2.8 Musculoskeletal Flashcards
(107 cards)
1
Q
Complications of Immobility In SCI-
Musculoskeletal
A
Musculoskeletal: Joint stiffness, contractures, foot drop Bone demineralization Muscle spasms/atrophy Joint contractures Osteoporosis
2
Q
Complications of Immobility In SCI-
Respiratory
A
Respiratory:
Risk for pneumonia
Decreased chest expansion
Decreased cough reflex
3
Q
Complications of Immobility In SCI-
Cardiovascular
A
Cardiovascular:
Orthostatic hypotension
DVT
Decreased venous return
4
Q
Complications of Immobility In SCI-
Genitourinary
A
Genitourinary: Urine retention/incontinence Impotence Inability to ejaculate Decreased vaginal lubrication
5
Q
Complications of Immobility In SCI-
Gastrointestinal
A
Gastrointestinal:
Stool incontinence
Constipation/paralytic ileus
Stress related ulcers
6
Q
Complications of Immobility In SCI-
Integumentary
A
Integumentary:
Pressure ulcers
7
Q
Spinal Cord Injury (SCI)Causes
A
MVA Falls Violence Other/unknown Sports related accidents
8
Q
What Happens in SCI?
A
Injury occurs to either:
Vertebrae & ligaments
Blood vessels
Damage to vertebrae ligaments, blood vessels makes spinal cord unstable increasing possibility of compression or stretching of cord with further movement.
Rarely is spinal cord completely severed.
9
Q
SCI
Primary?
A
Primary injury to the spinal cord
The initial mechanical disruption of axons.
10
Q
SCI
Secondary
A
Secondary injury to the spinal cord
The ongoing, progressive damage that occurs to spinal cord neurons from:
Further swelling
Demyelination
Necrosis
Edema extends level of injury 2 cord segment levels above and below. Extent of injury cannot be determined for up to one week.
11
Q
Paralysis
A
Paralysis
Partial or complete loss of muscle function
12
Q
Complete SCI
A
Complete SCI:
Complete interruption of motor & sensory pathways
Results in total loss of motor & sensory function below level of injury
13
Q
Incomplete SCI
A
Incomplete SCI:
Partial interruption of motor & sensory pathways
Variable loss of function below the level of injury
14
Q
Paresis
A
Paresis
Partial paralysis/weakness.
15
Q
What is Upper Motor Neurons responsible for?
A
Upper Motor Neurons
Responsible for voluntary movement.
16
Q
Upper Motor Neurons
Injury leads to?
A
Injury leads to: Increased muscle tone/ spastic paralysis Decreased muscle strength Inability to carry out skilled movement Hyperactive reflexes.
17
Q
What are the Lower Motor Neuron responsible for?
A
Lower Motor Neuron Responsible for innervation and contraction of skeletal muscles.
18
Q
Lower Motor Neuron
Injury leads to?
A
Injury leads to:
Decreased muscle tone
Muscle atrophy/ flaccidity/weakness
Loss of reflexes.
Loss of voluntary & involuntary movements.
Partial to full paralysis depending on how many motor neurons affected.
19
Q
Some or All motor neurons effected, what happens?
A
If only some of the motor neurons supplying a muscle are affected only partial paralysis is experienced.
If all motor neurons to the muscle affected= complete paralysis and hyporeflexia.
20
Q
Paraplegia
A
Damage to thoracic, lumbar or sacral area of the cord.
Loss or impairment of motor and /or sensory function the trunk, legs, and pelvic organs.
Arms are spared
T6 level injury= use of arms & upper chest
L1 level injury use of all but legs.
Full independence in self care in w/c.
21
Q
Sacral Sparing
A
Some incomplete SCI patients experience this phenomenon where sensation is preserved in sacrum. Positive finding!
Patients with sacral sparing, then, may have fewer problems with bowel functioning and elimination than those with a complete injury.
22
Q
Sacral Sparing
results in?
