Chapter 44 - Foundations - Care of the Patient with a Musculoskeletal Disorder + Practice NCLEX Questions

Which patient is most likely to develop osteoporosis?

57-year-old white woman

What is Ankylosing Spondylitis (AS) (1365)?

A form of RA that primarily causes inflammation of joints between the vertebrae. It is a chronic, progressive rheumatic disorder that affects primarily the spine. Risk factors for AS include: testing positive for the HLA-B27 marker, a family history of the disease, frequent GI infections. Clinical manifestation of AS includes bones of the spine fusing (growing together). The accompanying fixation of the joint is referred to as Ankylosis. AS can affect joints such as the neck, jaw, shoulders, knees, and hips. Progression of it causes ligaments to become ossified/hardened. The cardiovascular system can be involved, with heart enlargement and pericarditis possibly occurring. If costovertebral joints are affected, kyphosis can occur, leading to a forward curvature of the upper back and altered respirations. Many patients have inflammatory bowel disease. Vision loss occurs with chronic AS, and blindness may result.

What is an Endoscopy (1357)?

A lighted tube is used to visualize inside a body cavity. Most procedures require only local anesthesia. Emotional support and complete explanations help relieve the patient's anxiety. To prepare the patient: have the patient sign consent, complete a preoperative checklist with attention to removing jewelry/dentures/contacts. Initiate NPO for 6-12h prior. Encourage the patient to void. Administer prescribed premedications. Record vital signs. Maintain bed rest with side rails up after giving premedication.

What is Gout (Gouty arthritis) (1369)?

A metabolic disease resulting from an accumulation of uric acid in the blood. It's an acute inflammatory condition associated with ineffective metabolism of purines. It can be primary (linked with hereditary factors), secondary (resulting from use of certain meds or the complication of another disease), or idiopathic (of unknown origin). Men are affected roughly 8x more frequently than women. Approximately 85% of all people with gout have a genetic tendency to develop the disease. Tophi - calculi containing sodium urate deposits that develop in periarticular fibrous tissue, typically in patients with gout. Tophi result in inflammation of the joint, and it's unclear why this occurs. More than 75% of people with gout experience big toe involvement. Other joints such as the foot, fingers, and wrists are affected with lesser frequency. Onset of gout occurs at night with excruciating pain, edema, and inflammation in the affected joint. The pain may last a short time but return at intervals, or be severe and continuous for 5-10 days. The patient may only have one attack, or repeated attacks across their lifetime. Surgical removal of tophi (around the rim of the ear) may be necessary.

What are some important terms related to skeletal muscle structure (1352)?

Cells - skeletal muscle is composed of hundreds of muscle fibers/cells. Epimysium - each skeletal muscle is surrounded by a covering of connective tissue called the epimysium, which joins with two other inner coverings, the perimysium and the endomysium. Tendon - The epimysium extend beyond the muscle to form a tough cord of connective tissue known as a tendon. Tendons anchor muscles to bones. As a muscle contracts, it pulls the corresponding tendon and bone toward it, creating movement. Tendon sheaths - tendons in the ankle/wrist are enclosed in these sheaths, which are sleeves or tube-like structures of connective tissue. Tendon sheaths contain synovial fluid and permit tendons to slide easily, also keeping the tendons in place. Fasciae - all of the body's tendons, ligaments (like tendons but anchor bone to bone), and aponeuroses (broad, flat tendons) are composed of connective tissue in various sizes/shapes/densities - these are known as fasciae.

How is gout managed medically (1369)?

Colchicine is used (oral or IV) for acute attacks. It is discontinued if GI symptoms develop or pain isn't relieved. Indomethacin suspension and injectable is an effective anti-inflammatory drug in treating gout. Corticosteroids can be administered and will relieve signs/symptoms within 12 hours. HCPs may order allopurinol to decrease uric acid production. Probenecid is prescribed to inhibit renal tubular resorption of uric acid by the kidneys. Febuxostat may be used to lower serum uric acid levels, but it is a risk for causing heart-related deaths and deaths from all causes. Aspirin inactivates the effect of uricosurics, resulting in urate retention, and should be avoided while taking uricosuric drugs (probenecid).

The patient who undergoes total hip replacement may be prescribed prophylactic drugs such as heparin or warfarin (Coumadin). The rationale for this is that it?

Decreases the risk of thrombus formation.

What is involved in the diagnosis and management of a hip fracture (1381)?

Diagnosis is confirmed by radiographic exam of the injured part, and blood tests like hemoglobin values often show decreased lab values because of the bleeding at the fracture site. Surgical repair is the preferred method of managing intracapsular and extracapsular hip fractures, and surgical treatment enables the patient to get out of bed sooner and decreases the major complications associated with immobility. Extremities may be temporarily immobilized by Buck's or Russell's traction until the physical condition is stabilized and surgery scheduled. Prosthetic implants, such as the bipolar hip replacement (hemiarthroplasty) are used to replace the femoral head and neck in fractures when the vascular supply to the femoral head may be compromised. Neufeld nails, Kuntscher nails, and sliding nails are used depending on the type of fracture, and these devices are called internal fixation. Immobilization devices such as casts or splints may also be used with open reduction.

A patient, age 64, has osteoarthritis of the left hip. He has had a left total hip replacement. The nurse should?

Encourage use of an incentive spirometer.

What is involved in nursing interventions and patient teaching on OA (1368)?

