Topic 10: Osteomyelitis (Ch 68), OA, and RA (Ch 69)

osteomyelitis

a severe infection of the bone, bone marrow, and surrounding soft tissue caused by a number of pathogens that can invade my indirect or direct entry, most commonly Staphylococcus

• After entering the blood, microorganisms grow, and pressure increases because of the non-expanding nature of most bone

• increased pressure eventually leads to ischemia and vascular compromise of the periosteum and spreads through the bone cortex and marrow cavity, obstructing blood flow and causing necrosis

• bone death occurs due to ischemia, eventually the area of the dead bone separetes from the surrounding living bone

• antibiotics/WBCs have issues reaching the dead bone and it becomes a reservoir for microorganisms that spread

• if not resolved or debrided surgically, a sinus tract with chronic, purulent drainage may develop

• older age

• debilitation

• hemodialysis

• sickle cell disease

• IV drug use

what are the RF for osteomyelitis

acute osteomyelitis

the initial infection of the bone, bone marrow, and surrounding tissue or an infection less than 1 month in duration

• constant bone pain that worsens with activity and is relieved by rest

• swelling

• tenderness

• warmth at the site

• restricted movement of the affected part

what are the local S/S of acute osteomyelitis

• fever

• night sweats

• chills

• restlessness

• nauseaa

• malaise

• late signs: drainage from skin sinus tracts or at the fracture site

what are the systemic S/S of acute osteomyelitis

• prolonged antibiotic therapy if bone ischemia has not yet occurred

• most start on IV antibiotic therapy and then switch to oral agents

• IV antibiotic therapy may need to continue at home for 4-6 weeks, for up to 3-6 months

• Cultures or bone density before antibiotics begin

• surgical debridement and drainage of any related abscess or ulcer

what are the nursing interventions for acute osteomyelitis

chronic osteomyelitis

a bone infection that lasts longer than 1 month or an infection that did not respond to initial antibiotic treatment; may be a continuous, persistent problem or recurrent, with exacerbations and remissions

• constant bone pain

• swelling and warmth at the infection site

• granulation tissue turns to avascular scar tissue, which is an ideal site for continued microorganism growth because antibiotics cannot penetrate it

what are the local signs of infection in chronic osteomyelitis which become more common

• surgical removal of poorly perfused tissue and dead bone

• extended use of antibiotics

  • oral therapy with a fluoroquinolone for 6-8 weeks

  • oral therapy for 4-8 weeks after IV therapy is done

what are the nursing interventions for chronic osteomyelitis

• long term and mostly rare

• septicemia

• septic arthritis

• pathologic fractures

• amyloidosis

what are the complications of osteomyelitis

• bone or soft tissue biopsy to identify the causative agent

• blood and wound cultures often positive

• increased WBC and ESR

• High CRP may occur with acute infection

what would diagnostic studies for a patient with osteomyelitis reveal

• restlessness

• high, spiking temp

• night sweats

• restricted movement

• wound drainage

• spontaneous fracture

• diaphoresis

• redness, warmth, and edema at the site of infection

what objective data would be gathered from a patient with osteomyelitis

• control of other current infections

• teach at-risk patients the signs of infection

• those at risk include immunocompromised, have DM, orthopedic implants, or vascular insufficiency

• contact HCP about bone pain, fever, swelling, and restricted limb movement

what does health promotion of osteomyelitis include

• immobilization and careful handling of the affected limb to decrease pain and the risk of injury

• assess and treat pain and muscle spasms with NSAIDs, opioids, and muscle relaxants

• use sterile technique for dressing care

• bedrest initially

  • ensure proper positioning and support of the extremity

  • prevent complications of immobility

• give IV antibiotics as ordered

• assess the wound for signs of worsening infection

• teach about antibiotic side effects, length of treatment, S/S of worsening infection

• use hyperbaric O2 if ordered

• encourage non-drug approaches to manage pain

• collaborate with PT and OT

• supervise AP:

  • handle affected limb carefully based on RN’s instructions

  • help with passive ROM of adjacent joints and active ROM exercises of the unaffected limb

