fever, pain, redness and heat, elevated leukocyte count, nausea with or w/o vomitting, headache, swelling and pressure.

Hemorrhage s/s diminished color, motion and sensitivity of distal limb; tachycardia; hypotension; rapid respirations; anxiety, panic or confusion; diaphoresis; oliguria (decreased urine output or anuria (no urine output)

Front 7

(5) Discuss at least six important areas of nursing care for the client who has had an amputation and now has a new limb prosthesis.

Back 7

Amputation is the absence or removal of all or part of a limb. Nursing care includes: (1) before the amputation discuss PHANTOM LIMB PAIN which happens although the limb is removed the nerves may have a sensation that eventually disappers (2) Compression bandages will be changed twice--a day or more often if ordered or client perspires frequently--teach client and family how to change the bandages to reduce edema and ease the use of prosthesis. You will wrap the stump cone shaped or as ordered.
PREVENT COMPLICATIONS:
keep a tourniquet within reach for severe, life-threatening bleeding; observe dressing for bleeding; use aseptic technique when changing bandage; document draingage (color, amount, consistency, odor); avoid dislodging drains when turning client; observe incision for DARK RED to BLACK tissue means gangrene due to lack of blood supply; leg amputate lies in prone position to avoid hip contractures NO PILLOWS; elevate foot of bed to prevent edema; apply skin traction to stump if ordered; NO CAST,

Front 8

(6) Explain at least six aspects of nursing care needed for a client who has been surgically treated for IVD or HDP.
Intervertebral Disk Disease results when small pad or disk of cartilage between two vertebrae press against the spinal nerves that radiate out of the spinal cord. GENRALLY DISK PROBLEMS ARE IN LUMBAR OR CERVICAL AREA. a/k/a Herniated Nucleus Pulposus. The phenomenon is referred to as herniated disk or slipped disk

Back 8

Intervertebral disk disease "IVD" disk between the vertebrae press against each other causing pain.
Herniated Nucleus Pulposus "HNP" a/k/a herniated disk. The NURSE will provide routein post-op care and assist with pain management. (2) give meticulous wound care to prevent contamination--infection can lean to meningitis. (3) watch closely for signs of bleeding and other drainage, leakage of cerebrospinal fluid or shock caused by trauma (4) Evaluate neurologic function at frequent intervals and follow orders for client turning, positioning and getting out of bed. (5) observe sensation and mobility in the legs after lumbar compression (6) observe edema that may be inflammatory response to the trauma of surgery. (7) observe upper extremities for evidence of nerve damage or impaired respiratory function.

Front 9

(7) State at least three nursing considerations for client with TMJ "temporomandibular joint" muscular dystophy, and osteoporosis

Back 9

TMJ: nursing considerations: Encourage to eat food that are not hard to chew (2) take ibuprofen 30 minutes prior to eating a steak or anything that may require aggressive chewing (3) Reduce any stress--if possible.
MUSCULAR DYSTOPHY (1) encourage client to continue any activity they normally do (2) exercise is helpful to prevent deformities (3) Avoid upper respiratory infections by avoiding ppl who may be sick
OSTEOPOROSIS (1) take calcium (2) avoid caffeine intake and alcohol (3) do not lift heavy items

Front 10

(8) Differentiate among the following conditions: inflammatory disorders (RA, OA, ankylosing spondylitis

Butazolidin (could not find in Davis)

Back 10

Inflammatory Disorders: RA "rheumatoid arthritis" most painful and crippling, more common in women; theory suggest that a triggering mechanism (virus) causes the immune system to become overactive; has genetic history.
s/s large joints, fatigue, weakness wt loss, general body aches, joints become painfull and stiff and ADL's become limited.
OA "osteoarthritis" is genetic and caused by wear and tear on joint; cartilage wears away and exposes the bone, bone spurs form and break off and float in the joint making movement painful.
ANKYLOSING SPONDYLITIS a/k/a rhemuatoid arthitis of the spine primarly affects the facet joints and the stablizing ligaments of the spinal column. affects men at young age; s/s hip and lower back pain, stiffness, wt loss, fatigue, fever and conjunctivitis, difficulty breathing. TX Butaxolidin and refrain from lying on side to prevent spinal curvatures; light exercise, back brace.