Encouraging the maintenance of ADLs. Adapting to limitations of the disease. Alternating sitting, walking, and standing with periods of rest. Teach patients about the disease process and steps to control that process, the teaching should include the same information as for RA. OA is a chronic disease, ultimately causing permanent destruction of affected cartilage and underlying bone with variable pain and disability. Bones rub against other bones because of cartilage destruction between them.

The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include?

Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

What is included in patient teaching for RA (1361)?

Fatigue can be a major concern, achieving restful sleep is important - additional sleeping periods and naps are indicated during disease exacerbation. Exercise helps prevent the joints rom "freezing" and the muscles from weakening. An initial exercise program calls for 2 or 3 10-15 minute daily sessions of "quiet" exercises that gently put the joints through ROM. Strength training, yoga, and aerobic exercise may also be included. Warm packs and heat lamps may help. Patients should be taught about: Joint protection. Energy conservation. The Proper balance of rest and activity. The proper use of medications. Plans for implementation of the exercise program prescribed by the HCP or physical therapist. Proper application of heat or cold packs. Proper use of walking aids or safety measures to prevent injury. Basics of good nutrition and the importance of avoiding weight gain. Stressing the danger of following programs that promise a "cure".

What is Fibromyalgia (1374)?

Fibromyalgia is a chronic syndrome of unknown origin that causes pain in the muscles, bones, or joints. It's associated with soft tissue tenderness at multiple characteristic sites, contributing to poor sleep, headaches, altered thought processes, and stiffness or muscle aches. 80-90% of diagnoses are women, commonly in people aged 20-50 years. Clinical symptoms of fibromyalgia syndrome (FMS) can overlap those of chronic fatigue syndrome. FMS patients frequently complain of generalized achiness in axial locations, such as the neck and lower back, accompanied by stiffness that is worse in the morning. Cold/humid weather, physical/mental fatigue, excessive physical activity, and anxiety/stress can contribute to the condition being aggravated. Difficulty sleeping is common.

What is involved in nursing interventions and patient teaching on Gout (1369)?

Intervention is aimed at giving medications prescribed by the HCP for pain relief and inflammation. With colchicine, observe for diarrhea, nausea, and vomiting. Increasing the patient's fluid intake to 2000mL+ daily helps eliminate excess urinary urates. Carefully document I & O. Advise the patient to avoid excessive alcohol use and consumption of foods high in purines. Maintain bed rest and joint immobilization while the patient is symptomatic. Bed cradles prevent pressure from bed linens on the affected joints. Patient teaching is aimed at giving information about the disease and stressing the importance of keeping the serum uric acid levels within the normal range by taking the prescribed medications. Even when signs/symptoms aren't present, colchicine, probenecid, and allopurinol as a maintenance dose may be used.

Which diagnostic exam is used to find pathological abnormalities of the brain?

MRI

What is involved in nursing interventions and patient teaching on AS (1367)?

Maintaining alignment of the spine is important. A firm mattress, sleeping without a pillow, and doing respiratory exercises may help. Lying on the abdomen for 15-30m 4x daily is recommended, as well as turning and repositioning every 2 hours. Postural and breathing exercises help. Heat and cold may also be included in the plan of care. If not treated, it can leave permanent, irreversible systemic involvement.

What is involved in medical management of osteomyelitis (1373)?

Medical care includes wound management and antibiotic therapy. Surgery may be performed to remove a fragment of necrotic bone that is partially/entirely detached from the surrounding/adjacent healthy bone (sequestrum). Hyperbaric oxygen therapy may be initiated. IV antibiotic therapy will be used, with parenteral antibiotics used anywhere from several weeks to 3-6 months. Amputation of the infected limb is the last resort.

What is a Bone Scan especially valuable in detecting (1357)?

Metastatic and inflammatory bone disease. Note: nuclides are administered through IV 2-3h before the test is scheduled. There aren't fluid/food restrictions, and patients are encouraged to drink water over the next 1-3h to aid renal clearance of any radioisotope. The test takes 30-60m and requires the patient to lie still.

What is involved in medical management of AS (1366)?

Oral analgesics and NSAIDs may be prescribed. Corticosteroid therapy with prednisone may be prescribed. TNF inhibitors that target the immune cells include: etanercept, infliximab, and adalimumab. Regular exercise is recommended, such as swimming or walking. Exercising 2-3x weekly for 30-40 minutes is encouraged. Surgery may be necessary to replace fused joints.

What is Osteomyelitis (1373)?

Osteomyelitis is a local or generalized infection of the bone and bone marrow, and can occur from bacteria introduced through trauma such as compound fracture or surgery. Bacteria may also travel by bloodstream from another site in the body to a bone, causing an infection (Staphylococci are the most common causative agents). Bacteria invade the bone, and bone tissue degenerates. Osteomyelitis can become chronic as a result of inadequate acute treatment. Risk factors include severe injury involving a fracture or deep puncture surgery involving orthopedic implants, poorly controlled diabetes, peripheral artery disease, medications that suppress the immune system, the presence of an indwelling device such as a central line or urinary catheter, smoking, and illicit IV drug use. Clinical manifestations include fever, pain in the infected area, inflammation, and fatigue.

What is Computed Tomography (CT) (1357)?

