Exam 1 (Musculoskeletal Disorders)

non-pharmacologic interventions for LOW BACK PAIN

do NOT advise bed rest

heat/cold application

massage

PT & exercise (body mechanics, back/core muscles)

meditation

acupuncture

TENS

spinal manipulation

surgery IF PT fails

pharmacologic interventsion for low back pain

NSAIDS (ibuprofen)(1st line)

opioids (sparingly)

ibuprofen ROUTE

PO

IV

ibuprofen USES

inflammatory disease

pericarditis

PAIN

dysmenorrhea

ibuprofen ADVERSE EFFECTS

hepatotoxic

thrombocytopenua

CV events

GI events

contraindicated in CABG

ibuprofen TEACHING POINTS

take with food

monitor for upset stomach

black tarry stools

do NOT combine with ETOH

geriatric patients at INC risk

Nonpharm treatment for strains/sprains (grades 1-2)

knee strengthening exercises

trekking poles

PT

thorough stretching before & after exercise

knee braces

KT tape

what grades of strains/sprains require surgery?

Grade 3 & Grade 4

focus of non-pharm treatment for osteoporosis

lifestyle modifications/interventions to improve bone health

non-pharm treatments for osteoporosis

Ca + VitD intake

regular weight bearing exercise

fall prevention strategy

avoid smoking/alcohol

maintain healthy body weight

limit caffiene intake

regular monitoring & screening

educational programs

physical therapy

pharmacologic interventions for osteoporosis

alendronate

raloxifene

conjugated estrogen

medroxyprogesterone

teriparatide

ibuprofen/celecoxib

acetaminophen

alendronate ROUTE

PO

IV

alendronate USES

decrease osteoclast activity & inhibit bone resorption

alendronate ADVERSE EFFECTS

nephrotoxic

osteonecrosis of jaw (Dead Jaw)

hypocalcemia

hyperparathyroidism (high dose)

dysphagia

N/D/C

MSK pain

blurred vision

alendronate TEACHING POINTS

food impairs absorption (take before breakfast)

INC risk for GERD (sit up for 30 minutes after eating)

monitor Ca++ levels

consider Ca++ supplements

raloxifiene ROUTE

PO

raloxifiene USES

estrogen agonist on bone (slow bone resorption/loss)

estogen antagonist on breast/uterine tissue

raloxifiene ADVERSE EFFECTS

INC risk for DVT & pulm emboli

inc risk of fatal stroke

hot flashes

leg cramps

peripheral edema

raloxifiene TEACHING POINTS

monitor bone density (once/year) & Ca++ levels

take supplemental Ca/VitD

importance of weight bearing exercises

conjugated estrogen ROUTE

PO

conjugated estrogen USES

blocks bone resorption & reduces menopausal symptoms

post menopausal osteoporosis

conjugated estrogen ADVERSE EFFECTS

DVT/clots

Uterine Cancer

abdominal pain

back pain

conjugated estrogen TEACHING POINTS

HIGH risk for uterine cancer

NOT for BRCA using estrogen-deprivation therapy

medroxyprogesterone ROUTE

PO

taken like birth control

medroxyprogesterone USES

post menopausal osteoporsis

for women who have NOT had a complete hysterectomy

medroxyprogesterone ADVERSE EFFECTS

DVT/clots

Uterine cancer

adominal pain

medroxyprogesterone TEACHING POINTS

high risk for uterine cancer

NOT for BRCA using estrogen-deprivation therapy

may cause birth defects

should NOT be used to prevent heart disease

teriparatide ROUTE

SQ

abdominal or thigh region

teriparatide USES

osteoporosis

same actions as PTH on bone and kidney

increases bone turnover

teriparatide ADVERSE EFFECTS

orthostatic hypotension

uriolithiasis

hypercalcemia

dig toxicity

NOT for pagets

teriparatide TEACHING POINTS

evaluate osteosarcoma risk

monior Ca++ levels

take when sitting or laying down

2 year MAX use

celecoxib ROUTE

PO

celecoxib USES

OA/RA

PAIN

celecoxib ADVERSE EFFECTS

renal

hepatitis

GI upset

GI bleed/ulcer exacerbation

edema

not for CABG

celecoxib TEACHING POINTS

use with PPI/H2 blocker to reduce ulcer risk

reduce dosage in liver impaired patients

lots of drug-drug interactions

acteaminophen ROUTE

PO

IV

acetaminophen USES

antipyretic, analgesic

1st line therapy for arthritis

osteoarthritis physiology

cartilage/cushion between the joints breaks down

leads to pain, stiffness, swelling

rheumatoid arthritis

chronic inflammatory symmetric polyarthritis

autoimmune disease

affects small joints of hands/feet, knees, shoulder

osteoarthritis symptoms

pain (worse w/ jt use)

