WEEK 12/ 13- MSK Challenges

Question 1

Osteoporosis

Answer 1

• Metabolic disease caused by bone demineralization =  bone density = fractures
• Areas commonly affected: wrist, hip, vertebral column

Question 2

Primary Osteoporosis

Answer 2

o Not associated with underlying disease
o Most common in women after menopause, men in later years
• Type I: postmenopausal: ages 55 to 65
• Type II: senile: over age 65

Question 3

Secondary osteoporosis

Answer 3

Related to an associated medical condition

Treatment related to underlying cause

Question 4

Risk Factors

Answer 4

o	Age over 60 years
o	Family history
o	Caucasian or Asian race
o	Thin, lean body build
o	Low lifetime calcium intake
o	Estrogen deficiency
o	Smoking history/high alcohol intake
o	Lack of physical exercise/prolonged immobility
o	Parathyroid disorder

Question 5

Parathyroid Hormone

Answer 5

regulates calcium in blood in part by promoting mov’t of Ca from the bone
↓ Ca in blood ► ↑ PTH prompt demineralization of the bone

Question 6

Primary Manifestations

Answer 6

o “Dowager’s” hump= kyphosis of dorsal spine/shortened height
o Sharp, acute back pain
o Tenderness, restriction of spinal movement suggests compression vertebrae fracture/s
o Constipation/abdominal distention/reflux esophagitis
o Respirations compromised
o Fractures most common:
 Between T8 and L3
 Distal end of radius and hip

Question 7

Diagnosis

Answer 7

o	Bone mineral density (BMD)
•	values = T-scores
	Normal = less than -1
o	Low bone mass (osteopenia)
•	T-score between -1 and -2.5
o	Osteoporosis in postmenopausal women
•	T-score at or below -2.5
o	BMD decreases rapidly as serum estrogen levels 

Question 8

Primary Osteoporosis – Interventions – Drug Therapy

Answer 8

 Calcium -1200 mg/day from all sources (includes diet and supplementation)
 Vitamin D - D-needed to promote Ca++ absorption
 800-2000 IU/day
 Bisphosphonates (BPs)- eg. Fosamax
• inhibit bone resorption
• Risk of esophageal ulcers if the pill is not completely swallowed-
• Caution to take with full glass of water on empty stomach
• Sit upright for 30 minutes afterwards

Question 9

More Interventions

Answer 9

o	Diet therapy
o	Prevention of falls
o	Exercise
o	Pain management
o	Orthotic devices

Question 10

Weight-bearing (local stress)

Answer 10

Stimulate bone formation & remodelling

Avoid prolonged bed rest: bone loses calcium(resorption) & becomes osteopenic & weak

Question 11

Falls

Answer 11

• # 1 cause of accidental death of persons >65 years
• Account for 65% of injuries to seniors each year
• 1/3 of Canadian seniors fall each year
• Account for 84% of injury admits to hospitals, 40% of nursing home admits
• High cost to person, family and HC system
• Research indicates falls are preventable with education/ awareness programs
• Major concern for health care providers as the Baby Boomers face their senior years

Question 12

Risk Factors

Answer 12

• History of falls
• Age>80
• Multiple Illnesses
• Generalized weakness or immobility
• Confusion- or use of drugs that can cause confusion, mobility limitations or orthostatic hypotension
• Urinary incontinence
• Communication impairments
• Location of client’s room
• Major visual impairments
• Substance abuse
• Location of client’s room

Question 13

Assess Risk for Fractures

Answer 13

Previous fracture after age 40
Parental hx of fracture 
High ETOH intake 
Use of steroids or smoker
Hx of rheumatoid arthritis
Falls: any in past year?
>10% loss of weight since age 25
Get up and Go test

Question 14

Classification of Fractures

Answer 14

• Complete - the break is across the entire width of the bone
• Incomplete - the break is through only part of the bone
• Compound - if the soft tissue around the fracture is open
• Pathological - occurs after minimal trauma to a bone that is weakened by disease (eg: bone cancer or infection)

Question 15

Factors affecting healing times

Answer 15

• age
• displacement
• site of fracture
• nutritional level
• blood supply to the area of injury

