Musculoskeletal Disorders Part II Final

Musculoskeletal Disorders
Part II
Degenerative Joint Disease/Osteoarthritis
Total Hip and Knee Prostheses
Bone Infections / Osteomyelitis
Concept Map: Selected Topics in Musculo-Skeletal Nursing
Physical Assessment
“Neuro / Circ Checks”
--”The 6 P’s”
Degenerative Joint Disease
Disease Specific
Total Joint Replacement
Lab Monitoring
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, more…based
On Nursing Process:
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary
Nursing Diagnoses That (Might) Apply
Pain, acute
Comfort, impaired
Mobility, altered
Self-care deficit –feeding, grooming; bathing, hygeine; toileting
Falls, risk for
Skin breakdown, risk for
Constipation, risk for
Diversional activity, risk for
Mobility, Physical, impaired
Mobility, bed, risk for
Walking, impaired,
Tissue perfusion, impaired peripheral
Peripheral neurovascular dysfunction, risk for
Knowledge, deficient
Body image, disturbed
Early or
Late Signs
Assessment Parameters
Client Teaching /
Symptoms to Report
Assess area involved using 0 to 10 rating scale:
Increasing pain not
relieved with elevation or
pain medication
“The 6 P’s”
0 = no pain
10 = worst pain imaginable
Assess for numbness/tingling, pins or needles
Should be absent.
Numbness or tingling, pins
or needles sensation
Assess capillary refill.
Increased capillary refill
time > 3 seconds, blue
fingers or toes
Brisk is < 3 seconds
Assess skin temperature by
Cool/cold fingers or toes
Warm <or> Cool
Assess mobility:
Moves fingers or toes
Able to plantar dorsiflex the ankle area
not involved or restricted by cast
Unable to move fingers or
Assess pulse(s) distal to
Pulse is palpable and strong
Weak palpable pulses,
unable to palpate pulses,
pulse detected only with
Musculoskeletal Disorders
 Degenerative Joint Disease (DJD)
 a degenerating arthritic condition that affects any joint in the
body, including the spine (then it is called DDD – Degenerative
Disc Disease)
 Risk Factors:
 Obesity (More in the weight – bearing joints)
 Poor nutrition, low in calcium or vitamin D
 Genetics – familial arthritis
 Overuse injuries or manual labor
 Sports injuries which affect the bursae or tendon - meniscal tissues that
cushion the joint
 Smoking – as it dehydrates and constricts tissues
Musculoskeletal Disorders
 Degenerative Joint Disease (DJD)
 Pathophysiology - the bone and supporting tissues start to
degenerate, causing atrophy of tendons, and bone spurring,
with degeneration of menisci and bursa which would
normally protect the joint. Main symptoms are “stiffness in
the morning” and pain. Eventually the bone spurring and
breakdown will cause joint deformities.
Musculoskeletal Disorders
 Degenerative Joint Disease (DJD)
 Also called OA – Osteoarthritis
 Diagnosis:
 Symptoms and history
 Arthroscopy
 X-rays
 MRI – for soft tissue visualization, i.e of menisci or bursae
 Bone scan if cancer has to be ruled out
Musculoskeletal Disorders
 Degenerative Joint Disease (DJD)
Note the loss of joint space with bone on bone
Musculoskeletal Disorders
 Degenerative Joint Disease (DJD)
Musculoskeletal Disorders
 Degenerative Joint Disease (DJD)
 Treatments – heat and cold therapy
 Preventative exercises – to strengthen supporting muscles
 Joint Injections – Hydralan, cortisone, etc.
