Adult Health Musculoskeletal Disorders
Fibromyalgia
-Chronic pain syndrome from neurogenic origin that amplify pain signals -Predisposing factors to pain: anxiety, depression, physical trauma, emotional stress, sleep disorder and viral infection **standard DX test often not useful EXCEPT to rule out other conditions - pain with pinching Achilles tendon will occur throughout WHOLE body**
Disease-Modifying Antirheumatic Drugs (hydroxychloroquine, chloroquine)
-May be administered concurrently with NSAIDs. -Assess for visual changes, GI upset, skin rash, headaches, photosensitivity, bleaching of hair. -Emphasize need for ophthalmologic examinations (every 6-12 mo).
Tumor Necrosis Factor (TNF) - Blocking Agents (Enbrel, Remicade, Humira)
-Patient should be tested for tuberculosis before beginning this medication. -Educate patient about subcutaneous self-injection. -Monitor for injection site reactions. Educate patient about increased risk for infection and to withhold medication if fever occurs. -Notify provider if any illness or infection occurs and medication is held.
Nonsteroidal Anti-Inflammatory Drugs (diclofenac, naproxen, meloxicam, ibuprofen)
-Administer NSAIDs with food. -Monitor for GI, CNS, cardiovascular, renal, hematologic, and dermatologic adverse effects. -Avoid salicylates; use acetaminophen for additional analgesia. -Watch for possible confusion in older adults. -Monitoring is the same as for other NSAIDs. -Increased risk of cardiovascular events, including myocardial infarction and stroke. -Appropriate for older adults and patients who are at high risk for gastric ulcers
Salicylates (Aspirin)
-Administer with food, milk, antacids or large glass of water to reduce GI effects. -Assess for tinnitus, gastric intolerance, GI bleeding, and purpura. -Administer enteric coated or extended-release whole, do not crush.
Corticosteroids (prednisone, prednisolone, hydrocortisone)
-Assess for toxicity: Cataracts, GI irritation, hyperglycemia, hypertension, fractures, avascular necrosis, hirsutism, psychosis. -Repeated injections can cause joint damage. Use caution in patients diagnosed with diabetes, due to effects causing elevation in blood sugar
Osteoporosis Risk Factors
-Small-framed women -Postmenopausal women -History of bone fractures during adulthood -History of impaired glucose tolerance and diabetes -Asian, Caucasian, and African American women -Poor calcium intake due to lactose intolerance -Use of aromatase inhibitors in women with breast cancer -Bariatric surgery GI disease that cause malabsorption (e.g., celiac disease, alcoholism) -Autoimmune disease (e.g., rheumatoid disease) -Men >60 years of age -Corticosteroid therapy >3 months
Nursing Interventions for Preventing Dislocation
1. Always maintain correct position - supine, head slightly elevated, affected leg in neutral position 2.Use abductor splints or pillows to support extremity 3. Support leg and place pillows between the affected legs when patient is turning. Always turn to the unaffected side 4. Avoid acute flexion of the hip (head of the bed 90 degrees or less) or crossing legs 5. Assess for dislocation (notify surgeon immediately if suspected)
Ankylosing Spondylitis (AS)
Chronic inflammatory disease of the SPINE; Cartilaginous joints of the spine and surrounding tissues; Large synovial joints (hips, knees, or shoulders) More prevalent in males Manifestations: Rigid joints; decreasing mobility leading to kyphosis & decreased stability/balance Back pain, which may mask cervical fracture, leading to neurologic problems SYSTEMIC: increased frisk for CV disease, pulmonary fibrosis, respiratory compromise w/ disease progression
A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included? a. Delaying exercise for at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. B. Exercising in the evening before going to bed is beneficial. C. The time of day when exercise is performed isn't important. D. Exercising immediately upon awakening allows the client to participate in activities when he has the greatest amount of energy.
A. Delaying exercise for at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. RATIONALE: A client with osteoarthritis has increased stiffness in the morning upon awakening. Exercise should be scheduled at least 1 hour after awakening. Exercising in the evening interferes with the client's ability to rest at bedtime.
