Musculoskeletal (Part I)

Osteoporosis (porous bones) p. 1223

Causes: Risk Factors (Unmodifiable)
-Age -Sex -Race -Family history

Risk Factors (Modifiable)

-Calcium deficiency -Skeletal calcium loss -High intake of diet sodas -Smoking -Lifetime exposure to estrogen -Excess alcohol intake -Sedentary lifestyle! -Medications

Manifestations -See picture pg 1225 in text -Loss of height

-Progressive curvature of spine -Low back pain -Fractures (wrist, spine, hip)

Diagnostic Tests
-X-rays DEXA scan Ultrasound

Prevention
Calcium Intake --Women: --Men: --Foods: --Supplements: Exercise Healthy Behaviors Hormone Replacement Therapy

Treatment (Medications)
Biphosphonates --inhibit bone resorption, increase bone density. --reduce hip fracture by 50%! --Example: Fosamax

Calcitonin

-- bone formation; bone resorption. -- Subq or intranasal.

Client Teaching?
Good web sites:
www.mayoclinic.com (medical and health information) search osteoporosis

www.nof.org click on osteoporosis listed in left column www.fda.gov search boning up on osteoporosis

Osteomyelitis p.1267
Introduction
See picture in text p. 1268: initial infection, acute phase, chronic infection.

Causes/Manifestations
Direct contamination Surgical infection Adjacent soft tissue infection (contiguous)

Hematogenous Risk factors: Signs and Symptoms: Pain Swelling, redness, warmth Purulent exudate (in chronic osteomyelitis) Systemic: Fever/chills Nausea Malaise Prognosis

Diagnostic Studies
(Refer to text p. 1267 for details of diagnostic studies) MRI CT Bone Scan Ultrasound Lab: Sed Rate, WBC, Cultures (blood, tissue, needle aspiration)

Treatment
Medications

Surgical debridement

Amputation (last resort)

Nursing Diagnosis?

Teaching?

Good web sites:

MEDLINEplus Medical Encyclopedia: Osteomyelitis

www.emedicine.com (more pictures!)

http://www.merckmedicus.com ( Best Practice MedicineProfessional Reference -Osteomyelitis)

Osteoarthritis p. 1239
Introduction
Facts

Types of Arthritis

Osteoarthritis (Wear and Teartype)

Idiopathic

Secondary

Pathophysiology

Manifestations

Diagnostic Tests
History and physical X-rays

Treatments
Conservative Treatment Analgesics

Other

Surgical Treatment Joint Arthroplasty (reconstruction or replacement)

Total hip replacement

Total knee replacement

IMPORTANT: Excellent information on pre and post-op care of client undergoing total joint replacement on page 1243!) (Shoulders and elbowssee p. 1242)

Nursing Care Plan

(Review p. 1246!)

Good web sites:

http://www.nlm.nih.gov/medlineplus/osteoarthritis.html (Osteoarthritis information plus interactive tutorial video!) http://www.allaboutarthritis.com http://www.merckmedicus.com http://www.arthritis.org (Arthritis Foundation) http://www.niams.nih.gov

Rheumatoid Arthritis p.1248

Introduction Pathophysiology
OA vs. RA

Manifestations

Diagnosis

History and physical exam Labs: Rheumatoid factors ESR (sed rate) Synovial fluid exam X-rays

Treatment
No Cure Goals: Relieve pain Reduce inflammation Stop or slow joint damage Improve well-being and ability to function

Medications: NSAIDS Steroids Disease-modifying drugs Biologics

Surgery Joint replacement Tendon reconstruction

Teaching
Balance between rest and exercise Care of joints Stress reduction Diet

Quackery

Gout (ouch!) p. 1233

Introduction/Pathophysiology

Definition Primary Secondary Cause

Manifestations
Stage 1Asymptomatic Hyperuricemia Stage 2Acute Gouty Arthritis Stage 3Chronic (Tophaceous) Gout

Diagnosis
History! Serum uric acid WBC Sed rate Joint fluid analysis

Treatment
Medications Pain relief: NSAIDS, narcotics

Colchicine

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Steroids (po or intra-articular)

Dietary management

Elevation, hot/cold compresses, fluid intake

Teaching: Prevent future attacks

(See Medication Administration p. 1236)

About medications:
Colchicine therapy ~1 2 years Allopurinol Probenecid (Benemid) Diet (same as above)

Nursing Diagnoses

Good website: http://www.nlm.nih.gov/medlineplus/goutandpseudogout.html (interactive tutorial)

Fractures (except vertebral) p. 1197

Review anatomy and physiology, terminology and assessment pages 1179-1189.

