Med-Surg: Musculoskeletal disorders

s/s of hip dislocation

**Stresses to new hip joint should be avoided for first 8 to 12 weeks, when risk of dislocation greatest 1. Increased pain at surgical site, swelling, and immobilization 2. Acute groin pain in affected hip or increased discomfort 3. Shortening of affected extremity 4. Abnormal external or internal rotation of affected extremity 5. Restricted ability or inability to move leg 6. Reported "popping" sensation in hip **hip must be reduced and stabilized promptly so that leg does not sustain circulatory and nerve damage

Paget disease pharm management

**antiosteoclastic therapy** --reduce bone turnover, reverse course of disease, relieve pain, and improve mobility --1. bisphosphonates ---may not suppress all Paget symptoms, but reduce serum ALP and urinary hydroxyproline levels 2. Plicamycin --> cytotoxic antibiotic --reserved for severely affected patients with neurologic compromise and for those whose disease resistant to other therapy --dramatic effects on pain reduction and on serum calcium, ALP, and urinary hydroxyproline levels --given IV --> hepatic, kidney, and bone marrow function must be monitored

Paget Disease Clinical Manifestations pt 1

**insidious 1. Some patients do not experience symptoms but only have skeletal deformity --> usually skull 2. Sclerotic changes and cortical thickening of long bones occur 3. thickened skull and enlarged cranium but not face 4. impaired hearing from cranial nerve compression 5. legs bow --> waddling gait

OA clinical manifestations

**insidious onset over many years 1. pain, stiffness, and functional impairment 2. aggravated by movement or exercise and relieved by rest 3. morning stiffness lasting less than 30 mins 4. affected joint may be enlarged with a decreased ROM 5. mostly in weight-bearing joints --exceptions = DIP (Heberden's nodes) and PIP (Bouchard's nodes) 6. crepitus over knee 7. mild joint effusion 8. disabilities associated with SPECIFIC joint, gait, gross/fine motor skills

low back pain pathophysiology

-Disuse weakens supportive spine structures -Obesity, postural problems, structural problems, and overstretching of spinal supports may result in back pain -disc degenerates as gets older --L4-5 and L5-S1 = subject to greatest mechanical stress and greatest degenerative changes -Disc protrusion or facet joint changes can cause pressure on nerve roots as they leave spinal canal, which results in pain that radiates along nerve

septic arthritis

-Joints become infected through spread of pathogens from other parts of body or directly through trauma, injection, or surgical instrumentation -S. aureus = most common cause followed by strep --pseudomonas in illicit drug users -Single knee or hip joints most commonly infected in patients with septic arthritis -Prompt recognition and treatment important because accumulating purulent material may result in chondrolysis (destruction of hyaline cartilage), and continued hematogenous spread may lead to sepsis and death -50% of cases involve the knee

Osteomyelitis Pathophysiology

-More than 50% of bone infections caused by S. aureus and MRSA --also strep, entero, and pseudomonas -initial response to infection = inflammation, increased vascularity, and edema -After 2 or 3 days, thrombosis of local blood vessels occurs, resulting in ischemia with bone necrosis -extends into medullary cavity and under periosteum and may spread into adjacent soft tissues and joints --bone abscess forms unless treated promptly --> sequestreum forms which does not liquify or drain easily --new bone growth (involucrum) around it --> looks healed but recurrent sequestreum infection occurs for rest of life

low back pain

-Most common MS complaint -Typically caused by DDD/Traumatic injuries -Pain aggravated by activity -Can affect nerves because of lumbar disc protrusion - radiculopathy or sciatica -Compression of nerves occurs because of deterioration/destruction of fibrous cartilage allowing nerve root to be exposed and cause nerve pain -Risk increases with age, overuse of straining, lifting, inappropriate use of body mechanics, or by other weakened support areas (legs)

THA pain relief

-Muscle spasms occur after total hip replacements -Immobility causes discomfort at pressure points 1. parenteral opioids during first 24-48 hours and then will progress to oral analgesic agents 2. use of pillows to provide adequate support and relief of pressure on bony prominences

fracture management

-Osteoporotic compression fractures of vertebrae treated conservatively unless acute pain --Percutaneous vertebroplasty or kyphoplasty --> injection of bone cement into fractured vertebra, followed by inflation of a pressurized balloon to restore shape of affected vertebra ---allows pain relief but might cause other complications from change in spinal mechanics ---contraindicated in presence of infection, multiple old fractures, and certain coagulopathies

dual mechanism agents

-Tramadol (Ultram), Tapentadol (Nucynta) -complications --> Avoid using tramadol with someone on SSRI's --> can cause serotonin syndrome (agitation, diarrhea, blood pressure changes, and loss of coordination)