Front 11

8) Differentiate among the following conditions: inflammatory disorders buritis and tenosynovitis); repetitive strain injuries (carpel tunnel syndrome)

BETAMETHASONE (prednisone) decrease inflammation

Back 11

BURITIS is inflammation of a bursa related to mechanical irritation, bacterial infection, trauma or gout. TENOSYNOVITIS is inflammation of the tendon sheath that may result from irritation or an infection, typically affecs the wrist or ankle; affecting tendon swells and is painful. S/S pain and tenderness. TX resting the affected body part; application of ice for 1 to 2 days to decrease swelling; physical therapy; use of NSAIDS; surgery; antibiotics; elimination of activities that exacerbate symptoms during inflammation phase.
REPETITIVE STRAIN INJURIES commonly occur in workplace from repetitive activity: typing.
Carpel Tunnel Syndrome is a compression of the neuropathy of the median nerve in the wrist. s/s forearm, wrist pain, numbness, tingling; increase at night. TX writs splinting, rest, NSAID, corticosteroid injections.

Front 12

8) Differentiate among the following conditions: lateral epicondylitis

Back 12

Lateral Epicondylitis occurs when repreated forceful wrist and finger movements stress the origins of the muscles, related to tennis, bowling, pitching and golf. s/s pain along the outer aspect of the elbow, radiating to the forearm, pain increasing on stretching and on resisted wrist and hand flexion. TX splinting, analgesics, rest and cortocosteriod injections.

Front 13

8) Differentiate among the following conditions: systemic disorders with musculoskeletal manifestations (gout, SLE, scleroderma) stating at least four nursing considerations for each disorder.

Gout: Colchicine (Colsalide)
SLE: NSAID (ibuprofen) Corticosteroids (Predinsone) Immunosuppresive Drugs (_______________)

Back 13

GOUT is an arthritic condition resulting from the body producing substances called purines that are unable to be metabolized therefore uric acid accumulates in the bloodstream forming crystal deposits in the joints A/K/A HYPERURICEMIA usually affecting the big toe, ankle or knee; more common in men. TRIGGERS: alcohol, allergies, surgery, infection or fatty foods or a fasting diet, emotional stress. S/S joint swelling, redness and severe pain, fever, tachycardia, and anorexia. LONG TERM DAMAGE: affect ROM, renal damage, vascular damage. TX: treat symptoms and avoid high purine foods (liver) no alcohol.
N/C (1) protect the joint, if client in bed use bed cradle (2) hang warning sign to prevent jarring of bed (3) warm or cold compresses, if ordered (4) elevate the effected joint for comfort and encourage ROM once pain and redness disappear.

SYSTEMIC LUPUS ERYTHEMATOUS (SLE)is an autoimmune systemic disorder that affects many body systems. Ppl with SLE produce autoantibodies that ultimately contribute to im

Front 14

(8) Differentiate among the following conditions: systemic disorders with musculoskeletal manifestations (Scleroderma, rickets or osteomalacia) stating at least four nursing considerations for each disorder

Back 14

SCLERODERMA "hard skin" is a collagen disorder, hardening and shrinking of the connective tissue.
SCLERODACTYLY is fingers and toes; ACROSCLEROSIS is distal extremities and face.
N/C (1) prevent skin breakdown by rotation of client and when giving shots note skin condition at injection site (2) Teach avoid smoking (3) avoid cold, bundle up in winter (4) Emotional support is vital.
DEATH results from rsp or renal failure or cardiac dysrthythmias.
RICKETS is deficiency of VIT D in kids and OSTEOMALACIA is def of VIT D in adults both resulting in softening of bones.
N/C (1) Suggest Vit D supplements (2) do not lift heavy objects (3) use assistance when walking if legs are affected (4) do not over exert causing weak legs

