Musculoskeletal System Ch.49 and Ch.50
What type of pt.should not take Bisphosphonates (BPs)?
Pt. with: - hypocalcemia -GERD -poor renal function -not for pt.who are sensitive to aspirin (bronchoconstriction may occur)
How do you assess pain in patients with MSK discomfort?
use pain scale Assess pain: LIQuid Location-does it radiate Intensity Quality-dull, burning, aching, stabbing Duration
What is the primary nursing intervention for kyphotic posture?
Sitting in supportive chairs with arms
What is arthroscopy?
-both, a diagnostic test or surgical procedure -fiberoptic tube inserted in joint for visualization of ligaments, menisci, articular surface -knee/shoulders are most COMMONLY evaluated
What is Evista [raloxifene]?
-currently the the only approved drug in postmenopausal women -it increases BMD -reduces bone resorption -reduces incidence of osteoporotic vertebral fx
What are calcium dietary recommendations for people at risk for osteoporosis ?
-1000mg daily= ALL postmenopausal women -1000mg daily= men b/w 50-70yo -1200mg daily=women/men 71yo or more -teach women to start taking supplements in young adulthood
What are Vit-D dietary recommendations for people at risk for osteoporosis ?
-800-1000units daily =women/men over 50yo -4000units daily= for.pt with severe bone loss or multiple non-modifiable risk factors
What is expected outcome for pt. with osteoporosis?
-Avoid fractures by fall prevention -managing risk factors -adhering to preventative measures or treatment
NI for pt. with osteoporosis?
-Nutritional therapy -Exercise -lifestyle changes -drug therapy -SME-self management education can help prevent osteoporosis
What is osteomyelitis?
-bone infection
Name physiological changes related to aging?
-decreased coordination -loss of muscle strength (muscle atrophy) -kyphotic posture/gait changes ( widened gait) -decreased bone density (risk for falls with injury) -slowed movement -decreased ROM -arthritis (cartilage degeneration) -increased bone prominence (risk for PrI)
Name some health conditions that would result in secondary osteoporosis?
-diabetes mellitus, hyperthyroidism, and hyperparathyroidism; long-term drug therapy, such as with corticosteroids; or prolonged immobility.
NI for neurovascular status of an extremity?
-every hour or according to the agency protocol. Includes: monitoring/ documenting distal pulses -warmth -color -pain -movement -sensation
What assessment will nurse perform when pt. being assessed already have a pressure injury?
-identify causes and factors that may impair wound healing.
What is plantar fasciitis and its S/Sx?
-inflammation of plantar fascia S/Sx: -severe pain in the arch of the foot, especially when getting OOB -worsens with weight bearing Often seen in: -athletes( especially runners) -middle age and older men -obesity is contributing factor
What are some risk factors that may cause primary osteoporosis?
-older age, smoking, and high alcohol intake
What data you will collect when assessing patient with impaired comfort/musculoskeletal problem?
-onset (date/time) -factors causing worsening -course or problem i.e intermittent or continuous -signs/symptoms -measures that improves -assess pain
Qualifying factors for drug therapy for pt.with osteoporosis?
-postmenopausal women - men over 50 when BMD T-score for hip and lumbar spine is below < -2.5 with NO RISK FACTORS -or men over 50 when T-score is below < -1.5 with risk factors or Hx of fx -anyone over age 50 or older who had a hip or vertebral fx
What assessment you will perform in a patient that will get MRI?
-pregnant -chronic kidney disease( r/t contrast) -ferromagnets or implants i.e older aneurysm clips -pacemaker, sten, electronic implant -need of life support -ability to lie still, supine, 30-45min -ability communication/verbal understanding -tattoo older than 35yo -claustrophobic
What is the function of calcitonin?
-produced by thyroid gland -Decreases serum Ca2+ concentration when its above the normal level -inhibits bone resorption and increases renal excretion of Ca2+/P as needed to maintain balance
What is function of PTH?
-promotes osteoclastic activity of the bone -releases calcium into the blood -reduces the renal excretion of calcium
Nutritional therapy for patient with osteoporosis?
