Chapter 46 - Nursing Care of Patients with Musculoskeletal and Connective Tissue Disorders

Strain

-A soft tissue injury that occurs when a MUSCLE or TENDON is excessively stretched

-Use RICE

Sprain

-Excessive stretching of LIGAMENTS from twisting movements

-RICE and NSAIDs

Dislocation

Common injury in which the ends of the bones (joints) are moved out of their normal position, usually caused by trauma or a disease

RICE

Rest, Ice, Compression, and Elevation used to treat soft tissue injuries like strains and sprains.

Bursitis

inflammation of a bursa

Bursae

fluid filled sacs that cushions tendons during movement to prevent friction between bone and tendon

S/S of Bursitis

achy pain, stiffness, swelling, redness, or burning pain

Rotator cuff injury

Muscle contraction causes these tendons to tighten and move or rotate the shoulder

Be Safe! Be Vigilant!

-Use lifting devices.

•Draw sheets

•Mechanical moving devices

-Avoid pulling up on patient's arms to avoid patient injury.

Carpal Tunnel Syndrome

-Median nerve compression in wrist's carpal tunnel

-Occurs with swelling in tunnel

§Finger, hand, arm pain/numbness

-Relieve inflammation and rest wrist.

•Splint

•Anti-inflammatory

•Surgery

-Teach prevention.

Fractures

break in a bone

Cause of Fractures

Trauma

Pathological

Closed fracture

does not break the skin

Open fracture

breaks the skin - infection risk

Avulsion

a piece of bone is torn away from the main bone while still attached to a ligament or tendon

Comminuted

Bone is splintered or shattered into numerous fragments. often occurs in crushing injuries.

Impacted

bone is forcibly pushed together, resulting in bone being pushed into bone

Greenstick

Bone is bent and fractures on the outer arc of the bend. Often seen in children.

Interarticular

fracture involves bones within a joint

Displaced

Bone pieces are out of normal alignment. One or more pieces may be out of alignment

Pathological

Caused when bone is weakened either by pressure from a tumor or an actual tumor within the bone

Spiral

fracture curves around the shaft of the bone; from a twisting motion

Longitudinal

fracture occurs along the length of the bone

Oblique

fracture occurs diagonally or at an oblique angle across th ebone

Stress

results in the bone being fractured across one cortex. this is an incomplete fracture.

Transverse

bone is fractured horizontally

Depressed

bone is pushed inward. often seen with skull and facial fractures.

S/S of Fractures

-Pain

-Decreased ROM

-Limb rotation

-Deformity, shortening of limb

-Swelling

-Bruising

Diagnostic tests of Fractures

X-ray

CT scan

Emergency treatment of Fractures

-splint it as it lies

-seek medical treatment

Therapeutic goals of Fractures

-Realignment of bone ends

-Immobilization

Fracture Healing Phases

inflammation, repair, remodeling

Management - Closed Reduction

-Manual realignment

-Elastic wraps/splints

-Casts

-Traction

*Skin

*Skeletal

Management - Open Reduction with Internal Fixation

Metal plates, screws

Prosthesis

Management - External fixaton

Pins, metal frame

Allows care of wounds

Internal Fixation

A. Intertrochanteric fracture of the hip with fracture fixation via a side plate and screw combination device

B. Side plate and screw fixation of radial fracture

Complications of Fractures

•Hemorrhage

•Acute compartment syndrome

•Neurovascular compromise

•Infection

•Nonunion

•Thromboembolic complications

•Fat embolism syndrome

Compartment Syndrome

Acute compartment syndrome is a limb-threatening condition in which pressure in limb compartments increases. This causes reduced circulation to the compartment's muscles and nerves.

6 P's of Compartment Syndrome

-Pain

-Paresthesia

-Pallor

-Paralysis

-Pulselessness

-Poikilothermia

Severe pain that is not relieved with opioids and occurs more in active movements than passive movements

Acute compartment syndrome

Pain

severe, unrelenting, and increased with passive stretching

Paresthesia

painful tingling or burning

Pallor

but there may be warmth or redness over the area

Paralysis

late symptom

Pulselessness

late and ominous sign

Poikilothermia

temperature matches environment; i.e. the extremity is cool to touch

Fat embolism S/S

-Respiratory failure, cerebral involvement, and skin petechiae.

-Tachypnea, dyspnea, and cyanosis

Fat embolism Causes

Long-bone fractures; surgical fracture repair; multiple fractures

Hip fracture

Nursing care for Fractures

•Neurovascular checks

•Pain management

•Cast, traction, pin care

‒Palming wet cast

•Skin care

•Nutrition

•Self-care deficits

Psychosocial

Patient Education of Fractures

-Cast care

-Pin care

-Nutrition

Osteomyelitis

Infection of bone

Site pain, redness, warmth, swelling, fever

True or False: Use sterile technique for all dressing changes with osteomyelitis

True

Osteomyelitis - Curative Therapy

debridement, reconstruction, antibiotic

Osteomyelitis - Palliative Therapy

chronic suppressive antibiotic therapy

Osteomyelitis - Nonresponsive

Amputation

Nursing Care - Osteomyelitis

Prevention is key!

Hand hygiene

Sterile dressing changes

Medication teaching

Osteoporosis

-Metabolic disorder of low bone mass

-Prone to fractures

-Most common: Spine, wrist, hip

-All bones affected

-Imbalanced remodeling process

Prevalence - Osteoporosis

•54 million people

•Women at greatest risk

•Healthy People 2030 objective: To increase the proportion of older adults who get screened for osteoporosis.

hip/vertebral fractures (osteoporosis)

Reduced quality of life

Increased disability

Risk of death (during year after fracture)

Osteoporosis - Nonmodifiable risk factors

•Aging

•Female gender

•Family history of osteoporosis or fractures

•History of fractures

•Postmenopausal status

•Small boned, petite body build

•Low testosterone and estrogen in men

•White or Asian

Osteoporosis - Modifiable risk factors

•Excessive alcohol use

•Low calcium and vitamin D intake

•Excessive caffeine, protein, sodium

•Sedentary lifestyle

•Smoking

Prevention of Osteoporosis

•Build adequate bone before age 30.