  • notify the RN about reports of pain, tingling, or decreased sensation in the affected extremity

what does acute care for osteomyelitis consist of

• educate on importance of taking antibiotics as prescribed and for the full course even when symptoms subside

• Educate on wound care and dressing changes

what does ambulatory care for osteomyelitis consist of

osteoporosis

a chronic, progressive metabolic bone disease marked by low bone mass and deterioration of bone tissue, leading to increased bone fragility; known as the “silent thief” because it slowly robs the skeleton of its banked resources, and bones eventually become so fragile that they cannot withstand normal mechanical stress

• advancing age

• females

• low body weight

• family history

• smoking

• low calcium/Vitamin D diet

what are RF for osteoporosis

• MC in the bones of the spine, hips, and wrists

• early: back pain and spontaneous fractures

• gradual loss of height

• kyphosis (humped thoracic spine/dowager’s hump)

what are the S/S of osteoporosis

• cannot be detected in conventional X-ray until 25-40% of the calcium in the bone is lost, so often goes unnoticed

• dual energy X-ray absorptiometry (DEXA)

• quantitative ultrasound

what do diagnostic studies for osteoporosis include

dual energy X-ray absorptiometry (DEXA)

diagnostic study that evaluates bone density to guide the decision on when to start drug therapy to prevent osteoporotic fractures

• proper nutrition

• calcium and vitamin D supplementation

• exercise

• prevention of falls and fractures

• quit smoking

• decrease alcohol intake

what are the nursing interventions for osteoporosis

• biphosphonates

• alendronate

• risedronate

• zoledronic acid

• denosumab

what does drug therapy for osteoporosis include

biphosphonates

drug used for osteoporosis to inhibit bone reabsorption and slow remodeling

osteoarthritis (OA)

a slowly progressive noninflammatory disease of the synovial joints in which gradual loss of articular cartilage with formation of body outgrwoth or spurts at the joint margins occur

secondary OA

OA that is caused by direct damage or joint instability

idiopathic OA

OA in which the event or condition that causes it may not be known and genetics may contribute

• drugs

• hematologic or endocrine problems

• inflammation

• joint instability

• mechanical stress

• neurologic problems

• skeletal deformities

• trauma

what are causes of osteoarthritis (OA)

• age

• affects women more often

• decreased estrogen at menopause

• obesity

• ACL injury

• frequent kneeling and stopping

what are RF for osteoarthritis (OA)

• joint pain ranges from mild discomfort to significant disability

  • worsens with activity

  • in early stages, rest relieves pain

  • when advanced, may have pain at rest or trouble sleeping due to pain

  • may worsen when barometric pressure falls before the onset of severe weather

  • can contribute to disability and loss of function

  • may be referred to the groin, buttock, or outside of the thigh or keee

  • can be hard to sit down or get up from a chair when the hips are lower than the knees

  • local pain and stiffness are common

• joint stiffness occurs after peiods of rest or an unchanged position (gelling phenomenon)

  • early morning stiffness is common

  • often resolves within 30 minutes

  • excessive activity can cause a mild joint swelling that temporarily increases the stiffness

  • crepitation

• affects joints ASYMMETRICALLY ON ONE SIDE OF THE BODY

• deformity or instability

  • Heberden and Bouchard nodules: red, swollen, tender on the fingers

  • bowlegged or knock-kneed appearance

  • one leg may appear shorter than the other

• no systemic effects like fatigue, fever, and organ involvement

what are the S/S of osteoarthritis (OA)

crepitation

a grating sensation caused by loose cartilage particles in the joint cavity, which can cause stiffness and is common in patients with knee OA

• X-ray to confirm disease and stage joint damage

• Synovial fluid analysis can distinguish from other types: fluid is clear yellow with little or no signs of inflammation

• ESR is normal except for slight increases during acute inflammation

what are the diagnostic studies of someone with osteoarthritis (OA)