Question 16

CLINICAL MANIFESTATIONS

Answer 16

Pain: immediate, severe
Loss of function
Deformity; abnormal positioning of extremity
Shortening of extremity
Crepitation: palpable or audible
Edema
Paresthesia- burning or tingling sensation
Numbness
Motor weakness
Pulselessness, impaired capillary refill time and cyanotic skin

Question 17

Nursing Assessment

Answer 17

• Pain - Continuous and increases in severity
o Muscle spasm accompanying the fracture is a reaction of the body to try and immobilize the fractured bone (mostly with hip and femur #)
• Deformity - Displacement, angulations or rotation of the fragments
• Crepitus - A grating sensation produced when the bone fragments rub each other

Question 18

Complications- Fat Embolism

Answer 18

Occurs usually in fractures of the long bones
Fat globules may move into the blood stream because the marrow pressure is greater than capillary pressure
Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs
 Onset within 24-72 hours after fracture
 Sudden dyspnea and respiratory distress & hypoxia
 Agitation, delerium
 Tachycardia
 Chest pain
 Crackles, wheezes and cough
 May have petechial rash over the chest, axilla and hard palate

Question 19

Fat Embolis Prevention

Answer 19

 Immobilization of fracture
 Minimal fracture manipulation
 Adequate support for fractured bone during turning and positioning
 Maintain adequate hydration and electrolyte balance

Question 20

Acute Compartment Syndrome

Answer 20

 muscles are wrapped with dense leathery tissue called fascia , a dense, inelastic cover
 Severe fractures, trauma, vascular injuries and electrical injuries can all produce muscle damage
 As injured muscle swells, the pressure rises within the constricting compartment
 Eventually, the internal pressure rises so high that local circulation is cut off and the affected muscle dies
 Can also damage associated nerves resulting in a loss of both power and sensation.

Question 21

Symptoms include:

Answer 21

 Deep throbbing pain that is not relieved by analgesics
 Decrease in sensation to the area,
 Pale tissue colour
 Weakened pulses
 PARESTHESIA- first sign
 PULSELESSNESS - late sign
 Pain during passive motion that is greater than pain during active motion.

Question 22

Treatment of ACS

Answer 22

Surgical treatment- a fasciotomy
An incision is made through the skin and subcutaneous tissue into the fascia of the affected compartment.
Relieves the pressure
Wound is left open- packed and dressed
May require skin grafting.

Question 23

Fractures- Interventions

Answer 23

Emergency care
fracture may be accompanied by multiple injuries to vital organs
assess for respiratory distress, bleeding and head injury
Reduction or realignment
Immobilization

Question 24

Bandages and splints

Answer 24

Used for certain areas of the body- such as the scapula and clavicle
Non weight-bearing bones!

Question 25

Fracture Care

Answer 25

• Immobilize any suspected fracture o Support the extremity above and below when moving the affected part from a vehicle o Suggested temporary splints- hard board, stick, rolled sheets o Apply sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged to the chest

Question 26

Reduction or realignment

Answer 26

• application of a pulling force to a part of the body to provide reduction, alignment and rest • Can also decrease muscle spasm (relieve pain), and correct a deformity and prevent tissue damage • May be open (surgical) or closed (traction) • Traction o manual o mechanical

Question 27

Treatment of Fractures

Answer 27

Closed Reduction is most common | Uses a manual pull or mechanical traction to manipulate the bone ends so that they realign.

Question 28

Casts

Answer 28

 Purpose is to immobilize the bone fragments after reduction  Also allows early mobility  Reduces pain.

