MS 1

Define a Electromyelogram (EMG) + purpose

Measure electrical charge associated with muscle contraction → Differentiate muscle vs neurological issues

Define Arthroscopy

Insertion of a lens/camera directly into the joint

Abnormal calcium, phosphate & parathyroid hormone labs meaning?

Metabolic changes, possibly secondary to renal disease or parathyroid hormone imbalance

What is Serum CK (creatine kinase)?

Protein that leaks out of damaged muscle cells into body fluids → telling of rhabdo/muscle injury

Healing process of fractures? (4 steps)

1. Hematoma forms (bleeding)

2. Inflammation (fibrin mesh + granulation tissue form)

3. Soft callus → hard callus

4. Bone remodeling

General healing periods for fractures?

• Kids: ~1 month

• Adults: 2+ months

• Older adults: LONG time

Co-morbidities of impaired bone healing? (5)

1. Anemia

2. DM

3. Nutritional deficits

4. Glucocorticoids

5. Nicotine → vasoconstricts

Define osteomyelitis + relevance

Bone infection → common complication of fractures

Define Compartment Syndrome + signs?

• Pressure builds (edema turns inward) → cuts off blood flow (compresses nerves + vessels)

• Pain + swelling + numbness

Define Fat Emboli

Fatty marrow escapes into vein → goes to lungs → obstruction, inflammation, and
respiratory distress

Define nonunion/malunion

Bone doesn’t heal properly

Define Osteoporosis

• Decrease in bone mass and density

• Loss of bone matrix and mineralization

2 Types of Osteoporosis?

1. Primary: postmenopausal, senile, or idiopathic

2. Secondary: develops as a result of another disorder, like Cushing syndrome

Pathophysiology of Osteoporosis? + Precursor?

Pathophysiology: reabsorption of bone by osteoclasts exceeds bone formation by osteoblasts → thin, fragile bones
○ osteopenia → precursor to full osteoporosis

Risk Factor Pattern for Osteoporosis? (10)

• Aging

• Female/postmenopausal

• Low calcium/vit D

• Sedentary

• Smoking, caffeine

• Steroids/Cushing’s

Key s/s of Osteoporosis? (3)

• Back pain

• Kyphosis (“hunchback”)

• Spontaneous fractures (KEY)

Diagnostic for Osteoporosis?

• DEXA scan

• T-score:

  • Normal: ≥ -1

  • Osteopenia: -1 to -2.5

  • Osteoporosis: ≤ -2.5

General Treatment for Osteoporosis? (3)

• Calcium & Vitamin D + protein

• Weight-bearing exercise

• Surgery

Prototype Osteoporosis Meds? (2)

Alendronate (Bisphosphonate) & Raloxifene (SERM)

Alendronate MOA?

Inhibits osteoclast-mediated bone reabsorption

Alendronate SE/AE? (3)

SE → dyspepsia

AE → HF, esophageal damage

Nursing considerations for Alendronate? (3)

1. Must be taken with 8oz water 30 min before other food/fluids

2. Must remain upright for 30 minutes after taking (esophageal damage)

3. Also comes with vitamin D for enhanced absorption of calcium

Raloxifene MOA?

Binds to specific estrogen receptors to reduce bone resorption and increase bone mineral density

Raloxifene SE/AE? (3)

SE → Hot flashes, leg cramps
AE → Increased risk for DVT, PE, & CVA (CLOTS!)

Nursing considerations for Raloxifene? (2)

1. Take with calcium and vitamin D to prevent/treat hypocalcemia while on it

2. Avoid prolonged periods of sitting, especially first 4 months of therapy (clot risk!)

Pathophysiology of Rickets & Osteomalacia?

Deficit of vitamin D and phosphates required for absorption of calcium → lack of
calcification of cartilage formation → weak bones, deformities, compression fractures

Rickets vs. Osteomalacia?

Children → Rickets (“bow legs”)
Adults → Osteomalacia

Key causes of Rickets & Osteomalacia? (3)

1. Poor diet

2. No sunlight (lack vitamin D)

3. Malabsorption

Define Osteosarcoma

Neoplasm in the metaphysis of the femur, tibia, fibula in children and young adults; primarily males

Define Ewing sarcoma

Neoplasm in diaphysis of long bones, commonly in adolescence

Define Muscular Dystrophy (MD)

Group of inherited disorders characterized by degeneration of skeletal muscle

Pathophysiology of MD?

Metabolic deficit of dystrophin (muscle cell membrane protein) → degeneration and necrosis of
the cell → skeletal muscle fibers replaced with fat/fibrous connective tissue & hypertrophic muscle appearance → gradual loss of muscle function

Key s/s of MD? (3)

1. Weakness (starts in legs)

2. Gower’s maneuver

3. Waddling gait

Key MD diagnostic?