• no cure

• manage pain and inflammation

• prevent disability

• maintain and improve joint function

• rest and joint protection, use of assistive devices

• therapeutic exercises

• heat and cold applications

• TENS

• reconstructive joint surgery

what are the nursing interventions for osteoarthritis (OA)

• based on the joint affected and symptom severity

• NDAIDs are first line treatment

• intraarticular corticosteroid injection for those with local inflammation and swellin

• some start with a topical agent

  • capsaicin cream

  • diclofenac gel

  • OTC products: Bengay, Arthicare

what does drug therapy for osteoarthritis (OA) consist of

capsaicin cream

topical cream for osteoarthritis (OA) that blocks pain by locally interfering with substance P, which is responsible for the transmission of pain impulses

• Acupuncture may reduce arthritis and improve joint mobility

• nutritional supplements with anti-inflammatory effects: fish, oil, ginger, and SAM-e

what are complementary and alternative therapies for capsaicin cream

• type, location, severity, frequency, and duration of the joint pain and stiffness

• what makes the pain better or worse?

• how do these S/S affect the ability to perform ADLs?

• assess tenderness, swelling, limitation of movement, and crepitation of affected joints

what does assessment for osteoarthritis (OA) include

• avoid smoking

• promptly treat any joint injury

• maintain a healthy weight and eat a balanced diet

• use safety measures to protect and decrease the risk of joint injury

• reduce occupational and /or recreational hazards

• exercise regularly, including strength and endurance training

what are the ways to prevent osteoarthritis (OA)

• receives treatment outpatient and is only hospitalized if having joint surgery

• provide information about the nature and treatment, pain management, body mechanics, correct use of assistive devices, principles of joint protection, energy conservation, nutrition choices, weight and stress management, and an exercise program

• assure that it is a localized disease and severe deforming arthritis is not the usual course

• community resources

• use of heat and cold

• nutritional therapy

• exercise

• rest and joint protection

• remove throw rugs, place rails on the stairs and bathtubs, use night lights, wear well-fitting, supportive shoes

• sexual counseling: analgesics or warm bath to decrease stiffness before sexual activity

what does ambulatory care for osteoarthritis (OA) include

• maintain a healthy weight

• avoid forceful repetitive joint movements

• avoid awkward positions that stress joints

• use good posture and body mechanics

• seek help with needed tasks that may cause pain

• organize routine tasks and pace yourself to decrease fatigue and joint pain

• modify the home and work environment to perform tasks in less stressful ways

what does joint protection and energy conservation teaching for a patient with osteoarthritis (OA) consist of

ice

used for patients with osteoarthritis (OA) to reduce swelling for acute inflammation

heat

used for patients with osteoarthritis (OA) that is useful for stiffness, increases flexibility, and improves blood flow to the area; includes hot packs, whirlpool baths, ultrasound, and paraffin wax baths

• aerobic conditioning, ROM exercises, and programs to strengthen muscles around the affected joints

• warm up before any exercise to decrease risk of injury

• Balance exercises to improve the ability to control and stabilize body position

• Tai Chi which focuses on strength and balance

what should exercise for a patient with osteoarthritis (OA) include

• balance rest and activity

• rest during periods of acute inflammation

• keep joints in a functional position with splints or braces

  • Splints can rest and stabilize painful or inflamed joints

• review ways to modify usual activities to decrease stress on affected joints

• those with knee OA should avoid standing, kneeling, and squatting for long periods

• work with PT about the use of assistive devices to decrease joint stress

what does rest and joint protection for a patient with osteoarthritis (OA) include

rheumatoid arthritis (RA)

a chronic, systemic autoimmune disease that causes inflammation of the connective tissue in the synovial joints, which leads to extraarticular manifestations and affects every body system; one of the most disabling forms of arthritis with periods of remission and exacerbation

• rheumatoid factor combines with IgG to form immune complexes that deposit on synovial membranes or superficial articular cartilage in the joints, leading to complement activation and an inflammatory response