A client with rheumatoid arthritis is discharging to home following an exacerbation of joint pain. Which type of referral will be the priority for the client? A. Home health nurse B. Social services C. Physical therapy D. Occupational therapy
A. Home health nurse RATIONALE: During home visits, the nurse has the opportunity to assess the home environment and its adequacy for client safety and management of the disorder
The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which client goal is a priority for the client? Select all that apply. A. The client will maintain adequate nutritional intake. B. The client will experience a tolerable level of pain. C. The client will remain free from injury. D. The client will maintain effective airway clearance. E. The client will demonstrate wound care.
A. The client will maintain adequate nutritional intake. B. The client will experience a tolerable level of pain. E. The client will demonstrate wound care.
OA Treatment
Acetaminophen - INITIAL THERAPY NSAIDS -Cox-2 enzyme blockers for those at risk for gastrointestinal complications Opioids and corticosteroids Topical diclofenac sodium gel (Voltaren gel) Glucosamine and chondroitin
A nurse is caring for a client who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.) A. Encouraging the client to have family and friends view the residual limb to decrease self-consciousness B. Encouraging the client to care for the residual limb C. Introducing the client to local amputee support groups D. Allowing the client to express grief E. Encouraging family and friends to refrain from visiting temporarily because this may increase the client's embarrassment
B. Encouraging the client to care for the residual limb C. Introducing the client to local amputee support groups D. Allowing the client to express grief
A client arrives at the clinic with reports of pain in the left great toe. The nurse assesses a swollen, warm, erythematous left great toe. What disorder will the nurse relate the client symptoms to? A. Fibromyalgia B. Gout C. Osteoarthritis D. Rheumatoid arthritis
B. Gout
A client arrives in the emergency room complaining of severe pain in her left hip after falling out of the bed. What indication upon assessment does the nurse recognize as a dislocated left hip? Select all that apply. A. The skin over the left hip is warm. B. The left leg is shorter than the right. C. Limited range of motion of the left hip. D. The skin of the lower left leg is pale. E. The client is able to bend the knee but not move toes.
B. The left leg is shorter than the right. C. Limited range of motion of the left hip. D. The skin of the lower left leg is pale. RATIONALE: The leg may be shorter than its unaffected counterpart as a result of the displacement of one of the articulating ones. ROM is limited. Evidence of soft tissue injury includes swelling, coolness (not heat), numbness, tingling, and pale or dusky color of the distal tissue. The client will not be able to bend the knee but will be able to move the toes.
The nurse is performing a health history with a new client with fibromyalgia. What will the nurse expect to assess as the most common finding associated with fibromyalgia? A. butterfly facial rash B. widespread chronic pain C. Heberden nodes D. jaw locking
B. widespread chronic pain RATIONALE: The most common finding associated with fibromyalgia is widespread and chronic pain. Heberden nodes are associated with osteoarthritis. Jaw locking is a manifestation of temporomandibular joint dislocation. A butterfly facial rash is associated with systemic lupus erythematosus.
RA Treatment
Biologic of Non-Biological Disease-modifying antirheumatic drug (DMARD) AE: -Hydroxychloroquine can cause retinal degeneration -Methotrexate-bone marrow suppression, GI ulcerations, skin rashes -Infliximab (Remicade) MUST HAVE TB TEST BEFORE ADMINISTRATION
A client with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the client to do? A. Avoid using analgesics so that further damage is not masked. B. Apply topical anesthetics to accessible skin surfaces as needed. C. Elevate the affected extremity to shoulder level when at rest. D. Engage in exercises that strengthen the unaffected muscles.
D. Engage in exercises that strengthen the unaffected muscles. RATIONALE: The nurse will encourage the client to engage in exercises that strengthen the unaffected muscles. Comfort measures may include appropriate use of analgesics and elevation of the affected extremity to the heart level. Topical anesthetics are not typically used.
