Post on 30-May-2018
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Review of Anatomy and
Physiology Skeleton
Classification of bones Compact (dense)
Cancellous (spongy) Bone marrow
Axial section
Appendicular section
Joint articulations Muscles
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Diagnostic Tests andAssessments
Radiologic tests Are diagnostic studies performed using x-
rays, with or without injection of contrastmedia, to detect musculoskeletal problemsand monitor effectiveness of treatment
X-ray (radiograph): most common and
widely used radiologic test for assessmentof musculoskeletal problems andeffectiveness of treatment
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Diagnostic Tests and
Assessments EMG (electromyogram or myogram):
records and evaluates the electricalactivity of muscles during contraction
Detects abnormal electrical activity inmuscle
There are two different types of EMG:intramuscular (IM) EMG (more commonly
used) and surface EMG (SEMG)
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Diagnostic Tests and
Assessments Long, small-gauge needles are inserted through
the skin into muscle
Needles detect electrical activity of the muscle
and transmit information into electromyogrammachine; electrical activity is displayed visuallyon an oscilloscope or heard audibly through anaudiotransmitter (microphone)
(SEMG): electrodes are placed above muscle to
detect electrical activity
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Diagnostic Tests and
Assessments Arthroscopy: a surgical procedure used
to examine the internal structure of a jointusing an arthroscope il-sized device with
optical fibers and lenses), which is insertedinto very small skin incisions; device isconnected to a video camera to allow forvisualization of the interior of the joint
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Diagnostic Tests and
Assessments Procedure may be used for diagnosis or
treatment of musculoskeletal disorders suchas osteoarthritis, rheumatoid arthritis,
infectious types of arthritis, and internal jointinjuries like meniscus tears, ligament strainsor tears and cartilage deterioration
Arthroscopic surgery can be done during
procedure to repair joint tissues;arthroscopic surgery creates less tissuetrauma, less pain, and allows for a rapidrecovery
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Diagnostic Tests and
Assessments Client education: postprocedure Encourage client to take analgesics for comfort
and limit activity as directed
Instruct client to observe site for hematoma orbleeding
Teach client how to perform neurovascularassessment (temperature, color, capillary refill,movement, and sensation) on affectedextremity
Teach client about signs and symptoms ofinfection to report; elevated temperature,warmth at injection site, purulent discharge,
and redness
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Diagnostic Tests and
Assessments Arthrogram: contrast media or air
is injected into the joint cavity toallow for visualization of jointstructures; client moves jointthrough a series of movements whilea series of x-rays are taken; assess
for allergy to contrast media
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Diagnostic Tests and
Assessments
Client education preprocedure: if injectedcontrast dye is used, inform client that once thedye is injected there may be a feeling of warmth,nausea, headache, salty taste in the mouth,itching, hives, and rash throughout the body(symptoms are usually temporary and will betreated if necessary
Client education postprocedure
Inform client that temporary discoloration of theskin and urine is normal after injection of dye
Teach client to perform neurovascular assessmenton affected extremity
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Diagnostic Tests and
Assessments CT scan (computerized axial
tomography): combines x-rays withcomputer technology to produce ahighly detailed, cross-sectionalimage of internal organs andstructures of the body; also known as
CAT scan
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Diagnostic Tests and
Assessments Body is visualized from skin to central part
of the body being examined; recordedimage is called a tomogram
Client education If ingested contrast dye is used, instruct client
to increase fluid intake to assist in eliminationof dye
Monitor for evacuation of contrast media and
possible constipation Initial stools may be white in color, which is
normal until all contrast media is evacuated
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Diagnostic Tests and
Assessments MRI (magnetic resonance imaging):
radiologic technique (without radiation)that uses magnetism, radio waves, and a
computer to produce cross-sectionalimages of the body structures
Machine is extremely noisy and may cause orexacerbate a claustrophobic sensation
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Diagnostic Tests and
Assessments Client education Explain procedure to the client; a mild sedative may
be given preprocedure to help decrease any anxietyassociated with a claustrophobic feeling
Instruct client to notify healthcare providers of anymetallic body parts such as implants, pacemakers,artificial joints, metallic bone plates, prostheticdevices, surgical clips, bullet fragments, metallicclips, or other al objects within the body that can
distort the MRI image or affect the magnetic field
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Diagnostic Tests and
Assessments
Bone scan: technique used to create images ofbones on a computer screen or on a film using asmall amount of radioactive material that travelsthrough the bloodstream Radioactive material is especially absorbed in
abnormal areas of a bone; degree of dye absorption isrelated to the amount of blood flow to the bone
A camera scans the entire body and a recording ismade on a special film
Increased dye absorption is seen with osteomyelitis,
osteoporosis, fractures, Pagets disease and cancer ofthe bone
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Diagnostic Tests and
AssessmentsArthrocentesis (joint aspiration)
and analysis: fluid is removed fromjoint to reduce swelling and pain
and/or obtain fluid for examinationusing a sterile needle and syringe Post-procedure complications are
uncommon but may include localizedbruising, minor bleeding into the jointcavity, and loss of pigment at injectionsite (septic arthritis is a rare butserious complication)
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Diagnostic Tests and
Assessments Client education
If cortisone medication was injected into the joint,teach client to monitor for inflammation of the
injected area, atrophy or loss of pigment at theinjection site, and increased blood glucose