A
Results in: Bowel & bladder training possible Perianal sensation Rectal function Highest possibility of sexual function
23
Q
Sacral Sparing
Bowel training with sacral sparing
A
Bowel training: Digital stimulation, stool softeners, suppositories High fiber high fluid diet Upright position Assess usual patterns
24
Q
Sacral Sparing
Bowel training without sacral sparing
A
Bowel Maintenance without Sacral sparing:
Digital removal, enemas
Abd. massage to stimulate peristalsis.
25
Sacral Sparing
| Teaching
Teach:
Home self cath=clean technique
Voiding triggers:
Stroke inner thigh
Pull on pubic hair
Tap on abdomen
Pour H20 over vulva
Crede, manual pressure on the abdomen at the location of the bladder, just below the navel.
Monitor residual urine <80 ml ok
Highest level of sexual function in sacral sparing patients.
Most people with SCI can have satisfying sexual relationship regardless of the level of injury
26
Tetraplegia
Tetraplegia
(Quadriplegia). Cervical damage causing loss or impairment of motor and/or sensory function in the arms, trunk legs and pelvic organs.
27
Tetraplegia
| C1-C4
```
C1-C4 injury
C1-C2 injuries could result in death
Often fatal at scene
Respiratory paralysis common
Require ventilator assistance.
Head and neck movement only
Require 24 hour care. Cannot live independently
May use an electric wheel chair with mouth stick, and head rest.
```
28
Tetraplegia
| Below C4 and C6
Below C4
May not be ventilator dependent
C6
Shoulder movement
29
IM Injections in SCI
I.M. injections should be given above the level of injury.
Clients with spinal cord injuries have reduced use and reduced blood flow to muscles (ventral gluteal) and legs (vastus lateralis).
30
IM Injections in SCI
| decreased blood flow to muscle?
Decreased blood flow to muscle can result in:
Impaired drug absorption
Increased risk of local irritation and trauma
May result in ulceration of the tissue.
31
Autonomic Dysreflexia
| what is it?
What is it?
Exaggerated sympathetic response in SCI patient’s at or above T6 level injuries.
Triggered by stimuli that normally causes abdominal pain.
32
Autonomic Dysreflexia
| Pathophysiology
Pathophysiology:
Stimuli is unable to ascend the cord.
Causes stimulation of sympathetic nerves below level of injured cord resulting in massive vasoconstriction.
Vagus nerve causes bradycardia & vasodilation above level of injury.
33
Autonomic Dysreflexia
| triggers?
```
Triggers:
Full bladder (most common)
Fecal impaction
Pressure ulcers
Dressing changes
Ingrown toenails
Surgical procedures
Labor contractions
```
34
Autonomic Dysreflexia
| S/S
Signs & Symptoms:
Pounding HA
Bradycardia & HTN (high as 240/120 risk of CVA)
Vasodilation with warm flushed skin & profuse sweating above level of injury.
Pale, cold (gooseflesh), dry skin below level of injury
Neurologic Emergency!!!!!
35
Autonomic Dysreflexia NI
1st Raise HOB/ sit patient up!!!
Identify cause (full bladder, bowel?)
Remove stockings or boots to decrease b/p.
Best intervention is through prevention.
May be hypotensive after stimulus removed.
**Bladder and bowel are most frequent causes of AD.
36
Complications of extremely high blood pressure
```
Complications of extremely high blood pressure:
Loss of consciousness
Seizures
Death
Stroke
```
37
Halo Traction
External fixation device
Used to provide stabilization if no significant involvement of ligaments.
Stability for fracture of the cervical and high thoracic vertebrae without cord damage.
4 pins inserted into the skull & ring attached to plastic vest.
38
Halo Traction
| Pro's
Pro’s
Greater mobility
Self-care
Participation in rehab programs
39
Halo
| Nursing Interventions
Inspect pin & traction sites for looseness.
Never use halo ring to reposition patient.
Assess sensation
Pin care per agency policy.
Turn immobile patients q 2 h
Tape wrenches to HOB for emergency intervention.