Front 15

(9) Identify the four categories and at least five types of common fractures

Back 15

S/S of fractures are pain that is more severe upon movement of the part or pressure on it. Loss of function, deformity, swelling over the part and disclorotaion
CATEGORIES:
COMPLETE: an entire cross-section of the bone is involved; bone is usually displaced or out of alignment. _______________ INCOMPLETE a portion of the cross-section of the bone is involved. __________________ CLOSED (simple) the overlying skin is intact; ______________. OPEN (compound) the overlying skin is broken with various grades of tissue involvement.
COMMON FACTURES TYPES
simple, compound, transverse, depressed, compression, spiral, greenstick and oblique

Front 16

(10) Describe the least six nursing implementations for the care of a client in a cast

Back 16

N/C (1) check for rough edges, pull sock over the cast to prevent snagging on clothes (2) be cautious around water do no immerse cast in water (3) check for tightness as the swelling will last for up to 3 days after cast is applied; be sure not too tight cause damage to nerve and blood vessels (4) wash, dry and massage skin around the cast daily (5) perform neurovascular checks frequently (circulation, motion, and sensation) (6) caution about to much activity.
BODY CAST
(1) turn client frequently (2) be sure no crumbs get in cast (3) keep room cool (4) keep buttocks and perineal clean (5) Isometric exercises can be done inside the cast (circulation and promote healing)

Front 17

(11) Differentiate between skin traction and skeletal traction, including indications and nursing considerations for each type

Back 17

Traction means immobilization as it exerts a continous pulling force on broken bones or keep them in the natural position for proper healing. SKIN TRACTION the pull is applied to the client's skin which transmits the pull to the muscoskeletal structures. TYPES: Dunlop's (side arm), Russell's (balanced traction), Pelvic Traction and Pelvic Sling; buck or bryant's left on 3 weeks; A belt or head halter with elastic bandage or foam boot is applied to the client's skin before the appendage is attached to traction. used for children and minor fractures in adults. Complications: skin breakdown. SKELETAL TRACTION is when s physican surgically inserts metal pins or wires into the client's bones so that traction is applied directly to them; uses up to 30 lbs of wt and can be used 4 months. Serious fractures typically use this method. Types: balanced suspension, skull tongs. Concern is infection at site which can go to bone causing OSTEOMYELITIS (bone infection)

Front 18

Skin Traction
p. 1138 Box 76-2

Back 18

Dunlop's (side-arm) Traction: temporary skin traction for stabilization of fracture before sugery: upper arm and shoulder with client SUPINE position. CMS checks of the finger and forearm are very important.



Russell's (balanced tractions), downward pull as in Buck's traction may be applied to the leg with an additional overhead pulley.




Pelvic Traction and Pelvic Sling Traction: used in pelvic fractures to support separated bones; either a belt or sling.

Front 19

(12) Discuss at least three nursing measures for care of clients with the following treatments: external fixation, ORIF

N/C ORIF:

Back 19

External Fixation is a device used to manage complex fractures that are associated either with soft tissue damage or open wounds in the fracture area. INFECTION is concern. N/C same was traditional care for fracture plus...(1) pin site, use a sterile cotton-tipped applicator to apply sterile hydrogen peroxide, rinse witih normal saline (2) sterile techinque to chagne dressing (3) apply traction to avoid formation of scar tissue when giving pin care by pulling the skin away from the pin site and observe ofr infection and rejection to the nails, screws.

ORIF "open reduction and internal fixation" is usually necessary if a client has a compound (open) fracture or if multiple bony fragments are present. OPEN REDUCTION surgeon makes an incision so that the injured or damaged tissue can be seen, the would is debrided and irrigated with antibiotics (peroxide, normal saline) then the surgeon visualized the bone fragments and determines exactly how to rejoin them. The fractured ends of the bone are placed in align

Front 20

(12) Discuss at least three nursing measures for care of clients with the following treatments: arthroplasty

Back 20

Repair or replacement of a joint is called arthroplasty. For a hip the femoral head is replaced or in other cases the hip socket is also replaced with a studded cup which may be cemented into a deepened hip socket called THA "total hip arthroplasty"