Instruct client to follow post-procedure activityrestrictions as directed by healthcare provider
Instruct client to monitor for post-procedurecomplications and check dressing for excessivebleeding
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Laboratory Studies
Antinuclear antibodies (ANA): sensitivescreening blood test used to detectautoimmune disease
ANAs destroy the nucleus (innermost core of thecell that contains the DNA) of the cells
Test not definitive but suggests presence ofauto-antibodies (antibodies directed against thebodys own tissue)
Present in clients with a number of autoimmunediseases such as rheumatoid arthritis, systemiclupus erythematosus, scleroderma, and others
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Laboratory Studies
Calcium (Ca++): one of the most abundantelectrolytes in the body that causesneuromuscular irritability and contractions; adultnormal reference value is 9 to 11 mg/dL Stored in bone and gives bone stability
Blood specimen is obtained to monitor calcium level Normal ranges vary slightly among healthcare
institutions Decreased calcium levels may be found in
osteomalacia, inadequate dietary intake of calcium,renal disease, and hypoparathroidism
Increased calcium levels may be seen in boneneoplasm, multiple fractures, immobilization, renalcalculi, and hyperparathyroidism
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Laboratory Studies
Phosphorus (2.5 to 4.5 mg/dL is normalreference range): blood sample is obtained tomonitor level and compare phosphorus level withother electrolytes in the body (such as calcium) A high percentage of total phosphorus in the body is
combined with calcium in teeth and bones Decreased levels can be seen with hypercalcemia,
starvation, malabsorption syndrome, osteomalacia, andvitamin D deficiency
Increased levels can be seen with healing fractures,metastatic bone tumors, and hypocalcemia
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Laboratory Studies
Rheumatoid factor (RF) (Normal-negative or
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Laboratory Studies
Erythrocytes sedimentation rate(ESR); normal is
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Laboratory Studies Uric acid(Normal male 4.5 to 6.5 mg/dL,
female 2.5 to 5.5 mg/dL): test generally used tomonitor serum uric acid levels during thetreatment of gout and may be used to diagnoseother health problems
Uric acid is the end product of purine metabolism;the kidneys normally excrete excess uric acid
Hyperuricemia (elevated urine or serum uric acidlevels) occurs because of poor renal function,excessive purine metabolism, and/or excessive
dietary intake of purine foods Elevated uric acid level is seen in gout
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Common Nursing
Techniques andProcedures
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Common Nursing Techniques
and Procedures Instructing the client on the use of
crutches
Crutch gaits: safe method of walkingusing crutches, alternating bodyweight on one or both legs and thecrutches;
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Instruction for the Client on
the Use of Crutches Four-Point Gait
Slow gait
Require good coordination Weight bearing is on both legs
Move each foot and crutch forward
separately (right crutch, left foot;left crutch, right foot)
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Instruction for the Client onthe Use of Crutches
Two-point gait
Faster than four-point gait
Requires more balance
There is partial weight-bearing on eachfoot
Arm movement simulate arm movementwhen walking
Move left crutch and right foot forwardtogether; move right crutch and left footforward together
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Instruction for the Client on
the Use of Crutches Three-point gait
Fast gait
Two crutches and unaffected legbear weight alternately
Weaker leg and both crutchesmove together followed bystronger leg
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Instruction for the Client on
the Use of Crutches Swing-to gait
Fast gait
Used by clients with paralysis oflegs and hips
Prolonged use may lead to atrophyand unused muscles
Advance crutches forward together,lift body using arms, then swing tomeet crutches
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Common Nursing Techniquesand Procedures
Traction: direct pulling forceapplied to a fractured extremity
that results in realignment of bone Reduces fracture, lessens muscle
spasms, relieves pain, correctsdeformities, promotes rest, and
allows for exercise
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Common Nursing Techniquesand Procedures
Skin and skeletal traction are mostcommonly used; manual traction is onlyused briefly under physician direction
Skin traction (using tape, boots, splints) Assists in reduction of a fracture (does notprimarily achieve reduction) and helpsdecrease muscle spasms
Generally used for short-term treatment (48 to72 hours) and is applied directly to the skin
Weights range from 5 to 10 pounds
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Common Nursing Techniquesand Procedures
Balanced suspension (traction that is ahanging support to immobilized body partin a desired position)
Used with skeletal traction to improvemobility while maintaining alignment offracture
Body part is suspended using splints, ropes,
and weights
Client able to perform activities such astoileting and personal hygiene; bed linen canbe changed without disturbing tractionalignment
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Common Nursing Techniquesand Procedures
Countertraction: pulling forceexerted in the opposite direction toprevent the client from sliding to theend of the bed; examples ofcountertraction include the clientsweight, elevating the foot of the bed
(Trendelenburg), and elevating thehead of the bed with cervicaltraction
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Nursing Care for the Client in
Traction
Ensure that all ropes, weights, and pulleys arehanging freely, not shredded or torn, in astraight line
Bed linen should be kept off traction ropes
Teach client that weights should not be lifted forany reason (lifting weights alters the line of pulland could potentially interfere with bone healing)
Ensure that the ordered amount of weight ismaintained at all times
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Nursing Care for the Client in
Traction Teach client how to perform skin
assessment to monitor and prevent skinbreakdown on bony prominence and
pressure areas Ensure that body is always kept in proper
alignment to prevent complications such asexternal rotation of the joint, increase pain,
and poor healing of the fracture Teach client how to monitor for infection at
pin sites
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Nursing Care for the Client in