 Analgesics/Anti-inflammatories –
 COX – 2 inhibitors i.e. Mobic, Celebrex
 Tylenol – contraindicated for liver patients
 Indocin - more risk for peptic ulcers
 Aspirin – more risk for peptic ulcers
 Partial or complete surgical repair
 Joint prosthesis
Musculoskeletal Disorders
 Degenerative Joint Disease (DJD) –
Musculoskeletal Disorders
 Hip Prosthesis
Musculoskeletal Disorders
 knee prosthesis
Musculoskeletal Disorders
 Care of Patients –
 Pain control
 Ambulation with assistance - only
 Prevent falls
 Exercise; usually has physical therapy from 6 - 8 weeks
 Non-smoking
 Encourage adequate intakes of vitamin C
 Post-op anti-coagulants, whether Lovenox, coumadin, heparin,
or aspirin
Musculoskeletal Disorders
 Hip prosthesis – NEVER adduct the leg (letting the hip and
leg cross the other one will pop the prosthetic ball out of the
 Only allow hip flexion to 90 degrees
 Turn patients using an adductor pillow while aligning the
Musculoskeletal Disorders
 Adductor pillow between knees
Musculoskeletal Disorders
 Bone infections
 Causes:
 Immunological problems
 Diabetes, nutritional problems
 Injury which allows pathogens into the bone
 fractures
 coral cuts
 trauma
 post-operative surgery
Musculoskeletal Disorders
 Bone infections
 Chronic Osteomylitis in a diabetic
Musculoskeletal Disorders
 Bone infections
 Diagnosis:
 Bone scan
 X-rays
 MRI for soft tissue view
 Blood cultures – need to be done 15 minutes apart from two
different sites
 Wound cultures – if drainage is apparent
Musculoskeletal Disorders
 Bone infection symptoms:
Foul smelling drainage
 Increased WBC’s on CBC with differential
 With increased neutrophils on the CBC, sometimes called PMN’s or
polymorphic neutrophils. These cells in particular replicate to fight
infection. If the WBC is not elevated with these symptoms, the patient is
immunosuppressed and at risk for sepsis.
Musculoskeletal Disorders
Bone Infections
Most common organisms:
Staphlococci Aureus – MRSA in the hospital postoperatively (a drug resistant
Enterococci from wounds/trauma
Clostridium Perfringens – gangrene
E-Coli – fecal contamination
Musculoskeletal Disorders
 Osteomylitis Treatments/Interventions
 #1 Pain control
 Monitor Vital signs every 4 hours and prn
 (Observe for signs of sepsis or drug reaction)
 Monitor skin integrity and site
intravenous antibiotics to get rid of infection (need a
physician’s order)
 Surgical repair or debridement
 Removal of infected prostheses
 Sometimes it is necessary for amputation
Musculoskeletal Disorders
 Ewing’s Sarcoma of the bone – usually malignant with mets,
often treated with amputation
Musculoskeletal Disorders
 Osteosarcoma –
 most common type of
malignant bone tumor, most
often in males between 10
and 30 y.o. or in older
patients with Paget’s Disease
 This is a photograph of 70 year
old woman who first presented
like this with a massive
chondrosarcoma of her right
upper humerus of 8 months
duration. She refused all
treatment, and she died of a
massive haemorrhage when the
tumour burst the following week.
Musculoskeletal Disorders
Musculoskeletal Disorders
 Types of amputations
 Simple Toe – uncomplicated, most often due to injury and
Musculoskeletal Disorders
 Amputations – BKA
 Below the knee
 Treatments for amputations will be further covered in Adult
Health Care II
Musculoskeletal Disorders
 Types of Amputations
 AKA – above the knee – a surgical technique for saving a
person’s life from an infected prosthesis or necrotic limb
Musculoskeletal Disorders
 Amputations - facts and figures:
 More than 100,000 amputations are performed in the USA
every year.
 The most common cause of amputations is diabetes &
 Of the 9,985 nonfatal workplace amputations in 1999, more
than 1 in 3 cases required 31+ days away from work to
recuperate (OSHA study)
 The third most common cause today is war-related.
Musculoskeletal Disorders
 Assessment must include:
 Pain as a no. 1priority
 Proper patient assessment must include pain intensity, radiation,
relief, medication side effects, and reassessment on a regular
 Skin integrity
 Tissue Perfusion
 Prevention of infection
 Promotion of nutrition
 Exercise & ROM
 Body Image
Musculoskeletal Disorders
Gout –
 Pathophysiology
 Gout is a disease caused by the kidneys not clearing the uric acid out of
the blood stream. Uric acid is the end product of purines in our diet (one
of the amino acids in the body).This causes a hyperuricemia (high levels of
uric acid in the blood) and initiates an inflammatory response in the joints.