-promotion of single nutrient will not prevent /treat osteoporosis -emphasize fruit/veggies -low-fat dairy and protein -increased fiber -moderation with alcohol and caffeine
What is necessary for you to know as a nurse in order to prepare pt. for arthroscopy?
-pt.MUST have mobility to the joint examined -need for consent -post-surgery ROM exercises -local, light general or epidural anesthesia TEACH pt.about procedure -small incision(s) -dressing maybe applied after procedure -maybe short term activity restriction for post-op only - ice used for 24hr -elevate extremity for 12-24hr -Tylenol for dx arthroscopy and opioids/Tylenol for surgical
What treatment is used for plantar fasciitis?
-rest, ice, stretching exercise -good fitting shoes/orthotics Meds: NSAIDS or steroids Surgery(severe cases): endoscopic to remove inflamed tissue
What would nurse teach to a patient taking Bisphosphonates (BPs)?
-take BPs early in the morning on empty stomach with 8oz of water -take drug 30min before other drugs or food/drinks to prevent interactions -wait 30-60min in upright position before eating -have dental exam before starting the drug due to osteonecrosis -DC drug and contact PCP if chest discomfort occurs (symptom of esophageal irritation)
What are some ways that women can prevent/slow bone loss and /or osteoporosis?
-taking Vit-D and Ca2+ supplements and increase these nutrients in diet -perform weight-bearing activities and maintain muscle strengths
What type of exercise is suggested for people with osteoporosis ?
-walking 30min 3-5x/week. No jogging or horseback ridding -Abdominal muscle tightening ,deep breathing and pectoral stretching -resistive and ROM exercise to improve mobility -general muscle strengthening-prevent falls/promote balance -swimming
What role insulin plays in bone health?
-works with growth hormone to build and maintain healthy bone tissue.
What is PRIORITY for post-procedure care after arthroscopy?
Assess neurovascular status of affected limb EVERY HOUR or according to agency policy/surgeons protocol Monitor/document: -distal pulses -warmth -color -pain CMS -capillary refill -movement -sensation
NI for pt.with decreased ROM? (r/t BMD)
Assess pt.ability to perform ADLs (pt.may need assistance with self care)
What hormone is released when Ca2+ levels are low?
PTH is released and stimulates osteoclastic (bone destroying cell) activity releasing Ca2+ in blood
What is the most common drug used for treatment of osteoporosis ?
Bisphosphonates (BPs)-slow bone resorption, especially spongy, trabecular bone tissue Most commonly used for treatment/prevention: -Fosamax [alendronate] -Boniva [ibandronate] -Actonel, Atelvia [risedronate]
What hormone reduces renal excretion of Ca2+ when serum levels of calcium are low?
PTH reduces renal excretion and facilitate its absorption from intestine
When assessing a female patient, the nurse learns that the patient has several risk factors for osteoporosis. Which risk factor will be the priority for patient teaching?
Ca2+ intake. (nurse will discuss the other risk factors as contributing to osteoporosis, but the teaching will focus on ways to increase calcium intake. Postmenopausal status, positive family history, and previous use of steroids are not risk factors that the patient can change.)
What is Hypertrophic Ungual Labium and its treatment?
Chronic hypertrophy of nail lip caused by improper nail trimming or untreated ingrown nail Treatment: Surgical removal of necrotic nail/skin Treatment of secondary infection
While assessing a patient with actual or potential musculoskeletal problems, which are the most important factors for the nurse to review in the patient history?
Chronic/previous illnesses [DM slows healing] Traumatic injuries/sports Occupation Nutrition-inadequate protein or Vit-C and Vit-D Allergies (lactose intolerance is common cause of low Ca2+ intake) Family history- osteoporosis/gout (occur in several generations)
Most common tool to measure bone mineral density (BMD)?
DXA- dual x-ray absorptiometry Most often assess spine and hip recommend for women in 40s for having baseline
Which medication is given for osteoporosis in postmenopausal women ? What are nursing implications for this medication?