A client with rheumatic disease has developed a gastrointestinal (GI) bleed. The nurse caring for the client should further assess for medications that typically exacerbate this condition. Which medication applies? A. Corticosteroids B. Immunomodulators C. Antimalarials D. Salicylate therapy
D. Salicylate therapy RATIONALE: GI bleeding is an adverse effect that is associated with salicylates. Corticosteroids, antimalarials, and immunomodulators do not normally have this adverse effect.
A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure: A. that pedal pulses are present. B. that the cast cutter blade is new. C. that the leg will be as good as new. D. the client that he or she won't be cut.
D. the client that he or she won't be cut. RATIONALE: Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.
Prevent Venous Thromboembolism (VTE)
DVT S/S: - Pain & tenderness at or below the area of the clot -swelling & tightness of the affected log - possible pitting edema - warmth or cooling, skin discoloration PE S/S: -Acute onset of dyspnea -Tachycardia -Confusion -Pleuritic chest pain Treatment: -SCDs while patient is in bed -Medication: Coumadin (warfarin) Xarelto (rivaroxaban) Arixtra (fondaparinux) Lovenox (enoxaparin sodium) Eliquis (apixaban)
Paget Disease of bone
Disorder of localized rapid bone turnover w/ unknown cause -commonly affecting: skull, femur, tibia, pelvic bone, and vertebrea Manifestations: -Skeletal deformity Skull deformity most common -Waddling gait -Forward bent spine and is rigid -Chin rests on the chest -Thorax becomes immobile during respiration -Trunk is flexed on the legs to maintain balance -Arms are bent outward and forward, appearing long in relation to the shortened trunk -Tenderness and warmth over bones -Pain is mild to moderate, deep, and aching, increases with weight bearing
Total Hip Arthroplasty
IND: -OA -RA - Femoral neck fractures - Failure to previous reconstruction surgeries -conditions resulting from developmental dysplasia S/S of dislocation: -Increased pain, swelling and immobilization - Shortening of the affected extremity -Abnormal external or internal rotation of the affect extremity - Restricted ability or inability to move the log - Reported "popping" sensation in the hip
psoritatic arthritis
Inflammation arthritis associated with the skin disease psoriasis Most common autoimmune disease; onset 30-50 years old male and female System Affected: Spine, Achilles tendon, plantar fascia, or tibial tuberosity areas Manifestations: Synovitis, polyarthritis, and spondylitis Inflammatory back pain is common; differentiated from back pain (symptoms presenting at young age, pain improvement w/ activity and occurring at night SYSTEMIC INFECTIONS
Rheumatic Disorders
Inflammatory -Rheumatoid Arthritis - Spondyloarthropathies - Systemic Lupus Erythematosus Non-Inflammatory -Osteoarthritis Metabolic & Endocrine Diseases -Gout -Fibromyalgia
antinuclear antibody (ANA) - Serum Immunology
Measures antibodies that react with a variety of nuclear antigens Significance: (+) test may be associated with RA, Raynaud's disease, and necrotizing arteritis ***Higher the titer, the greater the inflammation***
Erythrocyte Count - Serum Blood Studies
Measures circulating erythrocytes Significance: Decrease seen in RA
Uric Acid - Serum Blood Studies
Measures levels of uric acid in serum Significance: Increase is seen with GOUT. During acute flare, levels may be normal - AFTER flare, levels will be elevated
HLA-B27 Antigen
Measures presence of HLA antigens, which are used for tissue recognition Significance: Found in 80-90% of those with ankylosing spondylitis and Reiter's syndrome
Erythrocyte Sedimentation Rate (ESR) - Serum Blood Studies
Measures the rate at which RBCs settle our of UNCLOTTED blood in 1hr Significance: Increase is usually seen in inflammatory CT diseases. An increase indicates rising inflammation The higher the ESR, the greater the inflammatory activity
Hematocrit - Serum Blood Studies