Pathophysiology
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Classifications (Self studyknow these terms!)

Closed/Simple Open/Compound Oblique Spiral Avulsed Comminuted Compressed Impacted Depressed Complete Incomplete Stable Unstable

Manifestations
Pain Swelling Deformity Numbness Hematoma formation (may lead to hypovolemia) Muscle spasms 12

Bone Healing
(See Pathology Illustrated: bone healing pages 1195-1196) Inflammatory phase Reparative phase Remodeling phase

Factors which promote bone healing

Local Systemic

Factors which impair bone healing

Local Systemic

Emergency CareKey points

Immobilization Wound care Assessment of circulation

Diagnostic Procedures
X-rays Bone Scan 13

Lab studies

Medications
Pain Antibiotics Anticoagulants

Surgical Treatment
When is surgical intervention needed? External fixation Internal fixation (ORIF)

Traction
Types of traction Care of the client in traction

Casts
Selection of candidates and cast style

Nursing Care of client in a cast (key points)

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Complications of Fractures
Compartment syndrome

Fat emboli

Deep Vein Thrombosis

Infection

Reflex Sympathetic Dystrophy (Complex Regional Pain Syndrome)

Specific Fractures (read pages 1203 1207)

Hip Fracture Intracapsular Extracapsular Hip fracture facts

Surgical repair

Nursing Implications
Prevention/Teaching (Self Study 1207-1208)

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Care of client with immobilized fracture

Specific care of client after repair of hip fracture (p. 1211-1212) Good web sites:
HREF="http://orthoinfo.aaos.org/" MACROBUTTON HtmlResAnchor http://orthoinfo.aaos.org (HREF="http://www4.aaos.org/siteserver/knowledge/search/database/searc h/OrthoInfo/view.asp?id=164&table=fact&topcategory=Ab" MACROBUTTON HtmlResAnchor How to Use Crutches, Canes and Walkers) HREF="http://www.cdc.gov/ncipc/factsheets/falls.htm" MACROBUTTON HtmlResAnchor http://www.cdc.gov/ncipc/factsheets/falls.htm

Amputations (p. 1211)

Causes
Peripheral Vascular Disease Trauma Infections Tumors

Levels and Types of Amputations

Upper extremity Lower extremity Types of Amputations 16

Open Closed

Post Op Site Care

Complications
Infection Delayed Healing Chronic Stump Pain and Phantom Pain Contractures

Prosthesis Selection

Nursing Diagnosis
Important: See A Client with Amputation p. 1218 See A Client with BKA p. 1219

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Care of the Elderly Patient With Lower Extremity Amputation ( HREF="http://www.medscape.com/" MACROBUTTON HtmlResAnchor http://www.medscape.com ) search amputation

Good web article:

See: http://www.cbsnews.com/stories/2004/01/06/earlyshow/living/main591693.shtml Story of Ferry Crash Survivor with amputations. Click on Video. Very impressive.

Back Pain (p. 1280 low back pain; p. 1333 herniated disk)
Focus will be on low back pain; cervical neck pain essentially same information.

Causes and manifestations

Local back pain

Referred pain

Pain of spinal origin

Radicular back pain

Muscle spasm pain

Diagnosis
History and Physical exam X-ray

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CT and/or MRI

Treatment
Medications NSAIDS Muscle relaxants Pain medications Steroid injection (epidural) Other Treatment Modalities: Physical Therapy Hot/Cold applications Balance of rest and movement

Prevention
Exercise, stretching Weight loss Good body mechanics (at home and at work)

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Herniated Intervertebral Disk (Ruptured Disk) p.1333

Definitions
Cervical Lumbar

Pathophysiology / Manifestations
A herniated intervertebral disk occurs when the nucleus pulposus protrudes through a weakened or torn annulus fibrosus of an intervertebral disk. Symptoms depend on the level Pain, neuromuscular symptoms, sensory and/or motor involvement

Diagnosis
X-rays CT MRI Myelogram

Treatment
Conservative Treatment

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Surgical Treatment Laminectomy

Spinal Fusion See: Nursing Care of Client having Posterior Laminectomy p. 1337 Highlights? See: Nursing Care of Client with Ruptured Intervertebral Disk p. 1340 Highlights? Nursing Diagnoses?

Good web sites: http://www.mayoclinic.com Search for herniated disk. Nice interactive video for HNP.

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