Question 29

Materials

Answer 29

``` • Plaster o Takes 24-72 hours to dry o Feels warm when applied o Rough edges may cause irritation • Synthetic (fibreglass) o Dry more quickly and can support weight within ½ hour ```

Question 30

Cast Care

Answer 30

• Tell patient about the heat while the cast is drying • Do not cover the cast until it is dry • Handle the cast with palm of the hand • Turn client q2h to allow for drying • If limb is to be elevated- use a pillow with a cloth cover (not plastic) • Protect body casts from urine or feces with plastic • Assess neurovascular status- q1h for first 24 hours • After dry- inspect cast q8h for drainage, cracking crumbling alignment and fit • Areas of drainage on the cast should be measured and documented. • Risk of infection as a result of skin breakdown under the cast o Symptoms- hot spots, cast may feel warmer, odour, fever and elevated wbc

Question 31

Closed Reduction External Fixation

Answer 31

First, the facture is reduced Then, percutaneous incisions are made and pins are screwed into the bones Pins are held in place with an external device to prevent movement

Question 32

Open Reduction

Answer 32

Is a surgical procedure during which the patient has the bone realigned Provides immediate bone strength but risk for infection

Question 33

ORIF - Open Reduction Internal Fixation

Answer 33

Allows for early mobilization Often used for the elderly because they are susceptible to the hazards of immobility Plates, pins and screws will be placed in the bone

Question 34

Hip Fractures

Answer 34

• Common in elderly women • Clinical manifestation: o External rotation & adduction of affected extremity o Shortening of the length of the affected extremity o Severe pain & tenderness • Treatment: o Initially- Buck’s traction o Surgery • Neurovascular check • Position: PREVENT FLEXION, ADDUCTION & INTERNAL ROTATION • Do not adduct past neutral position • Maintain in abducted position with A-frame pillow or pillows between legs • Avoid flexion of hip of more than 90 degrees • Prevent internal or external rotation by using sandbags, pillows, trochanter rolls

Question 35

IMPAIRED PHYSICAL MOBILITY

Answer 35

 Instruct patient to perform range of motion exercises, either passive or active  Provide support in ambulation with assistive devices  Turn and change position every 2 hours  Encourage mobility for a short period and provide positive reinforcements for small accomplishments

Question 36

SELF-CARE DEFICITS

Answer 36

• Assess functional levels of the patient • Provide support for feeding problems o Place patient in Fowler’s position o Provide assistive device and supervise mealtime o Offer finger foods that can be handled by patient o Keep suction equipment ready • Assist patient with difficulty bathing and hygiene o Assist with bath only when patient has difficulty o Provide ample time for patient to finish activity

Question 37

Osteoarthritis

Answer 37

``` Most common connective tissue disease Progressive deterioration and loss of cartilage "Wear and tear disease" Primary (idiopathic) Secondary Nodal/nonnodal ```

Question 38

Etiology

Answer 38

Developmental-Age is main RF Genetic-FHx-especially with nodal Traumatic-usually excessive use

Question 39

Clinical manifestations

Answer 39

Begins with mild stiffness Usually pain diminishes after rest and increases with activity May be unilateral or a single joint Enlargement of the bone- bony hypertrophy Rarely does the joint appear to be hot and inflamed May have Heberden’s nodes or Bouchard’s nodes.

Question 40

Interventions for OA

Answer 40

``` Goal- pain control – Analgesics- Acetaminophen – NSAIDS Rest- – immobilize the joint – Adequate sleep – Psychological rest • Positioning- joint should be in a functional position • Avoid contractures • Weight control • TENS ```

Question 41

Clinical Manifestations

Answer 41

Onset may be acute or slow Early- fatigue, generalized weakness and stiffness, anorexia and weight loss Sometimes there is a low grade fever Joints (usually upper extremity) are reddened, warm, stiff, swollen and tender

Question 42

Later Manifestations

Answer 42

Increasing pain On palpation- joints are soft due to synovitis and effusions Most or all joints are affected Common deformities of the hands

Question 43

lab assesment- Rheumatoid Factor (RF)

Answer 43

Measures the presence of unusual antibodies Normal range is negative The higher the titer, the more active the disease process is

Question 44

Drug Therapy for RA

Answer 44

NSAIDs- eg: Ibuprofen Corticosteroids-eg: prednisone DMARDs-disease-modifying anti-rheumatic drugs-eg: methotrexate Biologics –eg: Remicade Gold salts- reduce pain and inflammation Analgesics Salicylates- ASA

Question 45

Other Therapies

Answer 45

Rest, positioning, ice, heat TENS Management of fatigue Care of altered body image

Question 46

Total Joint Replacement

Answer 46

Procedure of last resort for pain management Most often hips and knees Contraindication would include- infection, inflammation

Question 47

Care of the patient following THR

Answer 47