Measures the size, capacity, and number of cells present in blood **inflammation DECREASES hematocrit - erythrocyte production** Significance: Decrease can be seen in chronic inflammation (anemia of chronic disease); also, blood loss through GI bleed
Osteoarthritis
NON-inflammation degenerative disorder of the joints, most common of joint diseases idiopathic/secondary End result of an autoimmune disorder due to joint destruction By the age 40, 95% of population has degenerative joint changes Increase with age Risk Factors: Age - 65+ and older Work-related issues Gender - women Obesity - modifiable Hispanic/African American Previous Injuries Sports related accidents No systemic manifestations
Primary Osteoporosis
Occur is women after menopause (around 51) Men later in life Osteopenia development without bone loss due to: -low VitD levels -failure to develop optimal peak bone mass INT: -increase calcium/vitD (15-30 mins of sun daily or 400-1000IU vitamin D) intake) -regular weight bearing exercises -reduce caffeine, tobacco, carbonated drinks, and ETOH -early identification
Surgical Interventions
Osteotomy: Alter the distribution of weight within the joints Arthroplasty: diseased joint components are replaced Rehab PT: within the first 24 hours
Spondyloarthropathies Treatment
Pharm Management: -NSAIDs - FIRST LINE -Methotrexate, sulfasalazine, and leflunomide -Corticosteroids injections for PERIODIC flares (not long term) -Anti-TNF; Enbrel, Remicade, Humira -Additional: apremilast (Otezla) & ustekinumab (Stelara) Surgical Management: -Osteotomy of the spine for advanced AS and debilitating kyphosis -TJR
Rheumatoid Factor (RF) Serum Immunology
Positive titer >1:80 Positive in 80% of those with RA The higher the titer (# at right of colon), the greater the inflammation
rheumatoid arthritis vs osteoarthritis
RA: - Inflammatory (autoantibody) - Synovial proliferation - Symmetric/bilateral & morning stiffness - Spongy or bobby tissue; often, fluid may be aspirated - Begin in small joints and move to larger joints - Limited function may present before bony changes - Ulnar deviation & Swan neck deformity OA: - Noninflammatory - Pain/brief morning stiffness <30mins - Joints aggravated by movement; relieved by stress - Degeneration of articular cartilage caused by friction - Asymmetric, limited to just joints - Osteophytes - Crepitus may be palpated, especially over KNEE - Heberden's (DIP) and Bouchard's (PIP) nodes
Reactive Arthritis (Reiter's Sydrome)
Reactive b/c occurs AFTER INFECTION Mostly affects males System affected: GI/GU Manifestations: Primarily characterized by urethritis, arthritis, and conjunctivitis Dermatitis and ulcerations of mouth and penis may be present Low back pain is common NOT SYSTEMIC
Osteoporosis Nursing Interventions
Recommended calcium intake is 1000-1200mg daily depending on age and gender; vitamin D is 600 IU daily for adults up to 70 years of age, 800 IU for adults over the age of 70. -Promoting understanding of osteoporosis and the treatment regimen -Pain relief Improving bowel elimination -Fall prevention -Diet rich in calcium and vitamin D -Regular weight-bearing exercise -Pharmacological therapy -Fracture management: Referred to osteoporosis specialist
Secondary Osteoporosis
Result of medications of diseases that affect bone metabolism More likely in men than women Specific disease states: -celiac disease -hypogonadism Medications: Anticonvulsants (phenytoin, [Dilantin]) Thyroid replacement agents (levothyroxine [Synthroid]) Antiestrogens (medroxyprogesterone [Depo-Provera]) Androgen inhibitors (leuprolide [Lupron]) PPI (esomeprazole [Nexium])
Medication for RA
Salicylates -(Aspirin) Nonsteroidal anti-inflammatory Drugs (NSAIDs) -diclofenac, naproxen, meloxicam, ibuprofen Disease-Modifying Antirheumatic Drugs (DMARDs) -hydroxychloroquine, chloroquine Tumor Necrosis Factor (TNF) - blocking Agents -Enbrel, Remicade, Humira Corticosteroids -prednisone, prednisolone, hydrocortisone
Common Blood Studies