Straws for drinking, cut food small pieces
Monitor fatigue and balance
Assess skin under vest
Do not drive
40
Amputations defined
Definition:
| Partial or total removal of an extremity.
41
Amputations causes?
Causes:
PVD- primary reason
PVD risk factors: smoking, DM, HTN, hyperlipidemia.
Peripheral neuropathy (loss of sensation leads to injury)
Untreated infections.
Trauma (MVA, machinery accidents).
42
Amputations
| post-op complications
```
Post-op Complications:
Infections
Hemorrhage
Delayed healing
Phantom limb pain
Contractures
```
43
Amputations NI
Nursing Interventions:
Keep incision clean & dry
Maintain stump dressings to decrease edema. Replace if comes off
Medicate for pain including phantom limb pain. Teach: common to have phantom pain.
AKA (above the knee) patients avoid prolonged sitting (increased risk contractures).
BKA (below the knee) elevate stump keeping joint extended.
44
Amputations nursing care goals
Nursing care goals:
Relieve pain
Promote healing
Prevent complications
Support the patient and family with grieving and adaptation to body image and restore mobility.
45
Bone Tumors
| Benign
Benign bone tumors:
More common
Grow slowly
Do not often destroy surrounding tissues (symmetrical)
46
Bone Tumors
| Malignant
Malignant bone tumors.
Primary: rare <0.2% of all adult cancers.
Secondary: more common (primary lung, prostate, breast cancers)
Grow rapidly (invade surrounding tissues and blood supply)
Metastasize
47
Bone Tumors
| 3 main symptoms
```
1. Pain
Develops slowly
Lasts > week
Constant or intermittent
May be worse at night
2. Mass
Firm swelling or lump on the bone
Slightly tender
Palpable
3. Impaired function
May interfere with normal movement and/or cause a fracture.
```
48
Osteoporosis
| what is it
Porous bones/ Loss of bone mass
49
Osteoporosis
| non-modifiable
```
Non-modifiable risk factors
Older age
Family history of osteoporosis
Female (Caucasian or Asian)
Thin and/or having a small frame.
**Weight bearing exercises like walking, running increases blood flow to bones therefore bringing growth-producing nutrients to the cells
```
50
Osteoporosis
| Modifiable
Modifiable risk factors
Low estrogen
Low testosterone
Low lifetime calcium intake, Vit. D deficiency
Medications: corticosteroids, some anticonvulsants
Lifestyle: inactivity, cigarette smoking, excess alcohol use.
51
Osteoporosis and smoking
Smoking lowers estrogen levels in both men and women. Estrogen is important because it helps the bones to hold calcium and other minerals that make them strong. At menopause, a woman's body makes much less estrogen, and this puts her naturally at risk for osteoporosis. Smoking increases her risk even more.
52
Osteoporosis and steroid use
Steroid medications have major effects on the metabolism of calcium, vitamin D and bone. This can lead to bone loss, osteoporosis, and broken bones. Inhaled steroids are less likely to cause bone loss than steroids taken by mouth. However, in higher doses, inhaled steroids may also cause bone loss.
53
Osteoporosis
| complications
Complications
Fractures: spontaneous & everyday activities.
Hip and vertebral fractures increase risk of death and disability.
54
Osteoporosis
| diagnosis
Diagnosis
Bone mineral density test (BMD) estimate skeletal mass or density.
Duel-energy x-ray absorptiometry (DXA) Highly accurate. Measures bone density of spine or hip.
55
Osteoporosis
| Treatment Goals
```
Treatment Goals
Early identification of risk
Stop or slow the process
Alleviate symptoms
Exercise
```
56
Osteoporosis
| medications
```
Treatment:
Calcium
Vitamin D
Bisphosphonates (Fosamax, Boniva)
Estrogen replacement
Calcitonin (hormone that increases bone formation)
```
57
Inflammatory Conditions
| Bursitis
Bursitis
Inflammation of a bursa (fluid sac acts as gliding surface)
Shoulder, elbow and hip most common, also occurs in knee, heel and the base of big toe
Pain and decreased ROM.