Uses a narrow x ray beam and produces a three-dimensional picture of the structure being studied. It is useful for locating injuries to the ligaments or tendons, tumors of the soft tissue, and fractures. It should only be used when necessary, as it is approximately 100x more sensitive than the radiograph and involves radiation exposure. Contrast dye is sometimes used. Patient preparation includes: 1. Having patient sign a consent form. 2. Measure vital signs as a baseline. 3. Ask the patient to void before the test. 4 remove metal-containing articles like jewelry or hair pins. 5. Question about allergies. Note: the patient will be NPO for 3-4h prior to the test, an IV will be initiated to administer the contrast medium (the patient will report warmth/burning in their upper torso as the infusion begins). Afterward, observe for delayed allergic reactions and encourage fluid unless contraindicated. Pretest diet/activity can usually be resumed.

Which finding would delay a computed tomography (CT) scan?

Patient's allergy to shellfish.

The large, fan-shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate is?

Pectoralis major.

What are some lifespan considerations for older adults in terms of musculoskeletal disorders (1380)?

Physiologic changes of aging result in decreased joint flexibility and muscular strength. Changes in bone mass with aging increase risk of fractures. Degenerative joint disease related to wear and tear on joints is associated with aging, and joint replacement is no longer considered a last resort for older adults. Changes in the foot can occur with aging, poorly fitted shoes, or heredity. Check the homes of older adults for safety hazards such as rugs that could cause falls. Older adults should avoid climbing unsteady or uneven surfaces because coordination and balance change with age and falls may result. Instruct older adults in the correct use of assistive devices such as canes or walkers.

What should the nurse include in the plan of care for a patient following a myelogram?

Position in a semi-Fowler position for 8 hours to reduce potential of headache

The nurse explains to a patient who has had a knee replacement that warfarin (Coumadin) is ordered to?

Prevent formation of emboli.

What are the 7 P's of assessing circulation (neurovascular check) (1380)?

Pulselessness. Paresthesia (numbness/tingling). Paralysis/paresis. Polar temperature. Pallor. Puffiness (edema). Pain. Note: Numbness/tingling may result from general decreased mobility and may be relieved by flexing the fingers and toes and repositioning the extremity. However, if this is not relieved by these measures and the extremity feels cool to the touch, is slow in capillary refill, has diminished/absent pulses, and appears pale/cyanotic, these are symptoms of neurovascular impairment and these findings must be immediately reported.

What should the nurse stress to a patient who has had a hip replacement and is beginning strengthening exercises for the unaffected leg?

Push foot down against the footboard for a count of five

What should the nurse stress to a post-hip replacement patient in quadriceps setting exercises?

Push knee down to mattress and raise heel off the bed

What should the nurse instruct the patient before a magnetic resonance imaging (MRI) procedure?

Remove all metal, such as jewelry, glasses, and hair clips

Rheumatoid arthritis is distinguished from osteoarthritis in that?

Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints.

Which nursing intervention would be appropriate for a patient with rheumatoid arthritis?

Sleeping at least 8 hours at night and a nap during the day.

Calcium is a mineral found in many foods that can slow bone loss during the aging process. Which food is high in calcium?

Spinach

The immediate medical management of any fracture is?

Splint and elevate the involved part.

What is involved in assessment and diagnosis of Gout (1369)?

Subjective data - noting a complaint of pain occurring at night involving the great toe and other joints. Take a dietary history, with questions on alcohol consumption and foods high in purines (organ meats, anchovies, yeast, herring, mackerel, scallops). Objective data includes assessing joints for edema, heat, discoloration, and limited movement. Vital signs may reveal elevated temperature, hypertension, tachycardia, and tachypnea. Assess urinary output, as tophi can form in kidneys and alter function. Assess the patient for tophi (typically on earlobes, fingers, hands, and toes). Lab tests to diagnose include serum and uric acid levels, CBC, and elevated ESR. Radiographic studies reveal cysts and toe bone pockets. Synovial fluid contains urate crystals.

What is involved in assessment and diagnosis of Osteoporosis (1371)?

Subjective data includes questioning about lifestyle practices and complaints of pain (low thoracic and lumbar) that worsens with sitting/standing/coughing/sneezing/straining. Objective data includes assessing for dowager's hump (spinal deformity and height loss from repeated spinal vertebral fractures) and increased lordosis, scoliosis, and kyphosis. Also assess gait impairment associated with inability to maintain an erect posture. Diagnosis involves the HCP ordering various diagnostic tests - CBC, serum calcium, blood urea nitrogen (BUN), creatinine, urinalysis, etc. Bone Mineral Density (BMD) assesses the mass of bone per unit volume, or how tightly the bone is packed. Normal bones have a BMD within 1 standard deviation of the young female adult average Osteoporosis is 2.5 standard deviations or more below the young female adult average of -1 or above. Note: white women and postmenopausal women are both at high risk for incidence for osteoporosis.

What is involved in assessment and diagnosis of Fibromyalgia syndrome (FMS) (1374)?

Subjective data includes questioning the patient about muscle pain, headaches, premenstrual tension, jaw pain, excessive fatigue, anxiety, and depression. Objective data collection includes noting periodic limb movement, especially at night, or persistent need to move the lower extremities day and night. Ask about sleep deprivation and the patient's ability to complete self-care activities. No specific lab or radiographic test diagnoses FMS, with diagnosis confirmation possibly taking months to years. The Widespread Pain Index (WPI) may be used to affirm a diagnosis.

What is included in subjective and objective data for assessing AS (1365)?

Subjective data: low backache, sciatica pain. Complaints of weight loss, abdominal distention, visual problems, and fatigue are common. Objective data: tenderness over the spine and sacroiliac region. Peripheral joint edema. Decreased ROM. Assessment of vital signs may indicate elevated temperature, tachycardia, and hyperpnea.