• neutrophils are then attracted to the site of inflammation and release proteolytic enzymes that damage articular cartilage and cause the synovial lining to thicken, which drives the inflammatory response

autoimmune, genetics, and environmental triggers

what are the causes of rheumatoid arthritis (RA)

• infection

• work stress

• physical exertion

• childbirth

• surgery

• emotional upset

• smoking

what are the RF for rheumatoid arthritis (RA)

• typically a subtle onset

• fatigue

• anorexia

• weight loss

• generalized stiffness that becomes localized stiffness with progression in the following weeks to months

• specific joint involvement: pain, stiffness, limited motion, signs of inflammation (warmth, swelling, pain)

• stiffness after periods of inactivity

• morning stiffness may last from 60 minutes to several hours or longer, depending on the disease activity

• symptoms occur SYMMETRICALLY

• joint pain increases with movement and varies in intensity

• tenosynovitis

• joints are tender, painful, warm to the touch

• subluxation

• effusions are common

• often affects small joints and are usually swollen, usually doesn’t affect the axial skeleton

what are the articular S/S of rheumatoid arthritis (RA)

tenosynovitis

S/S of rheumatoid arthritis (RA) that affects the extensor and flexor tendons around the wrists and causes S/S of carpal tunnel syndrome and makes it hard for the patient to grasp objects

subluxation

S/S of rheumatoid arthritis (RA) in which muscle atrophy and tendon destruction cause 1 joint surface to slip past the other

• more common in those with a high rheumatoid factor (RF)

• atherosclerosis

• rheumatoid nodules

• Sjogren’s syndrome

• Felty syndrome

• Flexion contractures and hand deformities

• depression due to pain and disability

• increased CRP levels (inflammation)

what are the extraarticular S/S of rheumatoid arthritis (RA)

atherosclerosis

S/S of rheumatoid arthritis (RA) that is chronic inflammation that damages endothelial cells within BVs; more cholesterol plaques form and lead to a heart attack/stroke when they break loose, the risk of heart attack is 60% higher in those with RA

rheumatoid nodules

S/S of rheumatoid arthritis (RA) that is firm, nontender masses found under the skin on bony areas exposed to pressure, like the fingers and elbows, occurring in half of patients with RA, most do not need treatment, watch for skin breakdown like pressure injuries; may form in the lungs, but are usually harmless

Sjogren’s syndrome

S/S of rheumatoid arthritis (RA) that is damage to tear-producing (lacrimal) glands, causing dry, gritty eyes, and photosensitivity; may need to treat dryness to prevent damage to the eyes

Felty syndrome

S/S of rheumatoid arthritis (RA) that is enlarged spleen and low WBCs that results in increased risk of infection and lymphoma; is rare

• RF levels

• Anti-CCP

• ANA titers, ESR, CRP

• synovial fluid analysis: slightly cloudy, straw-colored fluid with many fibrin flecks, increased WBCs, and enzyme MMP-3

• joint involvement for staging

• serology

• acute phase reactants

• duration of s/s

what do diagnostic tests for rheumatoid arthritis (RA)

• disease-modifying antirheumatic drugs (DMARDs)

• biologic response modifiers (BRMs)

• NSAIDs

• Intraarticular or systemic corticosteroids

• Tumor necrosis factor (TNF) inhibitors

what is drug therapy for rheumatoid arthritis (RA)

disease-modifying antirheumatic drugs (DMARDs)

medications that slow rheumatoid arthritis (RA) disease progression and decrease the risk of joint deformity and erosion;

consists of:

• methotrexate (Trexall)

• Sulfasalazine (Azulfidine)

• Hydroxychlrooquine (Plaquenil)

• Leflunomide (Arava)

biologic response modifiers (BRMs)

medication that consists of biologics or immunotherapy, slow the progression of rheumatoid arthritis (RA) and is used alone or in combination with DMARDs to treat severe disease that doesn’t respond to DMARDs alone by inhibiting the inflammatory response

• perform tuberculin test and chest x-ray before starting therapy

• monitor for signs of infection, notify HCP if acute infection develops, as therapy may be stopped temporarily