stiffness

tenderness

grating sensation

swelling

bone spurs

progression NOT universal

rheumatoid arhtritis symptoms

stiffness (esp in arm)

swollen, painful joints

limited ROM

fever

fatigue

anorexia

joints feel warm to touch

joints look red/discolored

dry eyes/mouth

osteoarthritis risk factors

elderly age women

bone deformity

joint injury

obesity

blood iron INC

family hx of OA

diabetes

stress on joints

women>men

OA management

exercises

weight loss

walking aids & knee braces

topical capascin

prednisone

surgical management

alternative thearpies

prednisone ROUTE

PO

prednisone USES

anti-inflammatory

glucocorticoid steroid

prednisone ADVERSE EFFECTS

immune suppression

hyperglycemia

adrenocortical insufficent

prednisone TEACHING POINTS

ALWAYS taper

DO NOT stop abrupt

monitor BG

not for fungal infections

goals of OA management

minimize pain

optimize function

beneficially modify the process of joint damage

rheumatoid arthritis management

ibuprofen (NSAIDs)

Methotrexate (DMARDs)

prednisone (glucocorticod steroid)

ibuprofen ROUTE

PO

IV

ibuprofen USES

is an NSAID

reduce inflammation in RA

ibuprofen ADVERSE EFFECTS

hepatotoxic

thrombocytopenia

CV events

GI events

Not for CABG

ibuprofen TEACHING POINTS

take with food

monitor for upset stomach

do NOT combine with ETOH

geriatric at inc. risk for complications

methotrexate ROUTE

PO, IV, IM, SQ

methotrexate USES

RA

disease modifying anti-rhematic drugs

1st line treatment

methotrexate ADVERSE EFFECTS

liver/renal/pulm/GI toxicity

cancers

opportunistic infections

methotrexate TEACHING POINTS

closely monitor for bone marrow/hepatic/renal/pulm toxicities

can cause fetal death

lots of drug-drug interactions

purpose of total hip/knee replacement

replaced injured or degenerating joiint with an artifical joint

outcomes of total hip/knee replacement

improved mobility

reduced pain

new joints last >10 years

risks of total hip/knee replacement

artifical knee wearing out over time

bleeding

thrombosis (DVT/PE)

nerve damage in the knee

infection

nursing consideration post-op total hip/knee replacement

avoid hip flexion

HOB

osteomyelitis

infection of the bone

common agents are staphylcocccus & streptococcus

acute osteomyletits symptoms

fever

pain in the area of infection

irritability/lethargy in small children

swelling & warmth/rednes over the area of infection

assessment priorities for osteomyletitis

signs of infection

probe to bone test

elevated CRP/ESR/WBC

lack specificity

BONE BIOPSY (gold standard)

major complications of osteomyelitis

bone fractures

chronic/systemic infection

bone necrosis

osteomyelitis treatment

remove damanged bone if possible

IV antibiotic for 4-6 weeks

antibiotic seeds implanted at site of infection

assessment priorities for compartment syndrome

pain

pressure

pallor

parathesia

pulselessness

paralysis

major complications of compartment syndrome

untreated can lead to tissue death

reduced blood flow can result in a cool extremity and diminishsed capillary refill

traction nursing managment

weights engaged and off the floor AT ALL TIMES

only remove if patient is having a medical emergeny

osteosarcoma physiology

malignant bone tumor

VERY rare

seperate from bone metastasis

osteosarcoma symptoms

Pain

swelling/palpable mass

fatigue

weight loss

loss of function

pathologic fractures

osteosarcoma risk factors

teenagers & older adults

males > females

inherited conditions

bone disorders

radiation exposure

chemical exposure

osteosarcoma treatment options

surgery (limb salvage or amputation)

chemotherapy

radiation

what is the preferred treatment options for osteosarcoma?

surgery

chemotherapy and radiation are not very effective