58
Inflammatory Conditions
| Tendonitis
Tendonitis
Inflammation of a tendon
Tendonitis is most often caused by repetitive, minor impact, or acute injury (shoveling, skiing)
Pain and tenderness
59
Synovial fluid what is it?
Synovial fluid: Fluid in joints that lubricates the joint to reduce friction between cartilage of synovial joints during movement.
60
Inflammatory Conditions
| Myositis
Myositis
Inflammation of a muscle.
Injury, infection, or autoimmune causes.
S/S: fatigue after activity, tripping or falling, difficulty swallowing or breathing.
61
Inflammatory Conditions
| Myositis treatment
Treatment:
| Rest, cold, anti-inflammatory meds
62
Inflammatory Conditions
| Synovitis
Synovitis
Inflammation of the synovial membrane of a joint.
Common with knee injury.
Swelling, decreased mobility, pain, effusion in joint.
63
Inflammatory Conditions
| Synovitis treatment
Treatment
Synovectomy (reduces inflammation)
Rest, ice
64
Osteomyelitis what is it?
Infection of the bone. Can be acute or chronic
65
Osteomyelitis
| risk factors
Risk Factors:
Older adult (decreased immune system & more chronic illnesses)
Hemodialysis & IV drug users
Joint replacement & fracture stabilizing hardware
66
Osteomyelitis
| causes
```
Causes:
Penetrating wound
Bacteremia
Skin breakdown with vascular insufficiency
Usually by Staph Aureus
```
67
Osteomyelitis
| Symptoms
Symptoms:
Local: swelling, redness, warmth, pain.
Systemic: fever, malaise, tachycardia, anorexia.
68
What is ESR= erythrocyte sedimentation rate
ESR= erythrocyte sedimentation rate: detects inflammation associated with infections and autoimmune diseases.
69
Osteomyelitis
| Diagnosis
Diagnosis
Bone scan, ultrasound, MRI
Blood tests: ESR & WBC elevated
Blood and tissue cultures, biopsy
70
Osteomyelitis
| Treatment
```
Treatment
IV Antibiotics (4-6 weeks)
Oral Cipro for chronic
Surgery
Debridement is primary treatment with chronic osteomyelitis
```
71
Osteoarthritis (OA) aka Degenerative Joint Disease (DJD)
| risk factors
```
Most common form of arthritis
Leading cause of pain and disability in older adults.
Risk factors
Increasing age
Genetics
Obesity (knee and hip)
Inactivity
Repetitive joint use.
```
72
Osteoarthritis (OA) aka Degenerative Joint Disease (DJD)
| Pathology
Pathology
Progressive loss of joint cartilage causing increased friction in joint = pain, stiffness, loss of joint motion and gait disturbances. Bone-on-Bone over time
**Develops in hand, neck, low back, hip, knee.
73
Osteoarthritis
| Symptoms
```
Symptoms
Onset is gradual and slow progression.
Pain (deep ache) and stiffness
Pain may be relieved by rest
Joint stiffness after long periods of rest. Few min of activity relieve stiffness
ROM of joint decreased
Grating sound or crepitus with movement.
Herberden’s nodes on distal phalangeal joints
```
74
Osteoarthritis
| Diagnosis
Diagnosis:
Patient history
Physical exam
X-ray of joints
75
Osteoarthritis
| Treatment goals
Treatment goals
Control pain
Improve or maintain joint function and mobility
Reduce or prevent physical disability
76
Osteoarthritis- Treatments
Mild analgesics: Tylenol for long term use ok less side effects.
NSAIDS: reduce inflammation not for long term use.
COX-2 inhibitors (Celebrex) Less GI risk good for intolerant to NSAIDS.
Topical Creams: Less systemic adverse effects proven to help (Capsaicin, Biofreeze).