OA pathophysiology

-articular cartilage breaks down --> leading to progressive damage to underlying bone and eventual formation of osteophytes (bone spurs) that protrude into joint space -joint space narrowed, leading to decreased joint movement and potential for more damage --> joint can degenerate -infectious arthritis can also occur

low back pain gerontological considerations

-associated with: --osteoporotic vertebral fractures --osteoarthritis of spine --spinal stenosis -inactivity can have grave consequences on quality of life, progression of medical disease, energy level, and morbidity in older adults

Osteoporosis Pathophysiology

-characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength -rate of bone resorption greater than rate of bone formation --> PTH inc while calcitonin/estrogen dec -bones become progressively porous, brittle, and fragile --> fracture easily under minimal stress --most common fractures = compression fractures of thoracic and lumbar spine, hip fractures, and Colles fractures of wrist --> FIRST CLINICAL SIGN

TKA

-considered for patients whose joint pain cannot be managed by nonsurgical treatment and who have severe pain and functional disability related to destruction of joint surfaces by OA, RA, or posttraumatic (osteonecrotic) arthritis -fully constrained (hinged) or semi-constrained prosthesis may be used to provide joint stability if ligaments weakened -noncontrained prosthesis dependent upon patient having healthy and functional ligaments

Osteomalacia causes pt 1

-deficiency of activated vitamin D which promotes calcium absorption from GI tract and facilitates mineralization of bone -supply of calcium and phosphate in ECF low and does not move to calcification sites in bones 1. may result from failed calcium absorption or from excessive loss of calcium from body 2. GI disorders with malabsorption of fats likely to cause through loss of vitamin D, fat soluble vitmains, and Ca 3. liver and kidney diseases can produce a lack of vitamin D because convert vitamin D to its active form

Paget's disease

-disorder of localized rapid bone turnover -most commonly affecting skull, femur, tibia, pelvic bones, and vertebrae -incidence slightly greater in aging men -genetic, over 50

Osteomyelitis

-infection of bone that results in inflammation, necrosis, and formation of new bone -classifications: --1. Hematogenous osteomyelitis (due to bloodborne spread of infection) --2. Contiguous-focus osteomyelitis (from contamination from bone surgery, open fracture, or traumatic injury) --3. Osteomyelitis with vascular insufficiency (seen most commonly among patients with diabetes and PVD, most commonly affecting feet)

Preventing Dislocation of Hip Prosthesis pt 1

-maintenance of femoral head component in acetabular cup = essential -correct positioning maintained at all times (no full flexion, adducted (legs together), and internally rotated) --1. should be in a supine position with head slightly elevated and affected leg in a neutral position --2. use of pillow between legs to prevent adduction --3. keep hip in abduction when turn to unaffected side

osteoporosis diagnosis

-may be undetectable on routine x-rays until has been significant demineralization 1. diagnosed by dual-energy x-ray absorptiometry (DEXA) --> BMD of spine/hip --recommended for all women older than 65 years, for women who postmenopausal older than 50 years with osteoporosis risk factors, and for all people who have had a fracture thought to occur as a consequence of osteoporosis --also useful in assessing response to therapy and recommended 3 months post any osteoporotic fracture 2. use FRAX for women and MORES for men to determine risk of fractures --Treatment for both genders now reserved for those with a 10-year risk of more than 3% for hip fracture or 20% risk for other major fractures 3. Serum Ca, phosphate, ALP 4. ESR --> detects body inflamm by measuring how quickly red blood cells settle in a test tube

osteomalacia

-metabolic bone disease characterized by inadequate mineralization of bone --> skeleton softens and weakens --causing pain, tenderness to touch, bowing of bones, and pathologic fractures --spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling gait

benign bone tumors

-more common than malignant primary bone tumors -bone formation causing aching pain and possible pathologic fracture -slow growing, well circumscribed, and encapsulated; present few symptoms; and not a cause of death --some have potential to become malignant

osteoporosis

-most prevalent bone disease in world -consequence = bone fracture -1:3 women and 1:5 men over 50 will have an osteoporosis-related fracture at some point in their lives

osteoarthritis

-noninflammatory degenerative disorder of joints -most common form of joint disease -primary (idiopathic) or secondary (resulting from previous joint injury or inflammatory disease) -does not involve autoimmunity or inflammation and limited to affected joint (NOT systemic)