What is included in assessment of and diagnosis of OA (1367)?

Subjective data: question patient about pain and stiffness. Past illnesses, surgical procedures, or trauma may be relevant, as well as information on excessive weight gain and occupation. Complaints regarding reduced grip strength are common. Objective data includes: assess for joint edema, tenderness, instability, and deformity. There is no specific test to diagnose OA - however, radiographic studies, MRI, arthroscopy, synovial fluid exam, and bone scans provide supportive information.

What are the functions of the skeletal system (1350-1351)?

Support - the skeleton is the body framework that supports internal tissues and organs. Protection - The skeleton forms a firm, cage-like structure that protects many internal organs. Movement - Skeletal muscles are attached to the bones which enables the bones to provide leverage for movement. Mineral storage - the bones serve as a storage area for various minerals, particularly Calcium and phosphorus. When the body intake of these minerals is inadequate, the bones release the minerals. Hematopoiesis - (Blood Cell Formation) takes place in the red bone marrow. The red bone marrow is spongy bone found in the ends of the long bones. A child's bones contain a proportionately larger amount of red bone marrow than an adult. As a person ages, much of the red bone marrow converts to yellow bone marrow, which is composed of fat cells.

What are surgical interventions for total knee or total hip replacement (1375)?

Surgical procedures can prevent progressive deformities, relieve pain, improve function, and correct deformities resulting from RA, OA, or other disorders. Tendon transplants can replace damaged muscles. RA patients may need a synovectomy (excision of synovial membrane) to maintain joint function. An osteotomy (cutting into bone to correct bone/joint deformities) can improve function and relieve pain. Arthrodesis (surgical fusion of a joint) can be performed when severe joint destruction has occurred. Total joint replacement arthroplasty (repair or refashioning of one or both sides, parts, or specific tissue within a joint) is often required on the elbow, hip, knee, or shoulder joint to restore or increase mobility.

How is osteomyelitis assessed and diagnosed (1373)?

Take a complete history, along with a physical examination. Collect subjective data including a history of injuries, surgical procedures, and diseases. Assess complaints of persistent, severe, and increasing bone pain and tenderness, as well as regional muscle spasm. Also inquire about allergies, especially to medications, because antibiotics are given long-term. Objective data collection includes the inspection of any wounds, assessing drainage for color/amount/odor, monitoring vitals for signs of infection (temperature elevation, tachycardia, tachypnea), and noting any edema.

What should the nurse include in the teaching plan for a patient who is taking alendronate (Fosamax)?

Take drug first thing in the morning

What is Nuclear scanning - (1355-1366)?

Tests done in the nuclear medicine department, which has scanners or camera detectors that record images on radiographic film. Nursing interventions for patients scheduled for nuclear scanning procedures include: 1. Obtain a written consent form. 2. Inform the patient that the radioactive isotopes will not affect family or visitors. 3. Follow special preparations for specific scans.

What is Unicompartmental Knee Arthroplasty, what is a TKA (1375)?

Unicompartmental - This is also referred to as partial knee replacement. It is performed when only one of the compartments of the knee is affected by arthritic changes. The knee has three compartments, the medial/inside compartment, the lateral/outside compartment, and the patellofemoral compartment, which is where the kneecap rests. TKA refers to total knee arthroplasty and is performed on patients of all ages. Interventions are aimed at promoting healing and facilitating mobility. For a TKA, the typical post-op stay is 1-2 nights. Encourage the use of an incentive spirometer during waking hours, and begin clear liquids, advancing to regular diet as tolerated. Monitor IV fluids and antibiotics, and change the dressing as needed.

Which instructions should the nurse include in a teaching plan for a person with gouty arthritis? (Select all that apply.)

a. Avoid excessive alcohol. b. Maintain rest and immobility while disease is symptomatic. c. Check urine and urine output for possible kidney stones. e. Use bed cradle to support linens.

The characteristics of osteoarthritis that should be included in a teaching plan would include that osteoarthritis (select all that apply):

a. will cause the formation of Heberden nodes. c. results from wear and tear. d. may affect only one side of the body.

A patient, age 44, has chronic osteomyelitis. He should be taught to?

avoid trauma to the affected bone.

The three vital functions muscles perform when they contract are: (Select all that apply.)?

b. Maintenance of posture c. Motion e. Production of heat

Which of the significant neurovascular impairment symptoms, following a musculoskeletal trauma, should be reported to the physician? (Select all that apply.)?

b. Slow capillary refill c. Diminished or absent pulses. f. Unrelieved pain after administration of pain medication

A 71-year-old patient is manifesting signs and symptoms of gout. When assessing him for signs and symptoms of gout, the nurse should pay particular attention to?

edema or discoloration of the great toe.

When caring for a patient who is 34 years old and has rheumatoid arthritis, the nurse should remember that?

rest and exercise are both important parts of therapy.

Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines?

Brain, liver, kidney

Calcium is a mineral found in many foods that can slow bone loss during the aging process. The following are high in calcium?

Broccoli (green vegetables), yogurt.

A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to provide support and comfort, an immobilizing device known as a ______ is applied.

Buck's traction

_______ traction is utilized to provide support for the patient with a hip fracture?

Buck's traction

Which patient statement indicates the need for additional teaching for a patient with rheumatoid arthritis who is taking meloxicam (Mobic)?

"I take aspirin before I go to bed."

The patient has been diagnosed as having gouty arthritis. He asks the nurse to explain the cause of the inflammation of his great toe. The most appropriate nursing response is?