Serum: Erythrocyte Count Erythrocyte Sedimentation Count Hematocrit Uric Acid Serum Immunology: Antinuclear Antibody (ANA) C-Reactive Protein Rheumatoid Factor (RF) Tissue Typing: HLA-B27 Antigen
C-reactive protein (CRP) - Serum Immunology
Shows presence of abnormal glycoprotein due to inflammatory process Significance: (+) reading indicates active inflammation
Fibromyalgia Nursing Interventions
TX of symptoms: -NSAIDs -Tricyclic antidepressants -> amitriptyline and nortriptyline -Muscle relaxants -> cyclobenzaprine -Cognitive behavioral therapy to improve sleep and attentional dysfunction **PAY SPECAIL ATTENTION TO PTS CONCERNS AND SYMPTOMS**
Spondyloarthropathies
Three types: 1. ankylosing spondylitis (AS) 2. Reactive Arthritis (Reiter's Syndrome) 3. Psoriatic Arthritis Associated w/ Crohn's disease & UC Increased risk for CV disease
rheumatoid arthritis
a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked Risk Factors: Environmental factors -pollution Cigarette smoking -High related to RA Family Hx Bacterial/viral illnesses Females w/ 2.5X greater incidence than males Can occur at any age but increases after ag 60 Systemic manifestations: Fever Fatigue Wight loss Anemia - due to inflammation Lymph node enlargement Raynaud's Phenomenon
systemic lupus erythematosus (SLE)
chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs UKO: can be linked to environmental, genetic, and hormonal factors Lab Studies: ANA, anti-DNA, anti-ds DNA, anti-Sm, and CBC Medication: monoclonal antibodies, corticosteroids, antimalarial agents, NSAIDs, and immunosuppressive agents Manifestations: baldness, butterfly rash, anemia, neutropenia, thrombocytopenia, splenomegaly, lymphadenopathy, polyarthritis, myositis, fingertip lesions, osteoporosis, pericarditis/endocarditis, pleuritis/pneumonia, oral ulcers, CNS symptoms
Gout
hereditary metabolic disease that is a form of acute arthritis, characterized by excessive uric acid in the blood and around the joints MOST COMMON FORM OF INFLAMMATORY ARTHRITIS increases w/ age, BMI, ETOH, HTN, diuretic use Primary hyperuricemia: severe starvation & excessive intake of foods high in purines (shellfish, organ meats) or hereditary Secondary hyperuricemia: leukemia, multiple myeloma, some types of anemia, psoriasis, diuretics (thiazides and furosemide), low-dose salicylates, or ETOH Manifestations: Acute gouty arthritis Tophi Gouty Nephropathy Uric Acid urinary calculi Stages: 1. Asymptomatic hyperuricemia 2. Acute gouty arthritis 3. Inter critical gout (symptom free gout) 4. Chronic tophaceous gout (increased uric acid level)
Osteomalacia
insufficient mineralization of bone; major defect of activated vitamin D Manifestations: -Softened, weaked bones (spinal kyphosis and bowed legs) -Wadding gait -pain & tenderness to touch -pathologic fractures -fall risk DX: -Xray - Lab Studies: serum calcium, phosphorus, & ALP -Urine test: Ca & Ph - Bone Biospy Management: - reduce discomfort and pain -Ca &/or Vitamin D supplement & diet -Exposure to sunlight -Braces or surgery
Gout nursing interventions
low purine diet: avoid organ meats, wine, and aged cheese encourage increased fluids increase urine pH through alkaline foods like green beans and broccoli Medications: -Colchicine for acute attacks (common) -NSAIDs(indomethacin) -Corticosteroids (do not use for long period treatment) -Allopurinol; uric acid lowering therapy given post ACUTE ATTACKS -Probenecid; uricosuric agent for pts w/ FREQUENT ATTACKS Education: -Lifestyle changes; avoiding purine foods, weight loss, decreasing ETOH, avoiding certain medications (diuretics, ACE inhibitors) -Pain management and avoidance factors that increase pain and inflammation, such as trauma, stress, and ETOH
Osteoporosis
reduced bone density & mass, deterioration of bone matric, and diminished bone architectural strength Most prevalent bone disease in the world bone fracture frequent men account for 1/3 of all hip fractures and hive higher mortality rate then women