Rest, Exercise (especially H2O exercises)
Steroid/ Lidocaine injections
Surgery (arthroplasty hips/ knees/ shoulders)
Assistive Devices (braces, canes, walkers)
Weight loss
77
Gout what is it?
Acute inflammatory arthritis caused by excess amount of uric acid in the blood. Occurs in stages.
Uric acid is product of purine metabolism is excreted in kidneys.
Deposits urates into the joints causing crystallization. Crystals stimulate and continue inflammatory process.
78
Acute Gout
Acute Gout:
Inflammation of joint usually great toe (also fingers, wrists, knees, elbows, ankles)
Pain wakes you up at night.
Joint hot, swollen, & very tender, Fever
Last hours to days
Elevated uric acid >8.5, WBC, & Sedimentation Rate
79
Gout
| Advanced Gout
Advanced Gout:
Occurs when hyperuricemia not treated.
Urate deposits called Tophi seen most common in helix of ear, tendons of fingers, tissues surrounding joints (elbows & knees).
80
Gout
Advanced Gout
Complications
Complications:
Kidney stones from urate can lead to kidney failure.
Tophi may develop in tissue of heart & spinal epidural compressing nerves.
81
Gout- Treatment Prophylactic
```
Prophylactic
Colchicine
Allopurinol (Zyloprim): lowers urate levels & mobilizes tophi.
Dietary & lifestyle modifications.
Avoid high purine foods such as:
Beer / grain liquors
Red meat, organ meats
Spinach, asparagus, cauliflower
Seafood especially shellfish.
```
82
Gout- Treatment
| Acute Treatment
Acute Treatment
NSAIDS = reduce swelling
Colchicine= stops urate crystal deposits in joint.
Steroids
83
Gout NI
Nursing Interventions:
Medicate for Pain relief during acute attack.
Diet low in purine (avoid organ meats, sardines, shellfish, alcohol, drinks sweetened with high fructose corn syrup)
Rest, ice, elevation
Teach uric acid levels should decrease with proper treatment
Protect joint from pressure.
Increase fluids. Desired output of 2000ml/day (promotes urate excretion & reduce risk of kidney stone formation)
84
Auto-Immune
| Systemic Lupus Erythematosus (SLE) what is it?
What is it?
Chronic inflammatory disease that occurs when your body's immune system attacks your own tissues and organs.
Inflammation can affect many different body systems — including joints, skin, kidneys, blood cells, brain, heart and lungs.
85
Auto-Immune
Systemic Lupus Erythematosus (SLE)
Risk factors
```
Risk factors:
Women 10:1 ratio to men.
Family history
Environmental (viruses EBV).
Women who use estrogen contraceptives or HRT. (hormone replacement therapy)
```
86
Auto-Immune
Systemic Lupus Erythematosus (SLE)
Pathophysiology
Pathophysiology:
Autoantibodies produced= target specific tissues= inflammatory response= destructive enzymes produced causing tissue damage.
Causes multisystem effects on body
87
Auto-Immune
Systemic Lupus
Clinical Manifestations
Clinical Manifestations:
Extreme fatigue
Unexplained fever
Swollen joints & muscle pain (mimics RA)
Red butterfly rash across the cheeks and bridge of nose(most specific sign indicative of lupus)
Photosensitivity (rash with skin exposure) Avoid the sun. UV light can trigger acute onset of symptoms. Rashes interrupt skin integrity & increase infection risks.
Complications: Renal failure & stroke
88
Lupus Treatments MILD
Mild: little to no treatment except supportive care Tylenol, NSAIDs, aspirin.
Skin & arthritic manifestations: hydroxychloroquine (Plaquenil). Effective in reducing frequency of acute episodes. Retinal toxicity & blindness side effects! Eye exam every 6 months.
89
Lupus Treatments SEVERE
Severe SLE: high dose corticosteroids to manage symptoms & prevent organ damage. May need steroids long term.
NI: monitor steroid side effects: HTN, wt gain, infections, osteoporosis, moon face, hypokalemia.