Traction
Inform client to avoid massaging calves orreddened areas to prevent clotdislodgement caused by venous stasis
Encourage client to increase fluid intake
(2,500 mL per day unless contraindicated)and roughage in diet to preventconstipation, UTI, and renal calculi
Teach client how to perform deep-breathing
and coughing exercises to preventrespiratory complication
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Nursing Care for the Client in
Traction Encourage client to use the overhead trapeze
(and unaffected leg if possible) to reposition forcomfort, shift weight to prevent skin breakdown,perform exercises, and assist with personal care,toileting and bed linen changes
Encourage client to adhere to exercise regimento maintain muscle tone, endurance, andprevent bone demineralization
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Nursing Care for the Client in
Traction Provide diversional activities and
encourage social interaction withfamily and friends to preventpotential isolation
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Common Nursing Techniquesand Procedures
Cast care: a cast is applied forimmobilization to ensure stability ofa fracture
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Nursing Care of the Client in
a Cast
Instruct the client to avoid covering a new castwith blanket or plastic for extended periods
Turn client from side to side (using palms notfingertips) every 2 hrs to facilitate to drying forthe first 24 to 72 hrs
Instruct client to apply ice for the first 24 hrsover fracture side to control edema, ensuringthat ice is securely contained so cast does notbecome wet
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Nursing Care of the Client in
a Cast Instruct the client to elevate the extremity above
the level of the heart to promote venous return forthe first 24 hrs after application
Instruct client to perform active ROM to jointsabove and below immobilized extremity
Teach client about signs and symptoms to reportto healthcare provider: increasing pain inimmobilized extremity, excessive swelling anddiscoloration of exposed limb, burning or tinglingunder cast, sores, or foul odor under cast
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Common Nursing Techniquesand Procedures
Splinting and immobilization: likecasts, splints are used to immobilizea fractured extremity to ensure
stability after closed reduction andexternal fixation; teach client how toperform neurovascular assessment
(color, temperature, capillary refill,and pulses)
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Laminectomy: surgical incision of the lamina doneprimarily to relieve symptoms related to herniatedintervertebral disc
Assess effectiveness of pain management
Perform neurological and neurovascular assessment;monitor bowel and bladder function
Assess client for complaints of severe headache orleakage of cerebrospinal fluid (CSF), nausea, abdominaldiscomfort, incontinence, amount and character ofdrainage on dressing
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Use the logroll technique (turning a client as aunit) to turn and reposition client; maintainproper alignment of the spine at all times
Inform client that bed rest may be maintained
for the first 24 to 48 hours after procedure;pillows may be used for comfort under thethighs in the supine position and between thelegs in the side-lying position
Assist client to rise as a unit when getting
out of bed (especially for the first time) Instruct client that paresthesias (numbness
and tingling of extremities) may not berelieved immediately after procedure
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Internal fixation: fracture immobilizationwith a metal device (made of screws, pins,and/or plates) that is surgically inserted torealign and maintain a fracture
Inform client that x-rays will be taken atregular intervals to ensure proper alignmentof the fixation device
Instruct client about signs and symptoms toreport related to infection; elevated
temperature, localized pain and warmth,tenderness, chills, malaise, and changes inneurovascular status of affected extremity
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Joint replacement, total hip replacement(THR) THR is frequently performed for client with
conditions such as rheumatoid arthritis,malignant bone tumors, arthriris associatedwith Pagets disease, juvenile rheumatoidarthritis, and hip fracture
Advantages of THR: substantial relief of pain,improved function and quality of life
Teach client about plan for effective painmanagement and side effects/adverse effectsof pain medications
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Teach client about dislocation precautions Avoid extremes of internal rotation, adduction,
and 90-degree flexion of affected hip for at least4 to 6 weeks after procedure
Prevent adduction: use an abduction pillow, avoidcrossing the legs, avoid twisting to reach forobjects behind, and avoid driving a car and takingtub baths for at least 4 to 6 weeks
Modify equipment to avoid 90-degree hip flexion(raised toilet seats, platform under chair, use ofreaches, long-handled shoe horns, and sockpullers)
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Teach client about signs and symptoms to reportto healthcare provider Infection-redness, swelling, abnormal drainage, foul
odor, and elevated temperature
Deep vein thrombosis (pain, sudden swelling in
affected extremity, enlargement of superficial veins,skin discoloration, and localized warmth)
Inform client that physical therapy exercises will beginon the first postoperative day to restore and maintainrange of motion, muscle strength, and mobility, and toprevent complications such as DVT
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Instruct client that homecaremanagement program will include: Ongoing nursing assessment of pain
management
Periodic dressing changes and monitoring forinfection Monitoring and adjustment of coagulation
status weekly if taking warfarin (Coumadin)and less often if taking enoxaparin (Lovenox), alow-molecular-weight heparin
An exercise program assisted by a physicaltherapist to assess and restore musclestrength and range of motion
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Instruct client to inform all healthcareproviders (dentists, etc.) of history of joint
replacement surgery so that prophylacticantibiotics can be prescribed as necessary
Inform client that periodic x-rays will berequired as follow-up throughout lifetime
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Amputation Provide client teaching about
effective pain managementtechniques; signs and symptoms toreport: redness, elevatedtemperature, and/or unusual, foul