Elevated CK levels

Typical outcome of MD?

• No cure → focus on PT/OT

• Death (usually by age 20) often from respiratory/cardiac failure (possible ventilation to prolong life)

Define Osteoarthritis (OA)

“Wear and tear” damage to weight-bearing joints → can be unilateral

Pathophysiology of Osteoarthritis (OA)?

Weight-bearing joint articular cartilage is damaged from excessive mechanical stress

Key s/s of OA?

• Pain with movement

• Crepitus

• Heberden’s nodes (DIP joints of hands)

Treatment for OA?

1. Minimize stress on joint, ambulatory aids, PT, OT

2. Pain relief; 1st line medication → Acetaminophen

3. Celecoxib (NSAID)

Celecoxib uses? (3)

OA, rheumatoid arthritis, & ankylosing spondylitis

Celecoxib MOA?

Inhibits COX-2, which normally promotes prostaglandin synthesis and inflammatory response (does not inhibit COX-1)

Key Celecoxib AE? (3)

Tinnitus, bronchospasm, blood dyscrasias

Nursing consideration for Celecoxib? (1)

Less risk for peptic ulcer/GI bleed than traditional NSAIDs

Define Rheumatoid Arthritis (RA)

Autoimmune disorder → chronic systemic inflammatory disease with exacerbations and remissions; with each exacerbation more damage & additional joints involved

RA genetic factor?

Rheumatoid factor (RF), antibody against immunoglobulin G, is present in the blood of most persons with RA

Pathophysiology of initial onset RA?

Abnormal immune response → Acute inflammation of synovial membrane → Formation of exudate → Typical red, swollen, painful joint (synovitis) → Appears to recover

Pathophysiology of subsequent exacerbations of RA?

Synovitis (inflammation recurs) → Granulation tissue spreads over joint causing “pannus” formation → Pannus releases enzymes that erodes cartilage → Fibrosis of joint space, limited
movement → Ankylosis (joint fixation and deformity)

Key s/s of RA? (4)

1. Morning stiffness (improves with movement)

2. Swollen, warm joints

3. Fatigue, fever (systemic)

4. Ulnar deviation

Medications for RA? (4)

Focus = pain control

1. High-doses of NSAIDs/aspirin

2. Celecoxib

3. Corticosteroids (if severe)

4. Disease-modifying antirheumatic agents (DMARDs)

   1. Immunosuppressant → methotrexate

   2. Immunomodulator → etanercept

   3. Antimalarials → hydrochloroquine

Methotrexate MOA?

For RA exact MOA unknown but decreases joint inflammation and damage

Key SE/AE of Methotrexate? (4)

SE → photosensitivity
AE → hepatotoxicity, bone marrow suppression → increased infection risk, gastric ulcers

Nursing considerations for Methotrexate? (5)

1. Class 1 hazardous drug → double chemo gloves

2. Teratogenic

3. Avoid aspirin, NSAIDs, PPIs, and alcohol

4. Monitor labs (bone marrow suppression, liver function, GI bleeding)

5. Take folic acid to decrease toxicity risk

Etanercept MOA?

TNFI → inactivates tumor necrosis factor (TNF) which prevents it from attaching to cells synovial fluid in joints → blocked inflammatory reaction

Key SE/AE of Etanercept? (2)

SE → Increased infection risk (blocks inflammation)
AE → Reactivation of latent TB

Nursing considerations for Etanercept? (3)

1. Give with methotrexate for enhanced effect

2. Monitor for infection symptoms & CBC

3. Test for TB before starting and periodically

Define Gout (Gouty Arthritis)

Uric acid and urate crystal deposits in joints → acute inflammatory response; most commonly effects big toe

Most common underlying cause of Gout?

Inadequate renal excretion → hyperuricemia (uric acid is purine metabolism waste product the kidneys excrete)

Define a tophus

Large hard nodule of urate crystals in soft tissue or bone → local inflammation

Define Ankylosing Spondylitis

Chronic, progressive autoimmune inflammatory condition of sacroiliac (SI) joints, intervertebral spaces, & costovertebral joints

Pathophysiology of Ankylosing Spondylitis?

Vertebral joints (SI) of lower back become inflamed → calcification/fusion of joints → ankylosis → progression up spine → “poker back” → kyphosis

Key s/s of Ankylosing Spondylitis? (3)

Morning body stiffness relieved by walking, rigid spine, & systemic signs (fever/anorexia)

Treatment for Ankylosing Spondylitis?

Pain relief with anti-inflammatory meds & maintain mobility