• live vaccines should be taken at least 4 weeks before starting the drug

• report bruising or bleeding

synovectomy (removal of joint lining) and arthroplasty (total joint replacement)

what is surgical therapy for rheumatoid arthritis (RA)

• symmetric pallor and cyanosis of fingers (Raynaud phenomenon), distant heart sounds, murmurs, dysrhythmias

• lymphadenopathy, fever

• splenomegaly, Felty syndrome

• symmetric joint involvement with swelling, redness, warmth, tenderness, deformation, enlargement of PIP and MCP joints, limitations of joint movement, muscle contractures, and muscle atrophy

• bronchiectasis, pleural effusion, TB, interstitial lung disease

• scleritis, uveitis, Sjogren syndrome, SQ rheumatoid nodules on the forearm and/or elbows, skin ulcers, shinty, taut skin over joints, peripheral edema

• positive RF, ANA, Anti-CCP, increased ESR, amnesia, increased WBCs in synovial fluid

what does assessment for rheumatoid arthritis (RA) include

• rest

• good body alignment during rest

• joint protection

• cold therapy

• moist heat

• exercise

• nutrition

• psychological support

what are nursing interventions for rheumatoid arthritis (RA)

• Alternate periods with activity (pacing) help relieve pain and fatigue

• the amount of rest varies based on disease severity and patient limitations

• avoid total bed rest as it can cause stiffness and other immobility effects

• get 8-10 hours of sleep plus daytime rest

• modify activities overexertion and fatigue, as it can worsen disease activity

what should rest for patients with rheumatoid arthritis (RA) look like

• a firm mattress or a bed board

• encourage positions of extension

• avoid flexion position

• no pillows under knees to decrease the risk of joint contracture

• place a small, flat pillow under the head and shoulders

what should good body alignment during rest for patients with rheumatoid arthritis (RA) look like

• modify tasks for less stress on joints

• work simplification techniques like organizing activities, use of carts, convenient, easy to reach storage, joint protective devices, and delegation

• maintain the joint in a neutral position to minimize deformity

  • press water from a sponge instead of wringing

• use the strongest joint available for tasks

  • when rising from a chair or when carrying a laundry basket

• distribute weight over many joints instead of stressing a few

  • slide objects instead of lifting them

  • hold packages close to your body for support

• change positions often

  • do not hold a book or grip the steering wheel for long periods without resting

  • avoid grasping pencils/cutting veggies with a knife for extended periods

• avoid repetitious movements

  • do not knit/sew for long periods

  • rest between rooms when vacuuming

  • use faucets and door knobs that push rather than turn

• modify chores to avoid stress on joints

  • avoid heavy lifting

  • sit on a stool instead of standing during meal prep

• occupational therapy to maintain upper extremity function with the use of splinting and assistive devices

what should joint protection for patients with rheumatoid arthritis (RA) look like

cold therapy

beneficial during periods of increased disease activity, can relieve stiffness, pain, and muscle spasms, do not apply for longer than 10-15 minutes at a time, can be used several times a day for a patient with rheumatoid arthritis (RA)

moist heat

relieves chronic stiffness in patients with rheumatoid arthritis (RA) that should not be used for longer than 20 minutes at a time or used with topical heat-producing cream; be alert for burn potential

• encourage program participation and reinforce correct performance

• need both recreational and therapeutic exercises

• avoid overly aggressive exercise

• daily gentle ROM exercises to keep joints functional

• Aquatic exercises in warm water allow easier joint movement and make muscles work harder than on land, so limit to 1-2 repetitions

what should exercise for a patient with rheumatoid arthritis (RA) look like

• high incidence of OA may keep the HCP from considering other types of arthritis

• age alone causes changes that make interpreting labs such as RF and ESR more difficult

• drugs taken for comorbid conditions can affect lab values

• MSK pain syndromes and weakness may have no physical cause and may be related to depression and physical inactivity

• Diseases such as SLE, which often occur in younger adults, can develop in a milder form in adults

what are the gerontologic considerations of arthritis