90
Lupus Treatments
| Immunosuppressive
Immunosuppressive Meds: Monitor infections, labs, kidney & liver function.
91
Lupus labs
Monitor labs: WBC, ESR, Platelet, Liver function, Kidney function,
92
Polymyositis what is it?
Autoimmune systemic connective tissue disorder causing inflammation of connective tissue & muscle fibers.
93
Polymyositis risk factors
Risk Factors:
Unknown cause.
Women > men
94
Polymyositis Manifestations
Manifestations:
Skeletal muscle weakness is the main symptom. Pelvic & neck muscles particularly
Muscle pain & tenderness
Weakness progresses over weeks to months.
Dusky red rash on face and upper trunk.
95
Polymyositis
| Diagnosis
Diagnosis
No specific test for diagnosis
Creatine kinase (CK) elevated (25-170 normal ranges)
96
Polymyositis Treatment
Treatment
Rest
Corticosteroids
Immunosuppressive agents if no response from steroids.
97
Polymyositis
| NI
Nursing Interventions
Monitor for aspiration with feeding
Assist with ADLs, promote comfort & independence
Communication alternatives if speech involved.
Family trained in Heimlich and CPR
98
Rheumatoid Arthritis(RA) what is it?
what is it?
Chronic systemic autoimmune disease causing inflammation of connective tissue primarily in joints.
Cause unknown
99
```
Rheumatoid Arthritis(RA)
Risk factors
```
```
Risk factors
Thought to be genetic
Emotional stress can cause flare ups.
Women 3:1 to men
Heavy Smoking
Speculated that infectious agent such as a virus plays role in initiating abnormal immune response.
```
100
```
Rheumatoid Arthritis(RA)
Clinical Manifestations
```
Clinical Manifestations
```
Joint swelling, stiffness, tenderness, warmth.
Stiffness > in AM >1 hour
ROM limited in affected joint.
Deformity of joints.
Joints feel sponge-like on palpation.
```
101
```
Rheumatoid Arthritis(RA)
Diagnostic Tests
```
Diagnostic Tests
Elevated c-reactive protein & ESR. Anti-CPA blood test more specific marker for RA.
Synovial fluid from joint cloudy.
X-rays of joints most specific test for RA.
102
```
Rheumatoid Arthritis(RA)
Treatment Goals
```
Treatment Goals
```
No Cure.
Relieve pain
Reduce inflammation
Slow or stop joint damage
Improve well-being & function.
```
103
```
Rheumatoid Arthritis(RA)
Meds
```
Meds
NSAIDS & Steroids : reduce inflammation & pain
Disease Modifying Anti-Rheumatic Drugs:
Slows bone erosion
Improves ROM
Monitor for blood dyscrasias (nonspecific term that refers to a disease or disorder, especially of the blood)
```
DMARD’s (Disease-modifying anti-rheumatic drugs)
Methotrexate
Remicade
Rituxcan
Humira
```
104
Rheumatoid Arthritis(RA) rest and exercise
Important to balance rest & exercise with RA. Short period of bed rest in acute period.
Balanced program of rest and exercise critical to maintain muscle strength and joint mobility.
105
```
Rheumatoid Arthritis(RA)
Labs
```
Labs:
Monitor for WBC, platelets, neutrophils during DMARDs (Disease-modifying anti-rheumatic drugs) therapy r/t possibility for blood dyscrasias (nonspecific term that refers to a disease or disorder, especially of the blood)
106
```
Rheumatoid Arthritis(RA)
Surgery
```
Surgery
Synovectomy (synovial membrane) to relieve pain and reduce inflammation.
Arthrodesis (joint fusion) to stabilize joints wrists, ankles& cervical)
Arthroplasty (total joint replacement) improved mobility, decrease pain.
Osteotomy (cut bone) to change alignment or correct deformity.
107
```
Rheumatoid Arthritis(RA)
other treatments
```
```
Other
PT and OT
Heat and cold
Assistive devices and splints
Nutrition (well-balanced with Omega 3)
```