Paget disease pathophysiology

-primary proliferation of osteoclasts occurs --> resorption -followed by a compensatory increase in osteoblastic activity that replaces bone --as bone turnover continues, a classic mosaic (disorganized) pattern of bone develops -diseased bone highly vascularized and structurally weak --> pathologic fractures occur -Structural bowing of legs causes malalignment of hip, knee, and ankle joints --> contributes to development of arthritis and back and joint pain

osteomyelitis surgical management

-purulent and necrotic material removed, and area irrigated with sterile saline solution -sequestrectomy --> All dead, infected bone and cartilage must be removed before permanent healing can occur -closed suction irrigation system may be used to remove debris --Wound irrigation using sterile physiologic saline solution may be performed for extended periods if debris remains --Typically, irrigation does not need to extend beyond a week -wound either closed tightly to obliterate dead space or packed and closed later by granulation or possibly by grafting

malignant bone tumors

-relatively rare and arise from connective and supportive tissue cells (sarcomas) or bone marrow elements (multiple myeloma) -metastasis to lungs = common -Osteosarcoma = most common and most often fatal primary malignant bone tumor (femur/tibia, humerus) --most frequently in children, adolescents and young adults (in bones that grow rapidly), in older adults with Paget disease, and in people with a prior hx of radiation exposure --localized bone pain that may be accompanied by a tender, palpable soft tissue mass -chondrosarcomas = hyaline cartilage tumors affecting middle aged and older adults --pelvis, femur, humerus, spine, scapula, and tibia

THA

-replacement of a severely damaged hip with an artificial join -metal femoral component topped by a spherical ball made of metal, ceramic, or plastic fitted into a plastic or metal acetabular socket -selects prosthesis best suited to individual patient, considering various factors including skeletal structure and activity level

TJA

-replacement of all components of an articulating joint -consist of metal and high-density polyethylene components -cement, cement-less, or hybrid --depends on gender, age, diagnosis, weight and activity level, presence of healthy bone with adequate blood supply, cost -post-op relief depends on preop soft tissue condition and general muscle strength -Rehab with PT within first 24 hours associated with dec hospital length of stay and improved balance and gait function

Cauda Equina Syndrome

-results from compression of cauda equina (bundle of spinal nerves that arise from lower portion of spinal cord) -s/s: --severe or progressive neurologic deficit --recent bowel or bladder dysfunction --saddle anesthesia -medical emergency requiring immediate referral so that patient may receive expeditious treatment to relieve underlying cause before nerve damage occurs

spinal column

-rod constructed of rigid units (vertebrae) and flexible units (intervertebral discs) held together by complex facet joints, multiple ligaments, and paravertebral muscle -allows for flexibility while providing maximum protection for spinal cord -spinal curves absorb vertical shocks from running and jumping -abdominal and thoracic muscles important in lifting activities, working together to minimize stress on spinal units

metastatic bone disease

-secondary bone tumor --> more common than primary bone tumors -Tumors arising from tissues elsewhere in body may invade bone and produce localized bone destruction (lytic lesions) or bone overgrowth (blastic lesions) -most common primary sites of tumors that metastasize to bone are: --kidney --prostate --lung --breast --ovary --thyroid -Metastatic tumors most frequently found in skull, spine, pelvis, femur, and humerus and often involve more than one bone (polyostotic)

arthroplasty

-surgical removal of an unhealthy joint and replacement of joint surfaces with metal or synthetic materials --for severe OA, RA, trauma, and deformity --can also be used in fractures that are cutting off blood supply and causing avascular necrosis

osteomyelitis postop

-typically occur within 30 days after surgery --incisional vs deep (deep can happen within 1 year if implanted metal)

nonopioids

1. Acetaminophen --> oral, rectal, IV infusion (Ofirmev) --dose = 1000mg every 6 hours (max 3000mg/day) 2. NSAIDS --> oral, rectal, transdermal, topical, IM, IVP --dose varies on drug --Ibuprofen, Meloxicam, Celebrex, Naproxen = oral --Diclofenac (Voltaren) = oral, gel topical, transdermal patches --Ketoraolac = Intranasally (Sprix), oral IV, IM (Toradol) --Complications: GI bleed, PUD, Renal concerns

types of pain

1. Acute < 3 months 2. Chronic > 3 months 3. Breakthrough - acute exacerbations of chronic pain 4. Nociceptive - normal response to damage of tissue 5. Neuropathic - abnormal response to sensory input 6. Somatic - MS system 7. Visceral - GI system