The urate crystals deposit into a joint and/or subcutaneous tissues..This
deposit and inflammation causes “gouty arthritis” and may appear the same
as OA on X-ray.The deposits can also cause kidney stones, as deposits build
up in the kidneys. Renal stones are `1000 times more common in people
with gout.
Musculoskeletal Disorders
Gout Symptoms:
 Tophi - white crystalized deposits in the tissue, usually
seen on the hands or toes.
 Heat & Redness
 Pain – Severe & sudden onset
 Swelling
 Inflammation – usually on one side of the body first, a
ankle joint, knee, or toe
 May become an acute inflammation after an injury, i.e.
stubbing your toe on the sprinkler
Musculoskeletal Disorders
Gout –
- X-ray of limb to rule out regular arthritis,
- blood test for a uric acid level
normal is 4.0-5.2 (lab values may differ
the age of the patient)
- Anything over 6.0 is consider high
- An aspiration of the fluid in the joint will
demonstrate crystalline deposits by
based on
Musculoskeletal Disorders
 Treatments
 Anti-inflammatories STAT – drugs of choice are colchicine and
indocin – Patients need to be educated to side effects and
 Sometimes, doctors will give Toradol IM for immediate pain
relief, as it acts like injectable aspirin and reacts quickly
 Pain control
 Maintenance on daily allopurinol – to allow the kidneys to
secrete the acid
 Educate patient to avoid high purine foods
Musculoskeletal Disorders
 gout
Musculoskeletal Disorders
 Gout tophi
Musculoskeletal Disorders
 Gouty tophi (in red)
Pharmacology Associated with
Musculoskeletal Patients--General Information
 Assess/monitor the client’s need
for pain medication, and plan and
provide care to meet the client’s
needs for pain intervention.
 Assess/monitor the client for
actual/potential specific food and
medication interactions.
 Identify contraindications,
 Assess/monitor the effectiveness of
pain intervention, and advocate
for the client’s needs as indicated.
 Provide appropriate client
education, and reinforce client
teaching regarding the purposes
and possible effects of pain
 Assess/monitor the client for
expected effects of medications.
 Assess/monitor the client for
side/adverse effects of medications.
actual/potential incompatibilities, and
interactions between medications,
and intervene appropriately.
 Identify symptoms/evidence of an
allergic reaction, and respond
 Evaluate/monitor and document
the therapeutic and adverse/side
effects of medications.
 Assess/collect data regarding the
client’s medication use over time.
Musculoskeletal Pharmacology : Medications for Pain & Inflammation
NSAIDs—Non Steroidal Anti-Inflammatory Drugs
Prototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®)
Pharmacological Action
Aspirin contraindications include:
Inhibition of cyclooxygenase: Inhibition of
COX-2 results in ↓ inflammation, pain, and
fever. Inhibition of COX-1 results in the ↓ of
platelet aggregation
Peptic ulcer disease.
Bleeding disorders (e.g., hemophilia, vitamin K
Hypersensitivity to aspirin and other NSAIDs.
Pregnancy (Pregnancy Risk Category D).
Children with chickenpox or influenza.
Use NSAIDs cautiously in older adults,
clients who smoke cigarettes, and in clients
with H. pylori infection, hypovolemia, hay fever, chronic
urticaria, and/or a history of alcoholism.
Therapeutic Uses
Inflammation suppression
Analgesia for mild to moderate pain
Fever reduction
Low level suppression of platelet
Musculoskeletal Pharmacology : Medications for Pain & Inflammation
NSAIDs—Non Steroidal Anti-Inflammatory Drugs
Prototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®)
Therapeutic Nursing Interventions and
Client Education
Advise the client to stop aspirin 1 week before an
elective surgery or expected date of childbirth.