N/C (1) provide route post-op care: deep breathing, high protein diet, IV and oral fluids (2) Perform neurovascular checks every 15 min:1 hour; 30 min:1 hour; every hour:24 hours every 4 hrs:24 hours; every 8 hrs therefater. (3) Initiate anticoagulation therapy as ordered, place antiembolism stockings or pneumatic compression devices as ordered (4) turn client every 1 to 2 hours from unaffected side to the back (CHECK ORDERS BEFORE TURNING CLIENT) (5) Get assistance to turn client to unaffected side (most client with hip replacement are NOT placed on the affected side) with a pillow beteen his/her knees for good alignment (6) Turn client to back again where he/she usualyl stays for an hour; elevate head of bed 30 degrees when on back to prevent aspiration

Front 21

(13) Identify at least nine complications of fractures or bone surgery

Back 21

(1) neurovascular pressure s/s complaints of numbness and tingling, loss of sensation (2) Wound infection s/s redness, heat from site (3) Osteomyelitis is serious bone infection s/s pain, fever, flushed appearance, elevated WBC and ESR (sediment rate) (4) Hypostatic Pneumonia or Atelectasis (collapse of all or part of the lung) can be prevented if the client maintains mobility; s/s dyspnea, elevated temp, tachycardia, cough, pleural pain (5) Embolism is the sudden blockage of one or more arteries by a piece of foregin material: blood clot, air bubble, piece of tissue, or piece of IV catheter. TX oxygen, steroids, IV fluids as ordered. Fat embolism s/s dyspnea, tachycardia, fever, petechial rash, hypoxemia, chest pain. Pulmonary Embolism s/s dyspnea, tachypnea, hemoptysis (bloody sputum), hyposemia, chest pain. (6) Deep Vein Thrombosis "DVT" is a primary complication of prolonged bed rest. s/s unequal leg circumference, pain, swelling, redness of affected leg (7) Hemorrhage s/s hypotension, tachycardia, chan

Front 22

(14) Explain the difference between primary and metastatic bone tumors.

Back 22

Primary metastatic bone tumor originate in the bone, may be benign or malignant, slow growing and seldom spread; rare occurrence and they include osteogenic sacromoa, chondrosacroma and multiple myelomas.

Metastatic bone tumors travel to the bone from some other part of the body; common; result from primary lesions in the lung, brest, prostate or kidney. occur in ribs, pelvis, femur or humerus bones. Poor prognosis.

Front 23

(15) Identify dietary modifications for the client with musculoskeletal disorders

Back 23

A high protein diet will be ordered for client with multiple fractures.

Front 24

(16) Identify common medications for the client with musculoskeletal disorders

Back 24

Corticosteroids to reduce inflammation. PredniSONE; do not take with Grapefruit Juice; side effects: depression, thromboembolis

Anti-infective: CIPRO for possible bone infection; side effects renal impairment and arrhythmias; may increase the effects of WARFARIN, monitor PT time. Do not take with dairy products as it decreases absorption.

NSAID:
Ibuprofen: Motrin Advil

Indocin
Feldene
Naproxen: Aleve
Toradol
Dolobid
Relafen
Celebrex

GOLD SALTS
Ridaura
Solganal
Myochrysine

Antimalarials:
PLAQUENIL SULFATE
Side Effect: aplastic anemia, thrombocytopenia; assess vision periodically and assess ROM
ARALEN

Penicillamine (Cuprimine, Depen Titratabs)

Immunosuppresives (amethopterin, Imuran, Cytoxan) Cytoxan is an immunosuppresant in small doses. side effects leukopenia, thrombocytopenia; monitor for bone marrow depression. Avoid IM injections and rectal temps. Encourage client to drink 2000 to 3000 mL of liquid during use of this med. Monitor kidneys, liver and CBC.

Front 25

NSAID nonsteroidal anti-inflammatory drugs:
Ibuprofen "Advil" "Motrin" to decrease pain and inflammation. Instruct client to drink full glass of water and sit up for 15 to 30 minutes. Check for GI bleeding

Indomethacin "Indocin" check for blurred vision and GI bleeding

Back 25

Medications for Arthritis

Front 26

(17) Discuss general client and family teaching for clients with a musculosketal disorder, include ages across the lifespan

Back 26

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