reasons for lower blood needs during TJA surgery

1. Appropriate preoperative assessment and treatment of patients with anemia 2. Application of pneumatic tourniquets during orthopedic limb surgery --> minimizes bleeding and helps maintain clean surgical field 3. Employment of intraoperative RBC salvage systems during procedures when a large volume of blood lost (usually autologous) 4. Intraop administration of antifibrinolytic agent tranexamic acid --> significantly reduced overall blood loss and need for blood transfusions

osteoporosis pharm management

1. Ca and Vitamin D supplements TOGETHER 2. bisphosphonates --> "dronate", Zoledronic acid --inhibit osteoclasts --GI SE --given on an empty stomach, only with water, and person must sit upright for at least 30 minutes --need adequate Ca/Vit D to work BUT SHOULD NOT TAKE AT SAME TIME AS BISPHOS 3. estrogen agonist/antagonists --> Raloxifene --Promotes estrogenic effects on bone, preserving BMD, with concomitant antiestrogenic effects on uterus and breasts --SE = hot flashes, leg cramps, VTE 4. RANKL inhibitors --> Denosumab --Monoclonal antibody that increases BMD and reduces porosity by inhibiting osteoclasts --SE = rash, cellulitis 5. synthetic human PTH analogues --> Teriparatide --increases bone strength and density

opioid complications

1. Constipation (OIC) 2. N/V 3. pruritis 4. sedation 5. hypotension 6. respiratory depression 7. addiction/withdrawal

low back pain comorbidities

1. Depression 2. smoking 3. alcohol abuse 4. obesity 5. stress

OA med management

1. Exercise --> CV aerobic and LE strength training (prevents progression and dec symptoms) 2. weight loss --> dec excess load on joint 3. OT/PT 4. orthotic devices and walking aids --> improve pain and function by decreasing force on affected joint 5. alternative therapies

osteomyelitis med management

1. General supportive measures --hydration --diet high in vitamins and protein --correction of anemia 2. area affected with osteomyelitis immobilized to decrease discomfort and to prevent pathologic fracture of weakened bone 3. long term antibiotic therapy --> 6-12 weeks --prophylactic before surgery

nonpharm treatment modalities for muscle disorders

1. Hot/cold compresses 2. Lumbar support belt 3. Alternate rest and activity periods 4. Limit standing or sitting for long periods 5. Weight loss or management 6. Stretching paraspinal muscles regularly 7. Exercise recommended but with PT or MD approval

VTE risk factors

1. Increasing age (older than age 40) 2. obesity 3. taking prescription hormonal medications 4. preoperative leg edema 5. previous hx of any VTE 6. varicose veins increase risk for postoperative DVT and PE

Categories of MS abnormalities

1. Infection 2. Deterioration/Destruction/Disease 3. Perfusion Problems 4. Traumatic Injuries 5. tumors

treatment modalities of muscle disorders - pharm

1. LONG-TERM: --NSAIDS (Ibuprofen, Mobic-Meloxicam) --Muscle relaxants (Flexeril-Cyclobenzaprine) --Antidepressants (Elavil-amitriptyline, Cymbalta-Duloxetine) --Acetaminophen (Tylenol) 2. SHORT-TERM: --Opioid medications (Fentanyl, Ultram, Norco) --Steroids

pain assessment

1. Location 2. Intensity Grading Scale: NRS, FACES, VAS 3. Quality 4. Onset 5. Duration 6. Aggravating and Relieving Factors 7. QOL issues 8. Comfort-function goal

low back pain nursing management pt 1

1. Lumbar flexion increased by elevating head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing knees supported on a pillow --can also assume a lateral position with knees and hips flexed (curled position) with a pillow between knees and legs and a pillow supporting head 2. avoid prone position bc accentuates lordosis 3. get out of bed by rolling to one side and placing legs down while pushing torso up, keeping back straight 4. avoid locking knees when standing and bending forward for long periods of time

opioids

1. Morphine = oral, IVP, IM 2. Fentanyl = IV (Sublimaze), transdermal (Duragesic), buccal, intraspinal --conscious sedation in combo with Versed (amnesia) 3. Hydrocodone = oral (Lortab/Vicodin) 4. Hydromorphone = multiple routes (Dilaudid) 5. Oxycodone = oral (Oxycontin) 6. Oxymorphone = IVP, IM, oral (Opana)