Advise the client to take aspirin with food, milk, or
a full glass of water to reduce gastric
Instruct the client not to chew or crush enteric-coated
or sustained-release aspirin tablets.
Advise the client to notify the primary care provider if
signs and symptoms of gastric discomfort or
ulceration occur.
Clients unable to tolerate aspirin due to GI ulceration,
risk of bleeding, or renal impairment should be
prescribed a 2nd generation NSAID, such as
celecoxib (Celebrex).
One 1st generation NSAID, ketorolac (Toradol), is
used for short-term treatment of moderate to
severe pain such as that associated with
postoperative recovery.
Ketorolac provides analgesia without antiinflammatory effect.
When ketorolac is used concurrently with opioids,
the analgesic effect of opioids is enhanced without the
occurrence of adverse effects associated with opioids
(e.g., respiratory depression, constipation).
When ketorolac is used with other NSAIDs serious
adverse effects can occur; therefore, ketorolac should
be used no more than 5 days. Usually started as
parenteral administration and then progresses to oral
Depending on therapeutic intent, effectiveness
of NSAID USE may be evidenced by:
Reduction in inflammation.
Reduction of fever.
Relief from mild to moderate pain or dysmenorrhea.
Platelet aggregation suppression.
Musculoskeletal Pharmacology : Medications for Pain & Inflammation
Prototypes: acetaminophen (Tylenol® )
Pharmacological Action
Acetaminophen slows the production of
prostaglandins in the central nervous system.
Therapeutic Uses
Analgesic (relief of pain) effect
Antipyretic (reduction of fever) effects
Side/Adverse Effects:
Nursing Interventions and Client
Acetaminophen is a component of multiple
prescribed and over-the-counter medications. Keep
a running total of daily acetaminophen intake and
follow recommended dosages as prescribed by the
primary care provider to prevent toxicity, not to
exceed 4 g per day.
In the event of an acetaminophen overdose, liver
damage can be reduced by administering a weightbased dosage of the antidote acetylcysteine
(Mucomyst) in a diluted form via an
oroduodenal tube (has an unpleasant odor that ↑
risk of emesis).
Nursing Interventions and Client Education
Acute toxicity that results in liver damage with
early symptoms of nausea, vomiting, diarrhea,
sweating, and abdominal discomfort progressing
to hepatic failure, coma, and death
Advise the client to take acetaminophen as
prescribed and not to exceed 4 g per day.
Administer the antidote,
Nursing Evaluation of Medication
Depending on therapeutic intent, effectiveness may
be evidenced by:
Acetylcysteine (Mucomyst® ).
Use cautiously in clients who consume
three or more alcoholic drinks/day and
those taking warfarin (interferes with
Relief of pain.
Reduction of fever.
Musculoskeletal Pharmacology : Medications for Pain & Inflammation
Opioid Agonists
Prototypes: Morphine sulfate
Pharmacological Action
Opioid agonists, such as morphine, codeine,
meperidine, and other morphine-like
medications (fentanyl), act on the mu receptors,
and to a lesser degree on kappa receptors.
Activation of mu receptors produces analgesia,
respiratory depression, euphoria, and sedation,
whereas kappa receptor activation produces
analgesia, sedation, and ↓ GI motility.
Therapeutic Uses
asthma, emphysema, and/or head injuries
Relief of moderate to severe pain (e.g.,
postoperative pain, myocardial infarction pain,
cancer pain)
Infants and older adult clients
Pregnant clients
Clients in labor
Reduction of bowel motility
Clients with inflammatory bowel disease
Codeine: cough suppression
Clients with an enlarged prostate
after biliary tract surgery.
for premature infants (during and after
deliverydue to respiratory depressant effects).
Used Cautiously: because of respiratory
Demerol ®
-- meperidine
Repeated use of meperidine (Demerol) can
result in the accumulation of
normeperidine, which can result in seizures
and neurotoxicity.
Do not administer meperidine more than
600 mg/24 hr, and limit its use to less than
48 hr.
Morphine Sulfate
Side Effects / Adverse Effects
Nursing Interventions /
Client Education
Respiratory depression
--Monitor the client’s vital signs.