Evista [raloxifene]-currently the the only approved drug in postmenopausal women -should not be given to women with Hx of thromboembolism -teach pt.S/Sx of VTE-venous thromboembolism, especially in first 4mo of therapy -monitor liver function tests
What is callus and its treatment?
Flat, poorly defined mass on the sole of the foot over bony prominence; cause by pressure Treatment: Padding and lanolin creams Good overall skin hygiene
What is the name of the hormone that regulates the intestinal absorption of calcium and phosphorous?
Glucocorticoids
What is the best test for determining bone quality and presence of osteoporosis, but not commonly used? Why is is the best?
MRI - no radiation -provides info about yellow bone marrow, diffusion/perfusion of bone
What should nurse teach to a pt. that just had arthroscopy?
Monitor for these signs and contact MD immediately if any present : - swelling -increase joint pain -thrombophlebitis -infection -Severe joint/limb pain may indicate complication -Surgeon will see pt.about 1 week after procedure
What is the most common BMD test currently used?
Most common is DXA-dual x-ray absorptiometry -pt.height taken -pt.stays dressed but remove ALL metal objects (keys, coins-may interfere with result) -T-score is calculated -no fallow-up care -result discussed with PCP
The nurse teaches a class for older women who are at increased risk for osteoporosis. Which health strategies are most important for the nurse to teach this group?
Performing weight-bearing exercises Identifying fall risks and prevention strategies
What is the most common cause of MRSA in patients with MSK health problems?
Post surgical site infections (SSIs) Surgically implanted devices: open reduction: open-reduction internal-fixation device
What is PRIORITY problem for pt. with osteoporosis or osteopenia ?
Potential for bone fx due to weak, porous bone tissue.
NI for pt .with increase bone prominence? (r/t low BMD)
Prevent pressure on bony prominence (there is less soft tissue to prevent skin breakdown)
NI for pt.with cartilage degeneration (arthritis)?
Provide moist heat-showers or warm, moist compresses. ( moist heat increases blood flow to area)
Bacteria that commonly cause an acute osteomyelitis from penetrating trauma?
Pseudomonas aeruginosa -animal bites -puncture wounds -skin ulcerations -bone surgery
S/Sx of acute osteomyolitis?
S/Sx of osteomyelitis (puncture, bite): -fever greater than 101F (38.3C) may not be present in older adults -swelling around affected area -erythema/heat -tenderness (may not be present in severe cases) -bone pain-localized, pulsating, worsen with movement
What is ingrown nail and its treatment?
Sliver of nail causing inflammation Treatment: removal by podiatrist warm soaks; antibiotic ointment
NI for decreased bone density ( osteopenia)?
TEACH: - fall prevention -need for exercise, especially weight-bearing [porous bones are more likely to fx; exercise slows bone loss]
NI's for muscle atrophy and decreased strength?
Teach isometric exercises
What is corn and its treatment?
Thickening of the skin caused by friction/pressure Treatment Surgical removal by podiatrist
How is osteomyelitis categorized?
a)Exogenous-infection from outside i.e open fx b)Endogenous(hematogenous)-from bloodstream of other areas of the body c)contiguous-result of skin infection of adjacent tissue commonly seen with slow-healing ulcers in older adults
NI for pt.with slowed movement?
do not rush, be patient
What are nursing implications for pt. taking IV Bisphosphonates (BPs)?
infuse over 15-30min to prevent rare complication of Afib check serum creatinine before and after administration ( may cause renal insufficiency or chronic kidney disease)
S/Sx of osteomyelitis and most common cause of chronic osteomyelitis?
most common cause foot ulcers S/Sx of chronic osteomyelitis: foot ulcers sinus tract formation localized pain drainage
What screening techniques is used most commonly for testing BMD at skilled nursing facilities, community health fairs or women's health centers?
pDXA scan- peripheral dual x-ray absorptiometry - assess BMD on heels, forearms and fingers -effective, low cost, no radiation and are portable -can detect osteoporosis and predict hip fracture
What joints are most commonly affected by OA (osteoarthritis)?
weight-bearings