``` – Pain control- usually PCA morphine pump for the first 24-48 hrs which will be replaced with oral analgesics (T3s/oxycodone) and NSAIDs – May have femoral nerve block or epidural instead of PCA – Aggressive Physiotherapy! – DVT/PE prophylaxis- o LMW Heparin o coumadin or o rivaroxaban (Xarelto) – Replace blood lost during surgery prn – Calcium and iron supplementation – Nutritional support ```

Question 48

Moving the Patient following THR

Answer 48

Legs must remain abducted Hips never flex more than 90 degrees Keep operative leg in neutral position Turn to operative side or back only

Question 49

Nursing Interventions & Teaching to Prevent Complications of TJR

Answer 49

``` Dislocation (less common with knee replacement) Infection DVT/PE Hypotension, bleeding Neurovascular compromise Pain ```

Question 50

Total Knee Replacement

Answer 50

– Nursing care is similar to that with a THR – Maintenance of abduction is not needed – May use a Continuous Passive Movement (CPM) machine- to keep the prosthetic knee in motion and prevent the formation of scar tissue. – Ice to reduce inflammation.

Question 51

amputations

Answer 51

The psychosocial effects may be more devastating than the physical impairment

Question 52

goal of amputations

Answer 52

Preserve extremity length and function while removing necessary tissue

Question 53

Amputation: Post Op Care

Answer 53

Monitor: VS, dressing, circulation, warmth, sensation Post Op prosthesis may mask bleeding Prevention of Infection- Monitor temperature, WBC, administer antibiotics as ordered, wound care

Question 54

Phantom Limb Pain

Answer 54

– Should be distinguished from stump pain – Feels like limb is still present – Burning, itching, tingling, or aching sensation – Coldness, heaviness, cramping, or shooting pain – Can become chronic, but resolves with time – Pain is real to the patient, thus treat as if it is real

Question 55

Analgesics

Answer 55

Opioids for Residual limb pain | Beta blockers, anticonvulsants and antispasmodics for PLP

Question 56

Complementary and Alternative Rx for PLP

Answer 56

``` – TENS – Ultrasound therapy – Massage – Exercise – Biofeedback – Distraction therapy – Hypnosis – Psychotherapy ```

Question 57

Prevention of Infection

Answer 57

– Inspect the wound for: o inflammation, erythema, warmth, tenderness/pain, drainage – Record character of drainage o Serous, sero-sanguinous, sero-purulent, purulent – Change dressing daily – Below knee amputation may be casted in OR making it difficult to assess – Antibiotics

Question 58

Exercise

Answer 58

– Avoid hip flexion (ie: sitting in chair and leaning forward) – Avoid pillows under the surgical site (to avoid flexion contractures) – Lie on abdomen for 30 min TID – Hip should be in extension while prone

Question 59

Bandages

Answer 59

• May use rigid or soft dressings – Used to mold/shape residual limb – Reduces edema When using Tensor type pressure bandage – Re-wrap q 4h – Use figure 8 pattern – Pressure should be greater distally than proximally – Re-wrap if wrinkles noted or pain reported – No metal clips – Must be snug but not cut off circulation

Question 60

Residual Limb Care

Answer 60

* Inspect area daily * Wash area qhs with bacteriostatic soap, pat dry, and expose to air x 20 min * Do not use lotions, alcohol, powders, or oils * Change limb sock daily * ROM & strengthening exercises OD * Do not elevate limb on pillow * Lay prone with hip extension for 30 min TID

Question 61

Altered Body Image

Answer 61

Pt may go through grieving stages similar to death Denial, anger, bargaining, depression, acceptance Recognize and support patient’s struggle Include family in healing process Help them to achieve a realistic and positive attitude about the future Refer to War Amps or other community supports

Question 62

look at the doc at pnh in the course docs

Answer 62

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