Paget disease med management

1. NSAIDs for pain 2. walking aids, shoe lifts, and PT for gait problems 3. control weight to reduce stress on weakened bones and misaligned joints 4. asymptomatic may be managed with diets adequate in calcium and vitamin D and periodic monitoring **complications = fractures, hearing loss, and arthritis** 5. possible surgery 6. hearing aids if CN involvement

types of pain meds

1. Nonopioid 2. Opioid 3. dual-mechanism 4. adjuvant agents

THA indications

1. OA/RA 2. femoral neck fractures 3. failure of previous reconstructive surgeries 4. conditions resulting from developmental dysplasia or Legg-Calvé-Perthes disease (avascular necrosis of hip in childhood)

septic arthritis med management

1. Prompt treatment essential and may save prosthesis for patients who have had joint replacement surgery or may prevent sepsis 2. Broad-spectrum IV antibiotics started promptly then changed to organism-specific antibiotics after culture results --continued until symptoms resolve 3. synovial fluid aspirated and analyzed periodically for sterility and decrease in WBCs 4. Arthrotomy or arthroscopy used to drain joint and remove dead tissue 5. inflamed joint supported and immobilized in a functional position by a splint 6. Progressive ROM prescribed as soon as patient can begin movement without exacerbating symptoms of acute pain **If articular cartilage damaged during inflammatory reaction, joint fibrosis and diminished function may result

gerontologic pain considerations

1. Sensitivity of effects 2. Comorbidities 3. Increased risks for complications 4. Sedation concerns 5. Risk for falls 6. Polypharmacy 7. Mobility issues 8. Mental deficits

assessment of muscle disorders

1. Subjective --deep pain, pain that affects ADLs --sharp shooting pain (nerve) --tingling or burning (nerve) 2. Objective --pain with movement --abnormal gait --tight spasmed muscles --limited spinal mobility --impaired DTR --decreased sensory perception (sharp/dull or microfilament test) 3. neurovascular --decreased sensation --incontinence/inability to urinate (urinary retention)/ fecal incontinence --back pain in cancer patient --signs of infection (fevers) --bruising from fall **Any s/s lasting > 3 months OR involving neurovascular signs, history of fall, or back injury NEEDS to have diagnostic testing ASAP**

THA gerontologic considerations

1. THA within 24-36 hrs of hip fracture 2. VTE prophylaxis (LWMH or mechanical devices if contraindicated) 3. placed on a higher-specification, foam pressure-relieving mattress rather than an air-bed hospital mattress 4. Early assisted mobilization and ambulation on day of surgery

when should pain be assessed

1. When there is a new complaint 2. Before administering medications 3. After administering medications *Frequency of pain assessment will depend on unit and hospital policy, but general rule of thumb is to reassess 30 minutes after medication administration

osteomyelitis diagnostics

1. acute --early x-ray findings demonstrate soft tissue edema --> 2-3 weeks = areas of periosteal elevation and bone necrosis --Blood studies reveal leukocytosis and an elevated ESR --wound and blood cultures only positive 50% 2. chronic --large, irregular cavities, raised periosteum, sequestrum, or dense bone formations seen on x-ray --ESR and WBC count usually normal but may have anemia --Bone cultures aspirated through uninfected skin

low back pain causes

1. acute lumbosacral strain 2. unstable lumbosacral ligaments and weak muscles 3. intervertebral disc problems 4. unequal leg length 5. kidney disorders 6. pelvic problems 7. retroperitoneal tumors 8. abdominal aortic aneurysms **due to musculoskeletal disorders aggravated by activity, whereas pain due to other conditions not

medications that can cause osteoporosis

1. anticonvulsants (e.g., phenytoin) 2. thyroid replacement agents (e.g., levothyroxine) 3. antiestrogens (e.g., medroxyprogesterone) 4. androgen inhibitors (e.g., leuprolide) 5. SSRIs (e.g., fluoxetine) 6. proton pump inhibitors (e.g., esomeprazole) 7. corticosteroids (e.g., prednisone)

low back pain pt education

1. avoid twisting, bending, lifting, and reaching 2. change positions frequently 3. limit sitting to 20-50 mins at a time 4. resume ADLs as soon as possible 5. program of low-stress aerobic exercise 6. Conditioning exercises for both back and trunk muscles begun after about 2 weeks to help prevent recurrence of pain

osteoarthritis epidemiology

1. begins in third decade of life and peaks between fifth and sixth decades --By 40 years of age, 90% of population has degenerative joint changes in their weight-bearing joints, even though clinical symptoms usually absent --over 85% of general population over 65 years of age has radiographic changes indicating OA 2. Women 3. Hispanic/African American