"The inflammation is from small accumulations of uric acid crystals which are called tophi."

The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. What is the most appropriate nursing response?

"The inflammation is from small accumulations of uric acid crystals, which are called tophi."

What are the main parts of the skeleton (1351)?

1. Axial skeleton: A. Skull - cranium, ear bones, face. B. Spine - vertebrae. C. Thorax - ribs, sternum. 2. Appendicular Skeleton: A. upper extremities - shoulder (pectoral) girdle, arms, wrists, hands. B. Lower extremities - hip (pelvic girdle), legs, ankles, feet.

What is involved in medical management of RA (1361)?

1. Controlling the disease via disease-modifying and anti-inflammatory drugs. 2. Providing pain relief. 3. Reducing clinical symptoms with methotrexate (Rheumatrex). 4. Prolonging joint junction (often with physical therapy, traction, and splints). 5. Slow the progression of joint damage by promoting ADL, weight management, and an exercise program.

What is involved in assessment of RA (1359)?

1. Joint pain, tenderness, swelling or stiffness for 6+ weeks. 2. More than one joint is affected. 3. Morning stiffness for 30m+. 4. Small joints (wrists, certain joints of the hands and feet) are affected. 5. The same joints on both sides of the body are affected. Other symptoms include fatigue and low-grade fever. Flare-ups last for days up to months, frequently occurring or untreated flares can affect the patient systemically. Eyes may become dry or sensitive to light, oral cavities may become irritated or develop ulcerations, skin may have RA nodules, lungs and blood vessels may be inflamed, and bone marrow may develop anemia. Objective data collection includes: observing joints for edema, tenderness, subcutaneous nodules, limitation in ROM, symmetric joint involvement, and fever.

What are the four groups that bones are classified into, based upon their form and shape (1351)?

1. Long - found in the extremities. 2. Short - found in the hands and feet. 3. Flat - found in the skull and sternum. 4. Irregular - make up the vertebrae/backbone. Note: Long bones run the risk of a fat embolism, when they fracture.

What do patients with AS often have as laboratory results (1366)?

1. Low hemoglobin and hematocrit. 2. Elevated ESR and CRP 3. Elevated serum alkaline phosphatase levels. 4. Presence of HLA-B27 antigen. Sacroiliac joint and intervertebral disk inflammation are often revealed by radiographic exam.

What is a Hip Arthroplasty (1376)?

A total hip replacement, and it is performed when arthritis involves the head of the femur and acetabulum, or for fractures, tumors, and injuries. It typically is decided upon after periods of lengthy pain and discomfort. Prosthetic devices may be cemented or uncemented. Subjective data collection includes assessing the patient's level of orientation, as older adults can become disoriented from an environmental change (home to hospital setting) and from the effects of anesthesia & other prescribed medications. Complaints of unrelieved pain/numbness, tingling, or paresthesia indicate neurovascular impairment. Objective data includes assessment of the patient's compliance with nursing interventions to promote circulation, prevent impairment of skin integrity, and prevent hypostatic pneumonia by such means as coughing, turning (to the unaffected side, additional pillow use to keep the affected leg abducted), deep breathing q2h, and use of an incentive spirometer. Assess vitals for evidence of excessive bleeding (hypotension, tachycardia, tachypnea). Decreased urinary output indicates hypovolemia. Assess drainage of the surgical wound at least every 4 hours. Assess the incision line for signs of inflammation (erythema, edema, fever, pain). Assess traction, if used, for proper alignment and to ensure the affected leg is abducted. Check for a reaction to the cement, such as signs of phlebitis (edema, erythema, pain).

The movement of an extremity away from the midline of the body is called?

Abduction

What are the types of body movement (1355)?

Abduction - Movement away from the midline of the body. Adduction - Movement toward the midline of the body. Extension - Movement which increases the angle between two adjoining bones. Flexion - Movement which decreases the angle between two adjoining bones. Rotation - Movement of the bone along its longitudinal axis (pivot motion). Supination - a movement of the hand and forearm that causes the palm to face upward or forward. Pronation - A movement of the hand and forearm that causes the palm to face downward or backward. Dorsiflexion - A movement that causes the top of the foot to elevate or tilt upward. Plantar flexion - Causes the bottom of the foot to be directed downward.

What is a Myelogram (1355)?

An X-ray record of the spinal cord, that's used to detect structural disorders such as a herniated disk, presence of infection, or tumors. The test involves the same procedure as a lumbar puncture. Contrast medium may be used, so an allergy assessment is necessary. After a myelogram, the most common discomfort is a headache. With water-soluble dye, the patient should lie in semi-fowler's for approximately 8 hours. Encourage fluid consumption during this time, to help the body absorb the dye from the spinal column. The patient should inform the nurse if they experience: a headache, stiff neck, leg weakness, difficulty voiding... or rare complications like: seizure, infection, drowsiness, severe headache, numbness, and paralysis.

What is an Arthroscopy (1358)?

An endoscopic exam used to explore the joint to determine disease, to drain fluid from the joint, and to remove damaged tissue or foreign bodies. It can be done in the knee joint, hip, or shoulder. Afterward, advise the patient to limit activities for several days.

A patient has undergone a bipolar hip repair (hemiarthroplasty). She should be instructed to?

Avoid crossing her legs.

A 76-year-old female patient is being seen for osteoarthritis of the knee in the clinic. In discussing strengthening exercises, which exercises would you recommend?

Bicycling for short distances.

What is important to note about articulations/joints (1351)?