smelling drainage; abrasions; and anyother signs of skin breakdown
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Teach client how to care for residual limb:wash daily using warm water andbacteriostatic soap, rinse and gently pat
dry thoroughly, expose to air for at least20 minutes after washing; avoid use oflotions, alcohol, powder, or oils unlessprescribed by healthcare provider; change
limb sock daily, wash sock using mild soapand dry flat and discard sock that is inpoor condition
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Nursing Management of ClientUndergoing Musculoskeletal Surgery
Instruct client to perform upper extremity activerange of motion (AROM) exercise daily
Instruct client to lay prone for 30 minutes 3 to 4times/day (if client is able and if part of standard ofcare) and avoid elevat6ing or sitting with residuallimb on pillows to prevent flexion contractures
Tell client that pain mat persist in the amputatedextremity and that this is normal and real; thediscomfort will be treated with analgesics or otherinterventions
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Disorders of theMusculoskeletal System
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Osteoporosis (porous
bone) Osteoporosis (porous bone)Disease characterized by low bone
mass and structural deterioration of
bone tissue, causing the bone(especially weight-bearing bonessuch as the hip, spine, and wrist) tobecome fragile and more susceptibleto fractures
Affects both women and men;however, women are at greater risk
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Osteoporosis (porous
bone) Etiology and pathophysiologyAs people age, bone resorption happens
faster than bone formation, which causes the
bone to lose Ca++ and bone density; sincemost of the bodys calcium is stored in bonesand teeth, this rapid bone resorption leads toporous bone or osteoporosis
When serum Ca++ decreases, the bodytakes stored Ca++ from bone
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Osteoporosis (porous
bone) AssessmentRisk factors include female gender,
increasing age; thin, small body frame
Caucasian or Asian-American ethnicity;family history; inadequate dietary intake ofcalcium; sedentary lifestyle; smoking;excessive alcohol intake; steroidmedications; postmenopausal state; chronic
liver disease; anorexia; and malabsorption
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Osteoporosis (porous
bone) Females are at higher risk for osteoporosis than men Women have smaller body frames, which contribute to
less bone density
Bone resorption begins at an earlier age in women and
is accelerated in menopause
Breast-feeding and pregnancy deplete skeletal reservesunless calcium intake is increased to match demands
Since currently women often live longer than men,longevity increases the likelihood of osteoporosis
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Osteoporosis (porous
bone)
Planning and implementation Provide client teaching about prevention:
take adequate amounts of Ca++ throughoutlifetime to decrease the incidence ofosteoporosis;
proper nutrition for adequate calcium intake;
weight-bearing exercises to force Ca++ backinto the bone;
safety measures to prevent falls that can resultin fractures;
bone mineral density (BMD) tests to measurebone mass in clients at risk for developingosteoporosis
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Osteoporosis (porous
bone)Provide clients with informationabout recommended daily dietaryintake of calcium: Ca++ 1,000
mg/day for premenopausal andpostmenopausal women takingestrogen replacement therapy(ERT), and 1,500 mg/day forpostmenopausal women who arenot taking ERT
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Osteoporosis (porous
bone)Provide information about foods high in Ca++ and the importance of calcium intake withvitamin D: dark, green leafy vegetables (suchas broccoli, bok choy,collard greens,spinach), sardines, salmon with the bone,dairy products (such as milk, cottage cheese,cheese, yogurt, and ice cream); Ca++supplements can also be used to supplement
dietary intake
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Osteoporosis (porous
bone) Medication therapy Estrogen replacement therapy (ERT) is generally
used for prevention of osteoporosis after menopause Usually given in the form of a pill or skin patchDecreases bone demineralization and symptoms
of menopause
Can increase risk for endometrial cancer(progesterone may be given with estrogen, calledhormone replacement therapy or HRT, to decrease
risk)Client is at risk for developing deep vein
thrombosis (DVT)
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Osteoporosis (porous
bone)Alendronate (Fosamax): prevents boneresorption; used to treat both men andwomen with glucocorticoid-induced
osteoporosisReloxifene (Evista): used for prevention
and treatment of osteoporosis; selectivereceptor modulator (SERM) thatprevents bone loss; side effects are rarebut may include hot flashes or DVT
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Osteoporosis (porous
bone) Risedronate sodium (Actonel): biphosphonate, used forprevention and treatment of osteoporosis inpostmenopausal women and for prevention and treatmentof glucocorticoid-induced osteoporosis in both men and
women Slows and stops bone loss, increases mineral densityand reduces the risk of fractures
Instruct client to take drug with a glass of water at least30 minutes before the first food or beverage of the day
and avoid eating for at least 30 minutes after taking themedication
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Osteoporosis (porous
bone) Client educationReinforce the importance of weight-
bearing exercises (jogging, walking,
hiking, stair climbing, tennis, dancing,and weight training
Encourage client to stop smoking
Encourage client to avoid excessiveintake of alcohol
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Osteoporosis (porous
bone)
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Osteomyelitis
Osteomyelitis
Acute or chronic infection of the
bone usually caused by thestaphylococcus aureus organism
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Osteomyelitis
Etiology and pathophysiology
Infection can occur from direct orindirect invasion of infectious
organisms
Direct invasion generally occurs frominvasive procedures such as surgery
(joint prosthesis, arthroplasty) andinjuries such as fractures
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Osteomyelitis
Infection can also be caused by indirectinvasion (also referred to ashematogenous dissemination), where the
infection of the bone tissue or joint iscaused by spread of the infectiousorganism, through the bloodstream from apreexisting infectious focus; course and
virulence of infection is influenced byblood circulation to the affected bone