--Stop opioids if the client’s respiratory rate is less than 12/min, and then notify the primary care
--Avoid the use of opioids with CNS depressant medications (e.g., barbiturates,
benzodiazepines, and consumption of alcohol).
--↑ fluid intake and physical activity.
--Administer a stimulant laxative, such as bisacodyl (Dulcolax), to counteract ↓ bowel motility, or a
stool softener, such as docusate sodium (Colace), to prevent constipation.
Orthostatic hypotension
--Advise the client to sit or lie down if symptoms of lightheadedness or dizziness occur.
--Avoid sudden changes in position by slowly moving the client from a lying to a sitting or standing
--Provide assistance with ambulation as needed.
Urinary retention
--Advise the client to void every 4 hr.
--Monitor I&O.
--Assess the client’s bladder for distention by palpating the lower abdomen area every4 to 6 hr.
Cough suppression
--Advise the client to cough at regular intervals
to prevent accumulation of secretions in the
--Auscultate the client’s lungs for crackles, and
instruct the client to ↑ intake of fluid to liquefy
--Advise the client to avoid hazardous activities
such as driving or operating heavy machinery.
Biliary colic
--Avoid giving morphine to clients who have a
history of biliary colic. Use meperidine as an
--Administer an antiemetic such as
promethazine (Phenergan).
Opioid overdose triad
of coma, respiratory depression, and
pinpoint pupils
--Monitor the client’s vital signs.
--Place the client on a ventilator.
--Administer opioid antagonists, such as naloxone (Narcan) or nalmefene (Revex).
Musculoskeletal Pharmacology
Medications for Pain & Inflammation
Agonist – Antagonist Opioids
Prototypes: pentazocine (Talwin ®)
Pharmacological Action
 Compared to pure opioid agonists, agonistantagonists have:
 --A low potential for abuse causing little
euphoria. In fact, high doses can cause adverse
effects (e.g., anxiety, restlessness, mental
 --Less respiratory depression. Kappa receptors
will cause a certain degree of
respiratory depression and then no more (have a
Therapeutic Uses
 Agonists-antagonists opioids relieve mild to
moderate pain; not used for treatment of severe
 Use cautiously in clients with a history of
myocardial infarction (↑ cardiac workload) and
clients who are physically dependent on
Nursing Interventions and Client
 Take the client’s baseline vital signs. If the
client’s respiratory rate is less than 12/min,
withhold the medication and notify the primary
care provider.
Warn the client not to ↑ dosage without
consulting the primary care provider.
Nursing Evaluation of Medication
--Monitor for improvement of symptoms, such
as relief of pain.
Musculoskeletal Pharmacology
Medications for Pain & Inflammation
Opioid Antagonists
Prototypes: naloxone (Narcan ®)
Pharmacological Action
Opioid antagonists interfere with the action of
opioids by competing for opioid receptors. Opioid
antagonists have no effect in the absence of
Therapeutic Uses
Treatment of opioid overdose
Reversal of effects of opioids, such as respiratory
Reversal of respiratory depression in an infant
Opioid dependency
Pregnancy Risk Category B
Therapeutic Nursing Interventions
and Client Education
 Naloxone has rapid first-pass inactivation
and should be administered IV, IM, or SC.
Do not administer orally.
 Observe the client for withdrawal symptoms
and/or abrupt onset of pain. Be prepared to
address the client’s need for analgesia (e.g., if
given for postoperative opioid-related
respiratory depression).
 Nursing Evaluation of Medication
Reversal of respiratory depression (e.g.,
respirations are regular, client is without
shortness of breath, respiratory rate is 16 to
20/min in adults and 40 to 60/min in
Musculoskeletal Pharmacology
Medications for Pain & Inflammation
Adjuvant Pain Medications
Prototypes:Tricyclic anti-depressants; anticonvulsants; CNS Stimulants; antihistamines;
glucocorticoids; & biphosphonates
 Tricyclic antidepressants:
amitriptyline (Elavil)
Anticonvulsants: carbamazepine
(Tegretol), gabapentin (Neurontin),
phenytoin (Dilantin
CNS stimulants:
methylphenidate (Ritalin),
dextroamphetamine (Dexedrine)
Antihistamines: hydroxyzine
Glucocorticoids: dexamethasone
(Decadron), prednisone (Deltasone)
Bisphosphonates: etidronate
(Didronel), pamidronate (Aredia)
 Pharmacological Actions
Adjuvant medications for pain enhance the effects
of opioids.