Bones cannot bend without damage. To allow movement, individual bones articulate/join at joint sites. Bones are held together by flexible connective tissue. The joint is the point of contact between the individual bones and the structure of the individual bones depends on the function of the area. Every bone in the body (aside from the hyoid bone, which anchors the tongue), connects/articulates with at least one other bone. Joints hold bones together to form the skeleton and allow movement/flexibility of the skeleton. The three types of joints are: 1. Synarthrosis: no movement. 2. Amphiarthrosis - slight movement. 3. Diarthrosis - free movement. Note: a goniometer measures the angle of a joint, determining the degree of joint mobility.

Which ethnic group is at a highest risk of developing osteoporosis?

Caucasian and Asian women

What should be known about the fracture of the hip (1379)?

Hip fractures are the leading type of fracture requiring treatment in a hospital facility, and women are at greater risk (because of their increased osteoporosis risk and longer life expectancy vs men). Signs and symptoms of hip fracture are severe pain and tenderness in the region of the fracture site or inability to move the leg voluntarily, and shortening or external rotation of the leg. Assessment includes an accurate history of the events before the injury, assessing the patient's level of orientation, medical and surgical history, and family history of bone disease. Patients with GERD who take antacids or use proton pump inhibitors are at increased risk, due to the drugs causing malabsorption of calcium. Signs/symptoms of a fracture vary with the type and location of the break. Most patients complain of pain in the affected leg after sustaining a fractured hip, although patients suffering from an impacted intracapsular fracture have little pain, if any, immediately after the fracture. Impaired sensation may indicate nerve damage from the bone fragments "pinching" or severing the nerve. Assess for edema, tenderness, muscle spasms, deformity, and loss of function. Objective data includes assessing for soft tissue injury, with erythema or ecchymoses noted. Look for differences between the injured and uninjured limb. A change in curvature or length of the bone may indicate fracture - the affected leg is shorter. Crepitus may be felt/heard as the broken bone ends rub together. Assess neurovascular status of the extremity. Keep the injured part still, to help prevent turning a closed fracture into an open one and to not cause additional pain. Patients suffering from any trauma are at risk for shock - treating shock takes precedence over treating the fracture.

The nurse clarifies to a patient who is being evaluated for possible rheumatoid arthritis that the elevated erythrocyte sedimentation rate indicates the presence of?

Increased inflammatory reaction in the body

What should the nurse do when a patient with osteomyelitis is admitted with an open wound that is draining?

Initiate drainage and secretion precautions

What is involved in nursing interventions and patient teaching for total hip replacement (1377)?

Interventions are aimed at assessing of potential complications, promotion of healing, and facilitating mobility. Vitals should be taken every 4 hours or more. Document I & O. Measure oral intake, and urinary output as well as IV fluids and fluid from drainage devices such as the Hemovac. Weight-bearing and physical therapy may be ordered by the surgeon. Encourage coughing and deep-breathing every 2 hours. Give oxygen as needed. Instruct the use of incentive spirometry every 2-4 hours. Perform neurovascular checks every hour for 24 hours, then every 2 hours for the next 24 hours, and then every 4 hours. Check vitals every 4 hours. Assess for pain control. Maintain the position of the operative area with a splint, abduction pillow, immobilizer, or a brace. Turn the patient to the non-operative side. Begin clear liquids, advancing diet as tolerated. Maintain bed rest for 24h post-op, teaching active or passive exercises to help the joints involved. The patient should be up with a walker or crutched 4x daily, increasing ambulation as able. Chair sitting is initially limited to 10-15m 2-3x daily for the first week, and then 20-30m 4x daily. Discharge instructions include teaching the use of an ambulatory aid, avoiding adduction, and limiting hip flexion to 90 degrees for approx. 2-3 months.

What is involved in nursing intervention and patient teaching on Osteoporosis (1372)?

Interventions are aimed at preventing further bone loss and fracturs. Milk/dairy rich diets provide calcium in the diet. Caffeine should be limited, and smoking should be encouraged to be stopped. Teach patients relaxation techniques. Safety measures like side rails, hand rails, bedside commodes, and rubber mats in showers help prevent falls in older adults. Patients should be kept ambulatory and weight-bearing exercise (walking, bike riding, swimming 3+ days weekly) helps increase bone density. Limit caffeine and excess protein in the diet. Calcium and vitamin D supplements are encouraged. Prevention of osteoporosis should begin before bone loss has occurred.

What is involved in nursing interventions and patient teaching for osteomyelitis (1373)?

Interventions include being gentle in moving/manipulating the diseased extremity. The affected part may need rest, with use of pillows/sandbags for alignment. Wound irrigation may be indicated, and sterile dressings are employed using strict surgical asepsis. Diet planning includes a diet high in calories, protein, and vitamins. Monitor for worsening infection, assess vital signs, and review any lab results. Teach patients the importance of completing the antibiotic treatment and about signs of infection. Acute osteomyelitis may respond to treatment after several weeks, while chronic osteomyelitis may last a lifetime and consist of periods of exacerbation and remission.

What is an Electromyogram (1358)?

It involves the insertion of needle electrodes directly into skeletal muscles so that electrical activity can be heard, seen on an oscilloscope, and recorded on paper at the same time. Nerves can be observed for neuropathy and muscles for myopathy.

What is Aspiration (1357)?