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Osteomyelitis
Long bones are common sites of infection inchildren, and spine, hip, and foot are commonsites of infection in adults
At-risk populations include children, elderly, andindividuals with weakened immune systems
Osteomyelitis warrants aggressive immediatetreatment with antibiotics or surgery (wounddebridement) if infection of bone is extensive
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Osteomyelitis
li i
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Osteomyelitis
AssessmentObserve for symptoms of local and/or systemic
infection: elevated temperature, chills,restlessness, severe bone pain unrelieved by
analgesics or rest and aggravated bymovement, swelling, redness, and warmth atthe infection site
Wound culture, bone scan, CT scan, and MRIprovide information for diagnosis andassessment of the extent of infection
O li i
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Osteomyelitis
Planning and implementation Explain all therapies and interventions to client
and family to decrease anxiety and enhancecooperation with plan of care
Use a rating scale to assess pain and evaluateeffectiveness of pain management measures
Provide ongoing education and emotionalsupport since the seriousness of the infectious
process duration and uncertainty surroundingtime for recuperation, potential complications,and associated risk can be a very fearfulexperience for client and family
O li i
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Osteomyelitis
Teach client about risk factors forosteomyelitis, which include previous jointreplacement surgery and implants
Use sterile technique for all dressingchanges and manipulation of affected limb;handle extremity very gently
Avoid activities that increase circulation toaffected area or cause edema, pain, and
pathologic fractures, such as exercise,application of heat, or keeping extremity independent position
O t liti
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Osteomyelitis
Immobilize affected extremity as prescribed byphysician and keep body in proper alignment
Monitor temperature at least every 2 hours
Provide cool environment, light clothing, antipyretic
medication, antibiotics, and other therapies asprescribed and/or appropriate to keep temperaturewithin the clients baseline
Keep client well hydrated to prevent dehydrationfrom insensible water loss
O t liti
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Osteomyelitis
If long-term management is required,provide client with instructions aboutwound care using sterile technique,
medication regimen (includinginstruction on venous access devices ifneeded), antibiotic administration,proper diet, rest, followup visits, and
laboratory tests
O t liti
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Osteomyelitis
Provide information about adverse effectsof antibiotic therapy such as ototoxicityand nephrotoxicity (aminoglycosides) and
hepatotoxicity cephalosporins) Instruct and assist client with interventions
to prevent complications associated withimmobility (turn and reposition every two
hours, coughing and deep breathingexercises, etc.)
O t liti
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Osteomyelitis
Medication therapy
Indicated with or without surgicalintervention
Generally includes antibiotics andanalgesics
Reinforce information about adverse
effects of antibiotic therapy asoutlined in previous section
O t liti
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Osteomyelitis Client education
Teach client about the importance of takingantibiotic medications as prescribed (for thefull duration) and to report adverse effectsof the medication to prescriber
Review medication regimen and have clientverbalize an understanding of teaching
Reinforce the importance of rest and proper
diet to facilitate healing, and preventconstipation and dehydration
Reinforce the importance of limbimmobilization during treatment
O t liti
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Osteomyelitis
M l d t h (MD)
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Muscular dystrophy (MD)
Muscular dystrophy (MD)
Group of genetic childhood disorderscharacterized by progressive muscleweakness, muscle wasting ofsymmetrical groups of muscles, andincreasing disability and deformity
Types of muscular dystrophy includeduchenne, myotonic, Beckers,facioscapulohumeral, and limb girdle
Most common form is Duchenne
muscular dystrophy
M l d t h (MD)
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Muscular dystrophy (MD)
Etiology and pathophysiology
Inherited sex-linked group of disorders
Significant risk factor is family history
Each type differs in regard to musclegroups affected, age at onset, rate ofprogression, and pattern of inheritance
Each type of MD affects specific musclegroups
M sc lar d stroph (MD)
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Muscular dystrophy (MD)
Muscular dystrophy (MD)
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Muscular dystrophy (MD)
AssessmentMuscle biopsy is the primary test to confirm
diagnosis (test show degeneration of musclefibers)
EMG is also used as a diagnostic test thatidentifies origin of muscle weakness(destruction of muscle or nerve damage)
Progressive muscle weakness, hypotonia (lossof muscle mass), and delayed development of
motor skills such as walking may be observedand reported by parent or caregiver
Muscular dystrophy (MD)
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Muscular dystrophy (MD)
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Muscular dystrophy (MD)
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Muscular dystrophy (MD)
Planning and implementation
Provide support and assist family withdecision-making process surrounding
Development of a homecare plan to supportas much independence as possibleModifications in home environment to
support the clients maximal functional
abilityEncourage family to actively involve client in
care
Muscular dystrophy (MD)
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Muscular dystrophy (MD)
Family members may experience a myriad ofemotions including fear, guilt, anger and blame;support family to enhance coping with clientsprogressively worsening disease; refer to local
support groups including the MuscularDystrophy Association of America
Assist client and family to cope with theprogressive, incapacitating, and fatal nature of
the disease
Muscular dystrophy (MD)
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Muscular dystrophy (MD)Encourage family to interact with the familybased on developmental and not chronologicalage
Teach family strategies to prevent skinbreakdown (frequent skin care and linen