OA diagnostics

1. blood tests and exams of synovial fluid to rule out autoimmune cause 2. Xray --narrowing of joint space --osteophyte formation --dense, thickened subchondral bone 3. Rheumatoid Factor 4. Uric acid levels 5. autoimmune panel to determine causation

septic arthritis clinical manifestations and diagnostics

1. clinical manifestations --warm, painful, swollen joint with decreased ROM --chills, fever, and leukocytosis 2. diagnostics --aspiration, examination, and culture of synovial fluid --CT/MRI reveal damage to joint lining --Radioisotope scanning may be useful in localizing infectious process --may not be any external wound or reported recent trauma

TKA nursing management pt 1

1. compression bandage with ice application 2. neurovascular status every 2-4 hours 3. active flexion of foot every hour when patient awake 4. possible wound suction drain for only 24-48 hrs (BMI over 35) 5. continuous passive motion devices (CPMs) have no influence on functional recovery

osteoporosis med management

1. diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence and middle years --men 50-70 = 1000mg, women over 50 and men over 70 = 1200mg --vitamin D between 400-1000IU ---tale both together with vit. C 2. weight bearing exercises --20 to 30 minutes of aerobic, bone-stressing exercise daily 3. avoid excess alcohol intake and quit smoking 4. hormone therapy not recommended

THA complications

1. dislocation of hip prosthesis 2. excessive wound drainage 3. VTE 4. infection 5. heel pressure injury 6. heterotopic ossification (formation of bone in periprosthetic space) 7. avascular necrosis 8. loosening of prosthesis

low back pain clinical manifestations

1. either acute (less than 3 months) or chronic with fatigue 2. radiating down leg --radiculopathy --> radiating from a diseased spinal nerve root --sciatica --> radiating from an inflamed sciatic nerve 3. may affect: --gait --spinal mobility --reflexes --leg length --leg motor strength --sensory perception 4. paravertebral muscle spasm 5. loss of normal lumbar curve and possible spinal deformity

Paget diagnositics

1. elevated ALP and urinary hydroxyproline excretion --reflect inc. osteoblast activity --higher values = more active disease 2. normal blood Ca 3. Xrays confirm by revealing local areas of demineralization and bone overgrowth in mosaic pattern 4. bone scans demonstrate extent 5. biopsy aids in differentiating diagnosis from other bone diseases

adverse effects of osteoporosis meds

1. gastric and esophageal risks 2. osteonecrosis of jaw 3. atypical femur fracture 4. Afib from chronic use --contraindicated in Barrett esophagus, low Ca levels, pregnancy

adult bone mass factors

1. genetic factors 2. nutrition 3. physical activity 4. medications 5. endocrine status 6. general health

OA pharm management

1. initially = acetaminophen 2. some = non-selective NSAIDS and COX-2 enzyme blockers --COX-2 enzyme blockers must be used with caution because of associated risk of CV disease and little to no decrease in GI upset 3. nonopioids (tramadol), opiods if severe, intra-articular corticosteroids 4. topical analgesics 5. Viscosupplementation --> injection of gel-like substances --supplement viscous properties of synovial fluid

adjuvants

1. local anesthetics --> Topical (Lidoderm) 2. Anticonvulsants --> oral gabapentin (neurontin), pregabalin (lyrica) --drowsy/dizzy 3. Antidepressants --> desipramine (Norpramin), duloxetine (Cymbalta), venlafaxine (Effexor) --dry mouth, sedation, weight gain, insomnia, h/a, constipation, ortho hypo --caution heart disease --> cardiotoxic 4. Ketamine (Kelar) --> oral, rectal, nasal, SC, and IV --DOES NOT PRODUCE RESPIRATORY DEPRESSION --Complications: High doses can cause hallucinations

osteomalacia diagnostics

1. low serum calcium and phosphorus levels 2. moderately elevated ALP 3. Urine excretion of calcium and creatinine low 4. XRAY/biopsy shows increased amount of osteoid, a demineralized, cartilaginous bone matrix

clinical manifestations of malignant bone tumor

1. may be symptom free or have pain that ranges from mild and occasional to constant and severe 2. varying degrees of disability 3. obvious bone overgrowth 4. weight loss 5. fever and malaise 6. spinal chord compression if metastasize to spine --> neurologic deficits

low back pain med management

1. most resolves on own with rest in 4-6 weeks 2. Management focuses on relief of discomfort, activity modification, and patient education 3. NSAIDs and short term muscle relaxants for acute 4. TCAs, SNRIs, and anticonvulsants for chronic 5. can use short term opioids for 1-2 weeks --NOT for elderly, kidney dysfx, GI pts

osteomyelitis risk factors

1. older adults 2. poorly nourished/obese 3. immunocompromised 4. chronic illnesses 5. corticosteroids/immunosuppressants 6. illicit IV drugs 7. post-op

septic arthritis risk factors

1. older adults (older than 80) 2. people with comorbid conditions such as diabetes, RA, skin infection, or alcoholism 3. people with a history of a joint replacement or other joint surgery 4. IV drug abuse