It is done to obtain a specimen of body fluid. The HCP inserts a needle into a cavity with the patient under local anesthesia. It's performed using sterile technique. Nursing interventions include: 1. Having patient sign consent. 2. Reinforce the HCPs explanation of the procedure. 3. Encourage the patient to remain immobile. 4. Have the patient void before the procedure. 5. Maintain sterile technique. 6. Support the patient emotionally. 7. Apply sterile pressure dressing to the puncture site until the bleeding has stopped. 8. Assist with the collection, labeling, and transporting of the specimen to the laboratory immediately. 9. Observe for emotional and physical distress after the procedure.

When the patient with rheumatoid arthritis complains about the daily exercise, the nurse encouragingly reminds the patient that exercises?

Keep the joints from "freezing".

What do the terms Laminography/planography and Scanography refer to (1355)?

Laminography - useful in helping to locate small cavities, foreign bodies, and lesions that are overshadowed by opaque structures. Scanography - a method of producing radiograph of internal body organs using a series of parallels beams to eliminate size distortion, which allows accurate measurement of bone length.

Which foods should the home health nurse suggest for the patient with osteoporosis to help slow the disease?

Leafy green vegetables

Prolonged bed rest puts the older adult at risk for?

Pathological fractures - immobilization results in bone resorption and the bone tissue becomes less dense. Prolonged bed rest puts the patient at risk for pathological fracture.

What is Osteoporosis (1370)?

Osteoporosis is a disorder that results in a loss in bone density. This reduction is sufficient to interfere with the mechanical support function of the bone. Women between 55-65 years-of-age are at risk for postmenopausal osteoporosis, possibly related to the loss of the female hormone estrogen. Juvenile osteoporosis traditionally impacts children and young adults, characterized by the sudden onset of bone pain and fracture or a fracture after a trauma. Idiopathic osteoporosis includes post-menopausal (type 1) and age-associated/senile (type 2). Age-related osteoporosis is linked to the loss of bone mass related to aging. Genetic and environmental factors can contribute to bone loss. Osteoporosis affects the vertebrae, neck of the femur pelvis, hands, and wrists. Risk factors that an individual can control include social behaviors (smoking, alcohol use) and dietary habits (inadequate intake of calcium, vitamin D, fruits and vegetables... excess intake of protein, sodium, caffeine). Medical conditions associated with increased disease development include hyperthyroidism, chronic lung disease, cancer, inflammatory bowel disease, celiac disease, alcoholism, and vitamin D deficiency. Medications linked to osteoporosis include steroids, anti-convulsants, immunosuppressant therapies, and heparin. Most osteoporosis patients have no symptoms in early stages. fracture, usually of the vertebrae, is often the first symptom. Loss of height over time or stooped posture may indicate the disease before a diagnosis.

A patient's patellar-femoral cartilage has deteriorated due to arthritis. The medial and lateral cartilage is undamaged. This patient is likely to undergo ______ knee replacement surgery?

Partial Unicompartmental

The term Unicompartmental knee arthroplasty is also referred to as?

Partial knee replacement

What is involved in medical management of osteoporosis (1371)?

The HCP orders a treatment regimen aimed at increasing bone density and retarding bone loss. Calcium supplements that bring the total calcium intake per day to 1200mg for men and postmenopausal women are recommended, with 2000mg being the maximum amount. Alcohol intake should be limited. Weight-bearing exercise programs help to improve muscle tone (such as walking). Medications like alendronate, zoledronic acid, and ibandronate are bone resorption inhibitors that assist in increasing bone density. Risedronate is another bone resorption inhibitor. Selective estrogen receptor modulators, such as raloxifene, may be used as they mimic the effect of estrogen on bone by reducing bone resorption. Teriparatide is a parathyroid hormone approved for postmenopausal women at risk for osteoporosis fractures or who cannot use other treatments. Surgical interventions may also be used for patients with severe osteoporosis who are unresponsive to analgesics. Vertebroplasty and kyphoplasty may be used to relieve pain from compression fractures of the spine. Kyphoplasty involves inserting a balloon onto the center of the collapsed vertebrae, restoring the position of the vertebrae. After the procedure, patients stay up to 24h afterward in the hospital, with a flat bed required for 4h postoperatively and then allowing ambulation as able.

What is involved in medical management of OA (1368)?

The PCP prescribes an exercise plan that is balanced with rest periods. Physical therapy using heat application helps with stiffness/pain/spasms. Gait enhancers like canes/walkers help relieve discomfort. Pharmacologic therapies begin with OTC meds like Tylenol and progress to NSAID therapies like aspirin and Motrin. Cortisone is sometimes used to produce pain relief and halt (temporarily) the destructive process. As an alternative to pharmacologic measures, relaxation techniques, massage therapy, imagery, and therapeutic touch have been proven effective in reducing discomfort and the need for NSAIDs. Glucosamine supplements can also help to relieve pain and stiffness from OA. Cupping, which involves using a flammable substance in a cup, igniting it, and placing it on the skin, creates suction that increases circulation to the area and reduces pain/discomfort. Surgical interventions like osteotomy, joint replacement, or arthroplasty may be utilized.

How many muscles are in the body? What are the vital functions of muscles (1351)?

The body has more than 600 muscles, making up approximately 40-50% of the total body weight. As muscles contract, they create motion, maintain posture, and produce heat. Note: all body movements rely on the integrated functioning of the bones, joints, and muscles.

What is Osteoarthritis (degenerative joint disease) (1367)?