changes if incontinent, turn and reposition atleast 2 hours, use of protective barrierointments, and adequate fluid intake)
Perform passive range of motion exercises tomaintain function in unaffected extremities
and prevent/delay contractures in affectedextremities
Muscular dystrophy (MD)
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Muscular dystrophy (MD)
Medication therapy
There is no effectivepharmacological or other treatment
Corticosteroids are often used toincrease muscle strength
Muscular dystrophy (MD)
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Muscular dystrophy (MD)
Client education
Provide information about healthcareteam members and roles, including
those involved in homecare programfor client
Instruct family to offer client soft foods
and to cut into small pieces to preventaspiration and choking
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Muscular dystrophy (MD)
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Muscular dystrophy (MD)
Muscular dystrophy (MD)
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Muscular dystrophy (MD)
Pagets disease (osteitis
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Paget s disease (osteitisdeformans)
Pagets disease (osteitis deformans)
Description
Chronic skeletal bone disease with insidious
onsetDiagnosed around the fourth decade of life
Results in enlarged, deformed bones butdoes not affect normal bones
Generally affects skull, long bones, spine,and ribs
Pagets disease (osteitis
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Paget s disease (osteitisdeformans)
Etiology and pathophysiology
Cause of disease unknown; however,viral infection has been hypothesized
as a probable etiologyHereditary factor: may be seen in
more than one family member
Early diagnosis and treatment isimportant to prevent diseaseprogression and deformity
Pagets disease (osteitis
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Paget s disease (osteitisdeformans)
Excessive bone resorption followed bybone formation leads to weakenedbone, bone pain, arthritis, deformity,
and potential pathologic fracturesNormal bone marrow is replaced by
vascular, fibrous, connective tissue thatleads to formation of larger,
disorganized, and weaker bone tissue
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Pagets disease (osteitis
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Paget s disease (osteitisdeformans)
Symptoms include bone pain (most commoncomplaint) and other symptoms depending onwhich bones are affected with the disease
for example, if the skull is affected, headacheand hearing loss may be reported as well as
increasing head size
Hip pain may be present if the pelvis or femuris involved
Bowing of the lower extremities producing a
waddling gait and curvature of the spine may beseen in advanced stages of the disease
Pagets disease (osteitis
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Paget s disease (osteitisdeformans)
Planning and implementation
Prognosis is good especially if treatmentis started before major deformity occurs
Provide analgesics and muscle relaxantsfor comfort
Administer medications as directed tocontrol progression of disease (seemedication section)
Pagets disease (osteitis
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Paget s disease (osteitisdeformans)
Encourage client to take medication as directed byhealthcare provider since deformity and loss of bonestrength will continue without prescribed medications
If skull is affected, assists with diet modification,dentures, and eating utensils since teeth may
become weak from the diseaseHearing aid may be recommended if hearing lossresults from the disease
Refer client and family to support group
Pagets disease (osteitis
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Paget s disease (osteitisdeformans)
Medication therapyThe goal of treatment is to control progression
of the disease
The following medications are approved by the
Federal Drug Administration (FDA):biophosphonates, etidronate disodium(Didronel), pamidronate disodium (Aredia),alandronate sodium (Fosamax), tiludronatedisodium (Skelid), residronate sodium
(Actonel), and calcitonin (Miacalcin)
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Pagets disease (osteitis
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Paget s disease (osteitisdeformans) Encourage client to participate in an exercise
program to maintain skeletal muscle health, idealbody weight, and joint mobility
Instruct client to sleep on a firm mattress if backdiscomfort is present; if back brace is needed,instruct client on the prevention of skin breakdown
under brace (undershirt) and safety measures (nodriving with brace)
Encourage client to modify environment at home toprevent falls that may lead to subsequent fractures
Encourage client to participate in community supportgroup
Pagets disease (osteitis
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Paget s disease (osteitisdeformans)
Musculoskeletal trauma
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Musculoskeletal trauma
FracturesDescription A fracture is a break in the continuity of the
bone
Fractures may be classified as:Closed (simple fracture): the bone breaksbut the skin remains intact
Open (compound fracture): broken endsof the bone penetrate the skin
Musculoskeletal trauma
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Musculoskeletal trauma
Fractures may also be classified as: Avulsion: a fracture resulting fromthe tearing of the supporting tendonsand ligaments
Comminuted: the broken bonefragments into more then two pieces
Compressed: the bone is crushed
Impacted: ends of the broken aredriven into each other
Musculoskeletal trauma
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Musculoskeletal trauma
Depressed such as in skull fracture,where the bone structure is broken andpressed inward
Spiral: the break spreads in a spiral
fashion along the bone shaft; is usuallycaused by sports injuries
Greenstick: an incomplete break in thebone where one side splinters leavingthe other side bent or intact; morecommon in children
Musculoskeletal trauma
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Musculoskeletal trauma
Musculoskeletal trauma
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Etiology and pathophysiology
Fractures occur in all age group,although the elderly are more proneto fractures resulting from falls
When a bone breaks, the healing
process occurs in three phasesA fracture initiates an inflammatoryresponse (inflammatory phase)
Calcium eventually is deposited in the
area osteoblasts promote new boneformation (resparative phase)
Eventually the ends of the fracturereunite (remodeling phase)
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Musculoskeletal trauma
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Musculoskeletal trauma
