KEEP ON TRUCKIN...FINAL FOR N004!!!
Ch. 62-Nursing Assessment: Musculoskeletal System
1. Explain the effects of aging on the MS system.
-joint and muscle discomfort
-loss of bone density
-decreased tendon flexibility and muscle strength
-vertebral disc compression causing loss of height
2. Explain the different diagnostic tests of the musculoskeletal system and related nursing care.
*standard x-ray: determines bone density
-avoid unnecessary exposure and ensure patient is not pregnant
*diskogram: contrast dye x-ray to determine intevertebral disk abnormalities
-assess for allergy
*CT scan: identifies soft tissue and bony abnormalities and musculoskeletal trauma
-painless, assess for allergy
*myelogram: sensitive test able to pick up nerve impingement and subtle lesions and injuries
-risk for spinal headache which should resolve in 1-2 days with rest and fluids
*MRI: used to diagnose avascular necrosis, disk disease, tumors, osteomyelitis, ligament tears, and cartilage tears
-check for contraindications such as metal on clothing or metal implants like pacemakers
*DEXA: diagnose metabolic bone disease and monitor treatment progress
-painless
*QUS: measures bone density, elasticity, and strength of patella and calcaneous with ultrasound
-painless
*bone scan: radioisotope injection uptake by bone is monitored
-explain procedure
*arthroscopy: visualization of joint structure and contents using an arthroscope
-performed with strict asepsis, cover wound with sterile dressing
*mineral metabolism/serologic studies: studies of minerals and antibodies in the body
-obtain blood samples and observe for bleeding/hematoma
*arthrocentesis: puncture into joint capsule to obtain synovial fluid
-apply compression dressing and observe for leakage; send samples for examination
*electromyogram (EMG): evaluation of skeletal muscle contraction by insertion of small needles
-avoid stimulants and inform patient of discomfort with needle insertion
*duplex venous doppler: ultrasound to detect blood flow abnormalities
-painless
*thermography: infrared detection of heat radiation on skin surface
-painless
*plethysmography: records variations of volume and pressure of blood through tissues
-painless
*somatosensory evoked potential (SSEP): similar to EMG with electrodes placed to the skin
-no needles involved
Ch. 63-Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery
1. Identify patients at risk for musculoskeletal injury.
-young, elderly, women, occupations with high risks, history of injury
2. Explain the assessment findings and interventions for acute soft tissue injury.
*assessment
-edema
-ecchymosis/contusion
-pain/tenderness
-decreased sensation
-decreased pulse, coolness, and cap refill of >2 seconds
-decreased movement
-pallor
-shortening or rotation of extremity
-inability to bear weight if injury to lower extremity
-limited function if injury to upper extremity
-muscle spasms
*interventions
-ensure ABCs
-assess neurovascular status of affected limb
-RICE
-anticipate x-rays
-pain relief
-give tetanus or diptheria prophylaxis if skin integrity is broken
-give antibiotic prohylaxis for open fractures
-monitor neurovascular status
-monitor for compartment syndrome
-monitor for infection/sepsis
3. Explain the different stages of fracture healing and nursing implications.
-fracture hematoma: semisolid clots of blood surrounding ends of fragments 72 hours after injury
-granulation tissue: hematoma converts to granulation tissue which is the basis of new bone formation 3-14 days after injury
-callus formation: cartilage, osteoblasts, calcium, and phosphorus woven about the fracture parts and can be verified by x-ray 2 weeks after injury
>assist with ADLs if necessary
-ossification: ossification of callus prevents movement of fracture 3 weeks to 6 months after injury
>cast may be removed and limited mobility is allowed
-consolidation: distance between fracture eventually closes
>x-ray determines radiologic union of fracture
-remodeling: excess bone tissue is resorbed and bone gradually returns to preinjury shape and strength
>introduce exercise, then weight bearing activities
4. Describe the different fracture reduction techniques.
-closed reduction: non-surgical, manual realignment of bone fragments, followed by immobilization of alignment until healing occurs
>skin/skeletal traction
-open reduction: invasive correction of bone alignment using pins and wires
-traction: pulling and counteraction forces (weights) applied to affected part to prevent or reduce muscle spasm, immobilize affected part, reduce fracture or dislocation, and treat pathological joint condition