The most common arthritis, resulting from wear and tear on the joints. It is a non-systemic, non-inflammatory disorder beginning with degeneration of the cartilage of joints, thus causing damage to bones. Degenerative joint changes traditionally are noticed beginning in middle age and, by age 70, most adults have hypertrophic joint changes. Primary OA has no known causes, while Secondary OA is caused by trauma, infections, previous fractures, RA, stress on weight-bearing joints from obesity, occupations placing abnormal stressors on joints, and occupations requiring excessive stooping and bending (ex: plumbers). It most commonly affects the joints of the hand, knee, hip, and cervical & lumbar vertebrae. Symptoms include pain and stiffness in the joints, with the joints being the stiffest in the morning hours upon awakening.

What is Rheumatoid Arthritis (RA) (1358)?

The most serious form of arthritis, which can lead to severe joint deformity. It is a chronic, systemic inflammatory autoimmune disease that affects approximately 1.3 million people. It affects nearly 3x as many women as men, with it most often affecting women of 30-60 years of age. There is a noted genetic link, but smoking significantly increases the risk of RA in men and women who are predisposed genetically. It affects many organ systems (lungs, heart, blood vessels, muscles, eyes, skin). It's characterized by a chronic inflammation of the synovial membrane (synovitis) of the synovial joints. RA is believed to involve an immune reaction caused when the body's immune system chooses to attack one of its own proteins. The immune system causes an inflammatory response, and the repeated inflammation of joints & surrounding tissue may lead to gross deformity and loss of function. It's characterized by periods of remission and exacerbation, and flare-ups may be attributed to a stressful event such as infection, work stress, physical exertion, childbirth, surgery, or emotional upset.

The nurse instructs the patient who is to have a Unicompartmental knee replacement that a major advantage of this partial knee replacement is that?

The patient will be up and walking 2 to 3 hours after the operation.

How do nerves and blood supply relate to the musculoskeletal system (1354)?

The physical demands placed on the skeletal muscles necessitate a constant supply of oxygen and nutrition and are supplied with blood vessels that carry oxygen & nutrition to the area and remove waste products of metabolism. Skeletal muscles are voluntary, so they also need constant information - nerve cells or fibers send continuous impulses that stimulate the muscle cells. The impulses enter the neuromuscular junction and, as the nerve impulse passes through this junction, chemicals are released that cause the muscle to contract. Motor unit - muscle cells in union with the nerve cell that controls them. Synaptic cleft - impulses from nerve cells travel across a small gap, as the nerve & muscle cells do not directly touch each other. This is the synaptic cleft, and it is filled with tissue fluid. Neurotransmitter - a special chemical that travels through the fluid to stimulate the muscle fiber. Acetylcholine - the neurotransmitter for skeletal muscle tissue. Cholinesterase - an enzyme that breaks down the acetylcholine once it's transferred the message, allowing the muscle cell to relax between impulses.

What is Arthrocentesis (1357)?

The puncture of a patient's joint with a needle and the withdrawal of synovial fluid for diagnostic purposes. It's helpful in diagnosis trauma, SLE, gout, osteoarthritis (OA), and rheumatoid arthritis (RA). After the procedure, provide proper support to the affected extremity. Place it on a pillow and maintain joint rest for approximately 12 hours, if indicated. Apply ice to the affected joint for 24-48h unless otherwise ordered. Assess for signs of infection.

What is included in medical management, nursing interventions, and patient teaching on FMS? (1374)?

There is no cure for fibromyalgia, and the primary treatment approach includes patient education, and emotional support & reassurance. FMS is not a psychiatric disturbance. Antidepressants, anticonvulsants, muscle relaxants, and analgesics are utilized - analgesics should, however, not include opioids due to tolerance/addiction risk. Interventions are individualized, holistic, and goal oriented, focusing on functional goals that enable the patient to live as normal a life as possible. Good sleep hygiene, exercise programs (consisting of gentle, progressive stretching), relaxation techniques, and nonimpact exercise are all recommended. Large meals should be avoided for 2-3h before bedtime, and regular sleep patterns should be maintained. Fibromyalgia is challenging to treat, and emotional stressors affect a patient's ability to maintain employment and remain active in family processes.

How is RA diagnosed (1359)?

There is no single definitive test for RA. Diagnosis is based primarily on patient history and physical examination. Four classic symptoms are morning stiffness, muscle weakness, joint pain, and fatigue. Various lab tests may support the diagnosis and rule out other diseases.

What is the use of Magnetic Resonance Imaging (MRI) (1356)?

These assist in diagnosing abnormalities of bones and joints and surrounding soft tissue structures, including cartilage, synovium, ligaments, and tendons. The benefit is that MRI scanning can give much more detailed pictures of fluid-filled soft tissue and blood vessels than any other test. Before an MRI, the patient should remove: Jewelry, clothing with metal fasteners, glasses, and hair clips. Patients that cannot undergo an MRI include patients with metal prosthesis, orthopedic screws, or cardiac pacemakers. The patient must remain still in an MRI for 30-60 minutes. Note that the patient may be anxious and require a sedative if ordered by the HCP. Encourage relaxation techniques, such as imagery, during the test. Afterward, the nurse should take vital signs, and allow the patient to resume pretest activities.

What is Methotrexate (1363)?

This is often used to reduce clinical symptoms of RA. It alters the way the body uses folic acid, which is necessary for cell growth. This decreases inflammation. Side effects include: upset stomach, nausea, vomiting, anorexia, diarrhea, sore mouth, headache, blurred vision, dizziness. The drug is taken orally or by injection. Vital signs should be monitored. Patients should avoid pregnancy while taking this drug and not get vaccinations without HCP consent. Keep the patient well hydrated.