Crepitus may also be present in palpation;
crepitation is a popping or grating soundcreated by the movement of broken bonefragments
Muscle spasms may be noted near the
fractured boneEcchymosis or a bluish discoloration of the
area caused by blood extravasation intothe surrounding subcutaneous tissues
Pain that may be intense and possiblyshock if blood loss is severe
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Musculoskeletal trauma
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Musculoskeletal trauma
Elevate the fractured extremity to reduceswelling and pain
Apply ice to the affected extremity
Assist in fracture reduction
Closed: involves external manipulation torealign the bones
Open: involves a surgical procedure torealign the bones
Maintain traction as prescribed; see sectionon nursing care of the client in traction
Musculoskeletal trauma
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uscu os e e a au a Monitor for complications compartment syndrome:impairment of circulation within inelastic fasciacaused by external pressure (> 30 mmHg) thatresults in tissue death and nerve injury;
external pressure can be created by casts,splints, or dressings;
manifestations include unrelieved pain,extremity, tingling, or diminished sensation(paresthesia), loss of sensation, pallor, coolness ofthe extremity, and weakness; bivalving may benecessary if the cast is too tight
Musculoskeletal trauma
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Infection: wound drainage, fever, painand odor
Fat embolism: chest pain, dyspnea,
tachycardia, decreased O2 saturation,apprehension, changes in l;evel ofconciousness, petechiae on upper trunkand axilla
Deep vein thrombosis: calf pain andtenderness, swelling or edema
Musculoskeletal trauma
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Medication therapy: includes analgesics and
antibioticsClient education
teach the client to exercise the extremities notimmobilized to prevent muscle atrophy
teach client regarding cast care, splint, and/ortraction (see previous discussions)
teach the client about neurovascular assessmentsthat need to be done
teach client regarding pin care procedure andmethods of preventing wound infection
Hip fracture
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Musculoskeletal trauma
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Hip fracture
Description: the hip can be fractured atdifferent sites, namely, the head, neck,
and trochanteric areas;Pathophysiology: incidence of hip
fracture increases with age; 90 percentof hip fractures are caused by falls
Musculoskeletal trauma
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Assessment a hip fracture is a medical emergencyhip fractures are generally sustained from
falls; monitor level of consciousness and
assess for other injuriesperform neurovascular assessment on
affected extremity
extremity of affected hip will be shorter than
unaffected extremityfractured hip will generally externally rotate
Musculoskeletal traumal i d i l i
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Planning and implementation
Prepare client for surgical intervention (verifyallergies, informed consent, etc.)
Instruct client that an abductor pillow or splintmay be necessary to prevent disarticulation ofthe femur
Inform client that sandbags may be usedalong the external border of the affected limbto prevent external rotation
Inform client that pain medication will beavailable for comfort postoperatively(generally patient controlled analgesia [PCA] isused)
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Musculoskeletal trauma
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Teach client about the pain rating scale to beused postoperatively and encourage client toreport any discomfort
Teach client deep-breathing and coughingexercises preoperatively
Use aseptic technique for dressing changes andwound drainage
Provide information on therapies and equipmentto expect postoperatively (indwelling urinaycatheter, PCA, IV therapy, possible traction, etc.)
Monitor preoperative use of skin traction toimmobilize the limb until surgery is ordered
Musculoskeletal trauma
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Client education
Reinforce deep-breathing and coughingexercises postoperatively
Preoperatively teach client about
postoperative precautions to prevent hipdislocation (no hip flexion greater than 90degrees, internal rotation of affected hip, oradduction of affected hip); these include such
activities as avoiding low chairs, using raisedtoilet seat, no excessive bending
Reinforce teaching about postoperativecourse
Sprains and strains
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Musculoskeletal trauma
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Sprains and strainsDescription
A sprain is a stretch and/or tear ofa ligamentA strain is a twist, pull, and/ortear that may involve bothmuscles and tendons
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Musculoskeletal trauma
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Medication therapy: analgesicsmuscle relaxants, and anti-inflammatory agents as necessary
Client education: reinforceinformation covered above inplanning and implementation section
Gout
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Gout
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Primary form of disease is hereditary;secondary form is acquired
Laboratory findings show elevated
serum uric acid (hyperuricemia)Characterize by recurring attacks of
acute joint inflammation
Gout
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Etiology and Pathophysiology
Inherited abnormality in the bodys abilityto process uric acid
Hyperuricemia is caused by increasedpurine synthesis and/or decreased renalexcretion of uric acid
Elevated serum uric acid level can also be
caused by prolonged fasting andexcessive alcohol intake
Gout
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AssessmentRisk factors:
Obesity, excessive weight gain,
excessive alcohol intake, impaired renalfunction, hypertension,
chemotheraphy for leukemia andcertain lymphomas, certain thiazide
diuretics, aspirin, and tuberculosismedications
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Gout
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Gout Planning and implementation
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Planning and implementation
Prevent any bed linen from touching affected
extremity because of extreme tenderness (bedcradle and/or footboard can be used)
Instruct client to adhere to activity restriction suchas bed rest and immobilization of affected extremity
during periods of exacerbationMonitor uric acid levels to prevent exacerbation and
evaluate effectiveness of treatment