OA risk factors

1. older age 2. female 3. obesity 4. certain occupations (laborious tasks) 5. sports 6. hx of previous injuries 7. muscle weakness 8. genetics 9. certain diseases

routes of meds for pain

1. oral 2. IV infusion (PCA) 3. IVP 4. Topical 5. Rectal 6. IM 7. Intraspinal/Epidural

types of benign bone tumors pt 1

1. osteochondroma --> most common --large projection of bone at end of long bones --> then becomes static bony mass --cartilage cap of osteochondroma may undergo malignant transformation after trauma (fewer than 1%) 2. bone cysts --> expanding lesions within bone --Aneurysmal (widening) bone cysts seen in young adults --> painful, palpable mass of long bones, vertebrae, or flat bone --Unicameral (single cavity) bone cysts occur more often in first two decades of life --> mild discomfort and possible pathologic fractures of upper humerus and femur

osteomalacia s/s

1. pain at site 2. tender to touch 3. skeletal deformities (kyphosis or bow-legged) 4. unusual physical appearance that can affect self image

osteoporosis gerontological considerations

1. prevalence = over 50% in women over 80 2. 1/3 of all hip fractures occur among men --> higher mortality than women 3. at risk for fragility fractures (when fall from their height or lower or with low velocity) 4. 80% to 90% of these fractures can be seen incidentally on chest x-rays taken for other purposes 5. estimated that only one third of vertebral fractures diagnosed --> risk 5x higher among patients who have had prior fractures --20% of women who are postmenopausal and have a vertebral fracture will have another one within 1 year 6. absorb dietary calcium less efficiently and excrete it more readily through their kidneys --> need 1200mg/day

TJA preop/intra op complication management

1. preventing and managing blood loss --used to be that 50% of pts needed blood --> now only 4-9% 2. preventing VTE --discontinue meds that inc risk of clotting 1 week prior --LWMH after surgery 3. Preventing infection --Any infection presenting 2 to 4 weeks before planned surgery may result in postponement --prophylactic antibiotics given 60 minutes prior to skin incision and discontinued within 24 hours postop --use of antibiotic-loaded bone cement and preoperative nasal swabbing to screen for MRSA --Culture of joint during surgery may be important in identifying and treating subsequent infections 4. managing pain --patients supported and educated telephonically in preop period report better quality of life and well-being postop

primary osteoporosis vs secondary osteoporisis

1. primary -occurs in women after menopause -Failure to develop optimal peak bone mass and low vitamin D levels contribute to development of osteopenia without associated bone loss 2. secondary -result of medications or diseases that affect bone metabolism -men more likely --> corticosteroids and excess alcohol use -degree of bone loss related to duration of medication therapy --when discontinued, progression halted but restoration may not occur

THA nrusing management

1. promoting ambulation --assistance of a walker or crutches within a day after surgery --Weight bearing immediately after surgery may be limited to minimize micromotion of the prosthesis in bone 2. monitoring wound drainage --may be drained with a closed suction portable suction device --> more than 24 hrs = risk infection 3. preventing infection --> difficult to treat --acute may occur within 3 months after surgery and associated with progressive superficial infections or hematomas --delayed may be 4-24 months after 4. preventing VTE --7-14 days postop if no prophylaxis --intermittent compression devices on at all times --dorsi- and plantar flex ankles/toes 10 to 20 times every half hour while awake --aspirin/LWMH up to 35 days post op

patient self care after THA

1. pt resumes routine ADLs by 3 months 2. stair climbing 3-6 weeks --Some discomfort with activity and at night common for several weeks 3. sexual activity 3-6 months 4. no leg crossing or hip flexing over 90 degrees for 4 months 5. avoid low chairs and sitting for longer than 45 minutes at a time 6. drive 4-6 weeks 7. Other activities to avoid include tub baths, jogging, lifting heavy loads, and excessive bending and twisting

nursing interventions for osteoporosis

1. short periods of resting in bed in a supine or side-lying position to relieve pain 2. Knee flexion increases comfort by relaxing back muscles 3. Intermittent local heat and backrubs promote muscle relaxation 4. high-fiber diet, increased fluids, and use of prescribed stool softeners --> prevent constipation from immobility 5. monitors patient's intake, bowel sounds, and bowel activity --vertebral collapse involve T10-L2 vertebrae --> may develop a paralytic ileus

