musculoskeletal/ortho

radiography/x-ray

determine density of bone, structural/functional changes

arthrocentesis

joint punctured w/ needle and drawing out fluid for dx

arthroscopy

scope to visualize joint

myelogram

radiopaque dye into subarachnoid space at lumbar spine to determine herniated disc

nuclear scan

bone scan, radioisotope taken up in bone

magnetic resonance imaging MRI

view soft tissue

computed axial tomography CAT scan

3-D pic, to ID soft tissue and bony abnormalities, trauma

calcium normal range

9-10.5

hypercalcemia is seen in

bone cancer, osteoporosis, Paget’s disease

• too much in blood

ESR normal

15 - 20 mm/hr

increased ESR is seen with

inflammatory disease, disease worsening

lupus erythematosus preparation is used for

lupus, rheumatoid arthritis, scleroderma, drug sensitivities

rheumatoid factor normal

<60 u/ml

uric acid normal

2.0-8.5

increased uric acid is seen with

gout, kidney failure, alcoholism, leukemia, metastatic cancer, multiple myeloma, dehydration

anti-nuclear antibody ANA is seen in

SLE, some RA, sclerosis

sprain

injury to tendon/ligaments around joint

• 1st, 2nd, & 3rd degree

1st degree sprain

mild tenderness and swelling

2nd degree sprain

partial disruption of tissue w/ swelling and tenderness

3rd degree sprain

complete tearing of ligament w/ moderate-severe swelling, may feel gap in muscle

strain

excessive muscle & fascial sheath stretching

• 1st, 2nd, & 3rd degree

a strain often involves

tendons

nursing care for sprains and strains

RICE

dislocation

severe injury of ligaments that surround joint

• results in complete displacement or separation of the articular surface of joint

subluxation

partial or incomplete dislocation of joint surface

s/s of dislocation

deformity, local pain, tenderness, loss of function

dislocation is considered

an orthopedic emergency, longer time → more possible avascular necrosis

carpal tunnel s/s

weak thumb, burning pain, paresthesia, relief w/ shaking/exercising of hands, intenser at night, hyposthesia, altered grasp

tx of carpal tunnel

immobilizer/splint, corticosteroid injections, surgery, ergonomics

bursitis

from trauma/friction, gout, RA, infection

can lead to bursitis

improper body mechanics, repetitive kneeling, jogging in worn out shoes, prolonged sitting w/ crossed legs

s/s of bursitis

warmth, pain, swelling, limited ROJM

tx for bursitis

rest, ice, immobilize, nsaids, aspirate fluid, corticosteroid injection

amputation post-op

prevent hip flexion contractions, no pillows under extremity, limit chair sitting, prone position 3x/day

what should be taught to pt post-op AKA?

discourage semi-fowler’s

• prevents hip contractures

ankylosing spondylitis

chronic inflammatory disease affects axial skeleton

• bones of spine grow together

s/s of ankylosing spondylitis

inflammatory spine pain, stiff, ROM worse at night, pain/discomfort worse when erect

ankylosing spondylitis dx is made with

pelvic x-ray, low hgb & hct, + ESR

hemoglobin normal range

F: 12-15 g/dl

M: 13.5-18 g/dl

hematocrit normal range

F: 36-46%

M: 40-50%

managing AKS

analgesics, nsaids, exercise, postural control, surgery

• firm mattress, brace, enc prone 15-30 min QID, quit smoking

osteoporosis

loss of bone mass

• + risk w/ menopause, low estrogen, steroid use, immobility, caffeine use, slender, white, smokers, drinkers

osteoporosis dx is made with

DEXA sxan

medication for osteoporosis

bisphosphonates

osteomyelitis s/s

fever, night sweats, chills, restless, nausea, maleise, constant bone pain, swelling, tender, warmth at site, restricted movement of part, drainage to skin/site

dx of osteomyelitis

bone or soft tissue biopsy, radiography

lab tests:

• CBC, ESR, wound/drainage culture

tx of osteomyelitis

abx IV, nsaids, opioids, gentle movement, rest w/ bone alignment, wound irrigation, nutritious diet

fracture

break in continuity of bone tissue

a fracture can occur

w/o trauma, d/t cancer, osteoporosis, tumors, cushing’s, malnutrition, long term steroid use

a closed reduction is

nonsurgical, manual realignment

open reduction

surgical realignment

• internal fixation

open reduction internal fixation ORIF

surgical procedure to fix severe bone fractures

• surgically exposing bone

bone fracture healing

bleeding, hematoma, osteoblasts lengthen collagen strands, calcium deposited, callus forms, osteoclasts destroy dead bone, remodeling

nursing responsibilities for fractures

how pt moves in bed, safe transfers, weight bearing restriction, activity limits, assistive devices, elevation (edema), pain control, exercises, prevent clot, cleanse traction pins

data collection for casts

cap refill within 2 secs ideal, check skin integrity at edge, any odor or drainage, use of crutches, cast syndrome

cast syndrome

part of duodenum is compressed leading to partial or complete obstruction of abdominal aorta