5. Use the NP to provide care to a patient with mandibular wiring, post-hip replacement, and post-lower limb amputation.
*mandibular wiring
-maintain patent airway, oral hygiene, communication, and nutrition
-position with wire side up
-keep wire cutters at bedside in case of respiratory or cardiac emergency
-keep tracheostomy tray at bedside
-frequently rinse mouth
-use communication boards
-provide appetizing liquid choices for diet
-check for GI functioning
-address concerns with body image
*post-hip replacement
-general nursing care of post-operative patient
-assess for CSMPT
-use pillows for log rolling
-avoid extreme flexion or rotation at hip until soft tissue has healed
-avoid turning on affected side
-keep abductor pillow between legs
-apply CPM as ordered
-teach patient on correct positioning and risky activities
*post-lower limb amputation
-general post-operative nursing care
-monitor VS and dressing
-sterile technique dressing changes
-avoid prolonged sitting or pillow under extremity to avoid contractures
-correct bandaging to foster correct shape
-ROM exercises
6. List and explain the problems/outcomes of fractures and related nursing care.
-muscle atrophy: decreased muscle mass following a period of disuse or loss of nerve innervation
>implement passive exercises within the confines of mobilization device to prevent muscle atrophy
-contracture: flexion and fixation of joint caused by shortened muscles, loss of skin elasticity, and atrophy
>progressive stretching, passive ROM exercises, repositioning, and correct body alignment
-footdrop: shortened Achilles tendon caused by disuse
>apply foam boots and other preventative measures
-pain: associated with injury
>correct any underlying problems such as repositioning the patient or loosening dressings before medicating
-muscle spasms: involuntary muscle contracture which could lead to pain
>thermotherapy, especially heat
7. List and explain the complications resulting from fractures.
-infection: open fractures are vulnerable to contamination with bacteria
-compartment syndrome: compromised tissue integrity and confined myofascial space cause increased compartment pressure
>causes pressure pain, may cause loss of function if not addressed
-venous thrombosis: lower extremity thrombus formation is common with injury and can travel up after periods of immobility
-fat embolism syndrome: free fat droplets are released from injured bone or at the time of trauma and can cause an embolism
8. Use the NP to provide care to a patient with these complications.
*infection
-assess for signs and symptoms of infection
-implement aggressive surgical debridement
-administer antibiotics
-maintain clean technique when dealing with wound
*compartment syndrome
-recognize signs and symptoms of compartment syndrome
-extremity should not be elevated above heart level
-ice should not be used
-loosen or remove bandages, bivalve casts, or reduce traction weight
-surgical fasciotomy my be necessary
*venous thrombosis
-TED hose/SCDs
-ROM exercises
-administer anticoagulant drugs as ordered
*fat embolism syndrome
-CDB
-immobilize long bone fractures
-manage symptoms with fluid replacement and maintain airway/breathing
Ch. 64-Nursing Management: Musculoskeletal Problems
1. Explain the pathophysiology of osteomyelitis and osteoporosis.
-osteomyelitis: severe infection of bone, bone marrow, and surrounding soft tissue causing increased pressure and vascular compromise of periosteum
-osteoporosis: bone resorption is greater than bone deposition causing weakened bone prone to fractures, both spontaneous and secondary to minor trauma
2. Use the NP to provide care for a patient with osteoporosis and osteomyelitis.
**osteoporosis
*assessment
-subjective: age, family history, genetics, early menopause, sedentary lifestyle, anorexia, oophorectomy, history of smoking, alcohol use
-objective: weight/height, low calcium intake, low testosterone levels
-dx: serum calcium, bone mineral densitometry, x-ray
*diagnoses
-risk for injury
*planning
-nutritional therapy
-calcium supplementation
-exercise
-prevention of fractures
-drug therapy: estrogen replacement and increase bone resorption
*implementation
-diet high in calcium or supplement calcium/vitamin D
-weight bearing exercises
-quit smoking and decrease alcohol consumption
-estrogen therapy
**osteomyelitis
*assessment
-subjective: bone trauma, infection, bone surgery, IV drug abuse, chills, weight loss, weakness, muscle spasms, local tenderness, irritability, withdrawal, anger
-objective: restlessness, night sweats, edema, diaphoresis, restricted movement, wound drainage
-dx: bone or soft tissue biopsy, CBC, ESR, bone scan, CT, MRI
*diagnoses
-acute pain
-ineffective therapeutic regimen management
-impaired physical mobility
*planning
-pain and fever control
-no secondary complications
-follow treatment plan
-maintain positive outlook
*implementation
-immobilization to decrease pain
-drug therapy
-relaxation techniques
-drainage dressing changes in sterile technique
-repositioning for patients on bedrest
-monitor for adverse side effects of drug therapy
3. Use the NP to provide care after spinal surgery.
-maintain proper body alignment: log roll, use pillows or wedges, one or more staff members to move
-pain control
-fluid replacement
-assess for CSF drainage
-monitor neurological signs
-monitor GI/GU system for functionality
-patient teaching: avoid long periods of standing or sitting, mentally think through an activity to avoid injury and pain
Ch. 65-Nursing Management: Arthritis and Connective Tissue Diseases
1. Explain the pathophysiology of osteoarthritis, rheumatoid arthritis, gout and SLE.
*osteoarthritis: damage to cartilage triggers metabolic response
-body attempts to repair weakened cartilage leading to fissuring and erosion at joint surfaces
-pain caused by bone contact after cartilage is destroyed
*rheumatoid arthritis: pannus, or high vascular granulation tissue, forms within joint covering and eroding cartilage
-inflammatory cytokine production also contributes to destruction of cartilage -causes tendon and ligament scarring and shortening
*gout: marked by hyperuricemia; deposits of sodium urate crystals cause sudden swelling and pain in articular, periarticular, and subcutaneous tissues
*SLE: production of antibodies against nucleic acids, particularly directed against the make-up of the cell nucleus
-can deposit basement membrane of capillaries in a variety of locations in the body triggering an aggressive inflammatory response by the complement system