 Therapeutic Uses
 Used in combination with opioids –
cannot be used as a substitute for
Treating pain with an adjuvant
medication allows for lower dosages of
opioids, and thereby ↓ the adverse
effects experienced with opioids (e.g.,
sedation and constipation).
Help alleviate other symptoms that
aggravate pain (e.g., depression,
seizures, dysrhythmias)
Used in the treatment of neuropathic
pain (e.g., cramping, aching, burning,
darting and lancinating pain).
Used in cancer-related conditions (e.g.,
↑ intracranial pressure, spinal cord
compression, bone pain).
Musculoskeletal Pharmacology
Medications for Pain & Inflammation
Antigout Medication
Prototypes: colchicine
Pharmacological Action
Colchicine and indomethacin ↓ inflammation in clients with
gout by possibly preventing infiltration of leukocytes. These
medications do not effect uric acid production or excretion.
 Allopurinol inhibits uric acid production.
 Probenecid inhibits uric acid reabsorption by the renal
Avoid use of colchicine during pregnancy (FDA Pregnancy
Risk Category C, if used orally; Category D, if used
Use colchicine cautiously in older adults, debilitated clients,
and clients with renal, cardiac, and gastrointestinal
Therapeutic Nursing Interventions and
Client Education
Instruct the client to concurrently take preventive measures
such as avoiding alcohol and foods high in purine (e.g., red
meat, scallops, cream sauces). The client should ensure an
adequate intake of water, exercise regularly, and maintain an
appropriate body weight.
Nursing Evaluation of Medication
Depending on the therapeutic intent, effectiveness may be
evidenced by:
--Improvement of pain caused by a gout attack (e.g., ↓ in
joint swelling, redness, and uric acid levels).
 Therapeutic Uses
Colchicine and indomethacin:
--Treatment of acute gout attacks.
--If given in response to precursor symptoms of an acute
gout attack, can abort the attack.
--↓ in the incidence of acute attacks for clients with chronic
Allopurinol and probenecid:
--Hyperuricemia (chronic gout secondary to cancer
--Prolongs the effects of penicillins and cephalosporins by
delaying their elimination.
--↓ in number of gout attacks.
--↓ in uric acid levels.
Musculoskeletal Disorders
 Case Study Exercise Group I
 John is a 34 y.o. skier with a spiral fracture of the right tibia.
He has pins set to traction below his knee to continue with 5
pounds of pressure to hold the ones in place.
Create a nursing care plan, that you will present to the class.
Complete with two references:
Research articles on
Traction, pins, and
spiral fractures.
Musculoskeletal Disorders
 Case Study Exercise Group II
 Maria is a 48 y.o. with osteomyelitis and MRSA of the (R) tibia.
Medical history includes Diabetes Mellitus, Type 2. She is
returning from the operating room, S/P Right BKA
Create a nursing care plan, that you will present to the class.
Complete with two references:
Research articles on amputation.
Musculoskeletal Disorders
 Case Study Exercise Group III
Franklin is a 64 y.o. male who is returning from the operating
room, S/P (R) Total knee replacement. He is otherwise
“healthy,” on no home medications other than NSAIDs.
Create a nursing care plan, that you will present to the class.
Complete with two references:
Research articles on TJR.
Musculoskeletal Disorders
 Case Study Exercise Group IV
 Johnna is a 48 y.o. with severe pain to her right ankle. Has
just been diagnosed with gout.
Create a nursing care plan, that you will present to the class.
Complete with two references:
Research articles on Gout
and its treatment.

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