• more likely in full casts → hip spica, body casts

compartment syndrome

from too-tight cast

• increased pressure → reduced circulation

assessment after fracture/casts

paresthesia, pain, pressure, pallor, paralysis, pulselessness

• and urine for myoglobin (indicates muscle damage)

compartment syndrome interventions

do not elevate above heart, no cold compresses, fasciotomy, analgesics, infection check

permanent complication from compartment syndrome

Volkman’s contracture

• permanent shortening of muscles

• results in claw-like appearance

intracapsular fracture

hip fracture, femur broken inside joint

• blood supply to femur head may be low, chance of avascular necrosis

• tx with femoral prosthetic

extracapsular fracture

outside joint capsule

• tx with screws, nails, plates

hip fracture post-op

C & DB, stockings, CMD, turn q2h, main leg abduction, check circulation & drainage, pain control, mobilize asap

watch for these issues post-op hip fracture

inability to move leg, shortening & external rotation of leg

for a prosthetic implant hip or bipolar hip

abduction pillow 7-10 days, log roll w/ 2 nurses & 2 pillows, transfer pivot on good leg, max flexion 90 degrees, no leg elevation w/ sitting, use walkers, exercise good leg

for hip arthroplasty or ORIF

same postop plus: assess pain, numbness, tingling, paresthesia, circulation, wound care, drainage equip

knee arthroplasty

all postop plus: leg elevation 48 hrs post w/o flexing knee, CPM up to 22 hrs/day, when CPM is off knee extended (no pillow)

pelvix fx can occur from

falls or crushing accidents, may indicate damage to internal organs, could mean hemorrhage (rich blood supply to area)

what should be done when pt has pelvic fx

bowel sounds to check injury to GI, urine output to check injury to GU, check for fat embolism, watch for shock (restless, disoriented, anxiety, VS), hematuria

pelvic fracture tx

bedrest 3 weeks, crutches 6 weeks after

• surgery, traction, and NWB 3 months

• cast to support immobility

fat embolism

tissue fat w/ platelets and circulating free fatty acids within pulmonary capillaries

• seen more w/ multiple fractures, or fx of long bones, pelvis

• within 72 hrs of injury

s/s of fat embolism

mental changes, + temp & HR, headache, chest pain, tachypnea, dyspnea, muscles rigid & weak/apastic, abnormal LS, AP change

• petechiae in buccal, conjunctiva, hard palate, axilla, chest → occlusion of capillaries

fat embolism interventions

Iv to dilute (& decreases risk of shock), steroid, digoxin, o2, blood gas monitoring, incentive spirometer, C&DB

osteoarthritis

cartilage & bone wear (aging), non-systemic & inflammatory in joint capsule (may be only one area/side)

s/s of osteoarthritis

joint pain & stiff, unstable & deformed joints, tender, altered gait, + weight, Heberden (distal) & Bouchard (proximal) nodules

Herberden nodules

distal to site of osteoarthritis

Bouchard nodules

proximal to site of osteoarthritis

rheumatoid arthritis

rest, exercise, heat/cold application, wgt loss

• nsaids, corticosteroids, methotrexate, hydroxychloroquine, rituxmab, dmards (Humira, Xeljans)

gout is caused by

increased uric acid production, under-secretion of uric acid by kidneys, or increased intake of foods containing purines

primary gout is

almost exclusively in middle-aged men

hyperuricemia may develkop in pts:

taking thiazide diuretics, in postmenopausal women, & in organ transplant recipients receiving immunosuppressive agents

gouts takes….

20 years to accumulate

tophi

deposits of urate on joints, esp on big toe

diet high in purines will…

not cause gout, but triggers an attack if pt is susceptible

purine-rich foods

shellfish, lentils, asparagus, spinach, beef, chicken, pork

gout s/s

pain @ night, edema, inflammation

• in big toe

gout meds

C: colchicine (pain)

A: Allopurinol (zyloprim) lower uric acid

P: Probenecid (benemid) excrete uric acid

A: Anturane: decrease tophi develop.

F: Febuxostat (Uloric) LT for hyperuricemia

gout interventions

increase fluids to 2000ml or more, check for kidney stones, bedrest when symptomatic, wgt loss

SLE

autoimmune, chronic

• focus on skin, joints, kidneys, serous membranes

• butterfly rash

lupus/SLE dx

antibodies, LE cell prep may also be present for RA, slceroderma, and drug induced LE

most cases of lupus are in

women of childbearing years

commonly affected tissues lupus

kidneys, nervous tissue, lungs, heart lining, akin & muscle

typical lupus s/s

fever, wgt loss, arthralgia, excess fatigue may precede disease activity

lupus rash

when exposed to sunlight

SLE management

NSAIDS, antimalarial, corticosteroids, avoid sun, balance rest & activity, recognize exacerbations & infections, dec Na and + nutrition

fibromyalgia

muscle, bone, joint pain, soft tissue tender at multiple sites, most common in women 20-50

fibromyalgia is associated with

chronic fatigue, protein deficiency, possible toxic-related, autoimmune-related, irritable bowel

fibromyalgia common s/s

muscle pain/ache, general pain, anxiety, depression, numbness, tingling, insects crawling sensations, forgetful

fibromyalgia meds

tricyclic antidepressants for: antidepressant, anti-inflammatory, central skeletal muscle relaxant, pain inhibition

nursing fibromyalgia

holistic care, education, exercise, relaxation techniques, good sleep hygiene