2. Use the NP to provide care to client with osteoarthritis, rheumatoid arthritis, gout and SLE.
**osteoarthritis
*assessment
-subjective: type, location, severity, frequency, and duration of joint pain; effects on ADLs, pain relief measures
-objective: tenderness, swelling, ROM, crepitation, and comparison of affected joints -dx: CT, MRI, x-ray, and synovial fluid analysis
*diagnoses
-acute and chronic pain
-insomnia
-impaired physical mobility
-self-care deficit
-imbalance nutrition: more than body requirements
-chronic low self-esteem
*planning
-maintain/improve joint function with periods of rest and activity
-provide joint protection measures to improve activity tolerance
-optimize ADLs
-manage pain using drug therapy and non-pharmacologic strategies
*implementation
-drug therapy
-heat/ice packs
-relaxation techniques
-highly individualized depending on patient’s progression of disease
**rheumatoid arthritis
*assessment
-subjective: infection, joint surgery, medications, family history, anorexia, weight loss, swelling or weakness of joints, numbness and tingling to hands and feet, pain and aching of joints with activity
-objective: fever, peripheral edema, skin ulcers, shiny/taut skin over joints, symmetric pallor and cyanosis of fingers (Raynaud’s phenomenon), chronic bronchitis, Felty syndrome, joint deformity
-dx: positive rheumatoid factor, synovial fluid analysis
*diagnoses
-chronic pain
-impaired physical mobility
-disturbed body image
-ineffective therapeutic regimen management
-self-care deficit (total)
*planning
-pain relief
-minimize loss of affected joint functioning
-plan and carry out therapeutic regimen
-maintain positive self-image
-maximize self-care
*implementation
-drug therapy
-heat/ice packs
-relaxation techniques
-highly individualized depending on patient’s progression of disease
**gout
*assessment
-subjective: trauma, surgery, sepsis
-objective: dusky, cyanotic joints, extremely tender joints, inflammation of big toe, low grade fever, tophaceous deposits
-dx: elevated uric acid levels
*diagnoses
-acute pain
-activity intolerance
-self care deficit
-disturbed body image
*planning
-avoid unnecessary pain
-joint immobilization
-heat/cold application
*implementation
-drug therapy
-patient education: avoid overindulgence and excessive caloric intake of foods containing purines and other precipitating factors
**SLE
*assessment
-subjective: depression, withdrawal, irregular menstrual periods, visual disturbances, headache, diarrhea, dyspnea, fatigue, weight loss, dysphasia, frequent infections, photosensitivity with rash
-objective: proteinuria, arthritis, facial weakness, hallucinations, disorientation, dysrhythmias, symmetric pallor and cyanosis of fingers, murmurs, decreased breath sounds, alopecia, butterfly rash, leg ulcers, fever, edema
-dx: presence of assorted antibodies in the body (anti-Smith and anti-DNA)
*diagnoses
-fatigue
-acute pain
-impaired skin integrity
-deficient knowledge
*planning
-pain relief
-comply with therapeutic regimen
-awareness of activities which could cause exacerbation
-optimal functioning and self-image
*implementation
-individualized periods of activity and rest
-drug therapy and relaxation techniques
-monitor skin for breakdown
-educate on signs and symptoms of exacerbations
3. Explain the mode of action and resulting nursing care of the different drug categories used in the management of these conditions.
*osteoarthritis:
-acetaminophen: for mild to moderate joint pain
>should not exceed 4 grams daily
-topical creams: works to stop transmission of pain impulses
-NSAIDS: for moderate to severe pain, working by blocking prostaglandins
>risk for bleeding with warfarin and GI side effects
-antibiotics: decreases loss of cartilage with OA of the knee
>monitor treatment effectiveness
-hyaluronic acid (HA): supplements substances found in normal joint fluid and articular cartilage
*rheumatoid arthritis:
-disease-modifying antirheumatic drugs (DMARDS): lessen permanent effects of RA >potential for bone marrow intoxication and hepatotoxicity
-NSAIDS: anti-inflammatory effects
>may be used when patient is intolerant of high aspirin doses
-biologic/targeted drug therapies: slows disease progression
>follow schedule of injections; anakinra and abatacept should not be used in combination with TNF inhibitors
-corticosteroids: temporarily relieves pain and inflammation symptoms experienced during flare-ups
>can be used until DMARDS effects can be seen, but should not be a long-term therapy
*gout:
-colchicine: anti-inflammatory with no analgesic effect
>monitor effectiveness as it may add to evidence to diagnose gout
-NSAIDS: pain management
>used in combination with colchicine
-allopurinols: blocks production of uric acid
>patients who cannot tolerate side effects can be switched to oxypurinol
-selective xanthine oxidase inhibitor: reduces serum uric acid
*SLE
-NSAIDS: pain management
>monitor GI effects
-antimalarial agents: used in combination with NSAIDS to treat fatigue, and moderate skin/joint problems
>monitor for retinopathy; may be switched to anti-leprosy drugs if not tolerated -corticosteroids: used sparingly to control polyarthritis exacerbations
>monitor for toxicity and side effects