Instruct client about precipitating factors for the
diseaseEncourage diet low in purines
Gout
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Medication theraphy:
anti-inflammatory agents, (such ascolchicines, NSAIDs or
corticosteroids),
antihyperuricemic (such as allop-urinol [Zyloprim]) and uricosurics
(such as prebenecid [Probalan])
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Degenerative Joint Disease(DJD) O h i i (OA)
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(DJD) or Osteoarthritis (OA)
Osteoarthritis (OA)
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Slowly progressive disorder of articulatingjoints especially weight-bearing joints
Commonly affects hand and weight-bearingjoints (knees, hips, feet, and back)
Breakdown of articular cartilage occurs
Injury is usually limited to joint andsurrounding tissue
Disease ranges from very mild to very severe
Osteoarthritis (OA)
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Osteoarthritis (OA)
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Etiology and pathophysiology
Cartilage degeneration causes bones to rubagainst each other, causing pain and decreasingfunction of the joint
Risk factors
Age (most significant): primarily affectsmiddle-age to older adults
Obesity (generally causes arthritis of theknees)
Repetitive joint injuries caused by sports,accidents, or work-related injuries
Osteoarthritis (OA)
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Genetics (especially seen with OA ofthe hands): client may be born withdefective cartilage or slight defect in
the way the joint fits together, and asthe client ages, the joint cartilagecontinues to progressively, degenerateand enzymes (hyaluronidase) are
released, which cause furtherbreakdown
Osteoarthritis (OA)
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Assessment
Disease is diagnosed with physical examand a history of symptoms
X-ray confirms the diseaseJoint pain is present with movement and
weight-bearing and is relieved by rest
There is limited range of motion with
progressive loss of function
Osteoarthritis (OA)
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There is joint stiffness after rest
Crepitation (grating sensation caused by roughjoint surfaces rubbing together) occurs
Heberdens nodes (raised bony growths over the
distal interphalangeal joints) are presentBouchards nodes (raised bony growths over the
proximal interphalangeal joint of the hand) arenoted
Osteoarthritis (OA)
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Osteoarthritis (OA)
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Instruct client to apply heat/cold therapyto affected joint temporary pain relief
Assist client in planning scheduled restperiods to relieve stress on joints
Assist client with activities of daily living(ADL) as needed
Provide information aboutcomplementary therapies such as visualimagery and relaxation techniques forpain control
Osteoarthritis (OA)
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Medication therapy
Acetaminophen is generally used to controlmild pain without inflammation
Therapy also includes anti-inflammatoryagents such as NSAIDs and corticosteroids
If NSAIDs are ineffective in controllinginflammation and pain, glucocorticosteroidsmay be injected directly into the joint
Osteoarthritis (OA)
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Client education
Teach client about the nature of and treatment of disease
Teach client principles of good body mechanics
Instruct client about the correct use of assistive devicesand encourage use as needed
Assist client in planning daily activities and tasks thatallow for schedule rest periods
Teach client to avoid activities that put excessive stresson joints and caused pain
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Low Back Pain
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Low Back PainP i b lt f t t d t
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Pain may be a result of acute or repeated stress on
the lower back over a period of yearsPain occurs because of degeneration and/or acute
injury to the tissue of the lower back
Caused by sprain or strain of ligaments andmuscles
Pain may be felt at the site of the injury or referred
Overall health of muscles of the lower backdetermines the degree of risk for injury as well asthe speed of recovery
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Low Back Pain
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Assessment
Risk factors include but are not limitedto: degenerative disc disease, poormuscle tone of the lower back,
sedentary lifestyle, obesity, poor bodymechanics, smoking, and stress
Client will report pain caused by a shiftof one vertebra on another or pinching
and irritation of the nerve rootMuscle spasms are a common symptom
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Low Back Pain
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Planning and implementationThe goal of treatment is to improve
symptoms and slow progression of
the degenerative process Include client and family in plan of
care
Provide emotional support
Low Back Pain
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Medication therapyMedication therapy includes but is not
limited to analgesics, NSAIDs, and
muscle relaxantsEpidural corticosteroid injections may
be used if conservative treatment isineffective
Low Back PainClient education
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Client education
Teach client about expected therapeuticeffects, side/adverse effects, andcontraindications with medication use
Teach client about the pain rating scale
Teach client the importance of adhering toactivity restrictions such as bed rest asindicated
Teach client the importance of adhering to
gradual to activity restrictions such asadherence with exercise plan
Low Back Pain
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Teach client the importance ofmaintaining ideal body weight
Inform client that physical therapy will
be part of the rehabilitation process toassist in maintaining muscle strengthand flexibility as well as improvingmuscle tone
Teach client the use of heat/cold forcomfort
Low Back Pain
Teach client about the importance of adhering to the principles of
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p g p pbody mechanics to avoid excessive strain on the lower back
Encourage client to sleep on a firm mattress
Have client demonstrate correct sleeping position using the principlesof body mechanics (side lying or supine with knees and hips flexed)
Encourage client to avoid or stop smoking
Teach client about use of prescribed brace or corset (if needed) to
prevent flexion and extension motions of lower back
Low Back Pain
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