osteoporosis risk factors pt 1

1. small framed women (especially post menopause) 2. Asians and Caucasians --Af. Am. women have higher bone masses but still at risk bc of sickle cell and autoimmune diseases --> also have poor Ca intake from lactose intolerance 3. use of aromatose inhibitors in breast cancer 4. previous bariatric surgery where duodenum bypassed (most Ca absorbed there) 5. GI disease causing malabsorption 6. autoimmune diseases and corticosteroid use 7. alcohol/tobacco use

osteomyelitis clinical manifestations pt 1

1. sudden onset with systemic s/s (chills, high fever, rapid pulse, general malaise) 2. local s/s = painful, swollen, and extremely tender area 3. constant, pulsating pain that intensifies with movement as a result of pressure of collecting purulent material 4. no manifestation of sepsis when spread of adjacent infection or from direct contamination 5. chronic osteomyelitis presents with a nonhealing ulcer that overlies infected bone with a connecting sinus that will intermittently and spontaneously drain pus 6. diabetic osteomyelitis can occur without external wound --> may present as non healing fracture --Any foot ulcer more than 2 cm in diameter highly suspicious for osteomyelitis

low back pain non pharm management

1. thermal applications 2. spinal manipulation 3. Lumbar support belts not recommended to treat acute low back pain but can be used in OT 4. Orthopedic shoe inserts are recommended for prevention but may help correct an underlying issue contributing to problem 5. CBT, exercise/PT, yoga, acupuncture, massage for chronic

osteomalacia med management

1. treat underlying disorder --if kidney --> give activated vitamin D form (calcitriol) 2. inc. diet intake/supplements 3. exposure to sun 4. braces/surgery if persistent deformity

types of benign bone tumors pt 2

3. osteoid osteoma --> painful tumor in children and young adults 4. Enchondroma --> common tumor of hyaline cartilage that develops in hand, femur, tibia, or humerus --only symptom = mild ache 5. Giant cell tumors (osteoclastomas) --> benign for long periods but may invade local tissue and cause destruction --occur in young adults and are soft and hemorrhagic --may become malignant and metastasize

Preventing Dislocation of Hip Prosthesis pt 2

4. DONT turn to affected side 5. never flex hip past 90 degrees --> keep in extension 6. high seats and raised toilets --> hips should be higher than knees 7. affected leg should NOT be elevated when sitting

osteomalacia causes pt 2

4. Severe renal insufficiency results in acidosis --body uses available calcium to combat acidosis, and PTH stimulates release of skeletal calcium in an attempt to reestablish a physiologic pH --causes bony fibrosis and cysts 5. Chronic glomerulonephritis, obstructive uropathies, and heavy metal poisoning result in a reduced serum phosphate level and demineralization of bone 6. Hyperparathyroidism --> increasing phosphate excretion in urine 7. Prolonged use of anticonvulsant medication 8. malnutrition

low back pain nursing management pt 2

5. if standing for long time, shift weight frequently from one foot to other 6. sit with feet flat on floor and avoid chairs with no back support 7. dont use back muscles when lifting 8. avoid lifting more than one third of their ideal weight without help

TKA nursing management pt 2

6. goal = eventual flexion around 125 degrees to allow normal motion at end of rehabilitation --gentle manipulation of knee joint under general anesthesia may be necessary about 2 weeks after surgery if not achieved 7. mobilize and ambulate by first postoperative day 8. knee usually protected with a knee immobilizer and elevated when patient sits in a chair 9. Acute rehabilitation usually takes about 1 to 2 weeks --> Total recovery takes 6 weeks or longer

Paget Disease Clinical Manifestations pt 2

6. spine bent forward and rigid --> chin rests on chest 7. thorax becomes immobile during respiration 8. trunk flexed on legs to maintain balance and arms bent outward and forward, appearing long in relation to shortened trunk 9. Tenderness and warmth over bones from high vascularity --may develop high-output cardiac failure due to increased vascular bed and metabolic demand 10. deep, aching pain that worsens on activity and may precede deformities

osteomyelitis clinical manifestations pt 2

7. unsteady gait 8. drainage if open wound 9. affects ADLs 10. sharp shooting pain (nerve) 11. tingling/burning (nerve)

osteoporosis risk factors pt 2

8. fam hx/adult hx of fracture 9. glucose intolerance/diabetes 10. hx of rheumatoid disease 11. inactivity/low vitamin D 12. low BMI 13. PPI use 14. Depo-Provera for birth control use