•Ensure adequate calcium and vitamin D intake.

•Perform weight-bearing exercise (especially in childhood).

•Avoid alcohol and smoking.

S/S of Osteoporosis

-Back pain

-Height decreases

-Fracture

-Kyphosis

Effects of Osteoporosis

•Deformities

•Functional effects

•Emotional effects

•Socialize less due to body image

Diagnostic tests of Osteoporosis

•Dual-energy x-ray absorptiometry (DEXA)

•Serum calcium, vitamin D is decreased.

•Serum phosphorus is increased.

•Serum alkaline phosphatase is increased.

Therapeutic interventions of Osteoporosis

•Reduce risk factors

•Calcium supplements

•Vitamin D supplements

•Medications

Antiresorptive medications

Bisphosphonates

Calcitonin

Monoclonal antibody

Selective estrogen receptor modulator

Bisphosphonates

bind to bone and suppress osteoclast activity to prevent or reduce bone breakdown in osteoporosis

Examples of Bisphosphonates

-Alendronate (Fosamax)

-Ibandronate (Boniva)

-Risedronate (Actonel)

-Zoledronic Acid (Reclast)

Calcitonin

treats osteoporosis by decreasing bone loss

Examples of calcitonin

Fortical, Miacalcin

Monoclonal antibody

inhibits the protein that signals bone removal

Examples of Monoclonal antibody

Denosumab (Prolia)

Selective Estrogen Receptor Modulators (SERMs)

-Increases bone mass by 2% to 3% each year.

-Designed to mimic estrogen in some parts of the body while blocking its effects elsewhere.

Selective Estrogen Receptor Modulators (SERMs) Medication

Raloxifene (Evista)

Anabolic (bone forming) medications

Teriparatide (Forteo)

Nursing Care of Osteoporosis

•Pain relief

•Symptom management

•Education

‒Prevention

‒Diet: Increase calcium, vitamin D

‒Exercise

‒Medication

•Fall prevention

Paget Disease

-Rare noncurable metabolic bone disease

-Abnormal weak bones

-Painful

-Diagnostic test: X-ray

-Bisphosphonates, calcitonin

-Relieve pain, teaching, promote life quality

Primary malignant tumors

•Osteosarcoma

‒Most common

•Ewing sarcoma

‒Most malignant

•Both mainly in children and young adults

S/S of Bone Cancer

Site pain and swelling

Tender, palpable mass

Therapeutic interventions of Bone Cancer

Surgery, chemotherapy, radiation

Nursing Care of Bone Cancer

•Postoperative care

•Supportive care

Metastatic Bone Disease

-Bone-seeking cancers

•Prostate, breast, lung, thyroid

-Pathological fractures

-Severe pain

-Therapeutic interventions

•Radiation

-Nursing care

•Supportive care, as with other cancers

Gout Pathophysiology

•Systemic connective tissue disorder

•Uric acid build-up

•Urate crystals deposited in joints/ connective tissues

•Severe joint inflammation

Causes and types of Gout

•Primary

‒Inherited problem with purine metabolism

•Secondary

‒Another health issue

‒Medications

S/S of AcuteGout

-Swollen, red, hot, painful inflamed joints

-Great toe

S/S of Chronic Gout

- Urate deposits under skin

- Renal stones

Diagnostic tests for Gout

-Serum uric acid

-Joint fluid: Uric acid crystals

Medication for Acute Gout

Colchicine (Colcrys) and NSAIDs

Medication for Prevention of Gout

-Febuxostat (Uloric)

-Allopurinol (Zyloprim)

-Probenecid (Benemid)

Nursing Care of Gout

•Patient education

‒Avoid foods high in purines.

‒Eating cherries/cherry juice may be helpful.

‒Avoid aspirin, diuretics, alcohol, stress.

‒Increase fluids to avoid kidney stones.

Osteoarthritis

-Affects more than 32 million people

-Common

-Degenerative joint disease

-Increases with age

Osteoarthritis Pathophysiology

•Affects entire joint

•Articular cartilage/joints bone ends deteriorate

•Joint space narrows, bone spurs develop, joint inflamed

•Joint deformities, pain, immobility

•Weight-bearing joints

Risk factors of Osteoarthritis

-Heredity

-Aging

-Obesity

-Excessive "wear and tear" on synovial joints

S/S of Osteoarthritis

•Joint pain

‒Intensifies after physical activity

•Stiffness

•Heberden and Bouchard nodes

‒Bony nodes on joints of fingers

Diagnostic Tests of Osteoarthritis

-X-rays

-MRI

-Synovial fluid analysis

Therapeutic interventions of Osteoarthritis

•No cure

•Exercise

•Weight control

•Medication

‒NSAIDs

‒Synvisc-One

•Heat or cold therapy

•Complementary therapies

‒Imagery, music therapy, acupressure, acupuncture

•Surgery

Total joint replacement

Patient Education of Osteoarthritis

-Protect joints

-Conserve energy

Rheumatoid Arthritis

-Chronic, progressive, systemic inflammatory disease

-Destroys synovial joints and other connective tissues

-Includes major organs

Pathophysiology of Rheumatoid Arthritis

•Synovitis

•Synovium thickens, fluid accumulates

•Destructive pannus erodes joint cartilage, destroys joint bone

•Pannus converted to bony tissue

•Joint deformity

•Other connective tissue affected