West Coast University

1. West Coast University Musculoskeletal System Disorder -Degenerative Joint Disease Hip Fracture Joint Replacement (Hips and Knees) Osteoporosis Contractures Mobility Issues and Aids Cast Care Splints, slings, crutches, and braces

2. Degenerative Joint Disease Osteoarthritis (OA) • Is the most common joint disorder. • Progressive deterioration of the articular cartilage. • It is non-inflammatory (unless localized) • Non systemic disease. • No longer a wear and tear disease associated with aging. • It involves process where new tissue is produced as a result of cartilage destruction within the joint.

3. Osteoarthritis (OA) • The destruction overweighs the production. • There is formation of bone spur (osteophytes) after the cartilage and bone beneath the cartilage erode. • The changes within the joint lead to pain, immobility, muscle spasms, and potential inflammation. Risk Factors: 1. Age 4. Possible genetic link 2. Decrease muscle strength 5. Difficult to 3. Obesity distinguish early in disease process from Rheumatoid Arthritis (RA)

4. Symptoms • Deep aching joint pain that gets worse after exercise or putting weight on it, and is relieved by rest or inactivity. • Pain that is worse when you start activities after a period of no activity. • Pain with joint palpation or ROM • Observe for muscle atrophy, loss of function, limp when walking. • Over time, pain is present even when you are at rest • Grating of the joint with motion (crepitus) in one or more affected joints. • Increase in pain during humid or moist weather • Joint swelling • Limited movement • Muscle weakness around arthritic joints • Heberden’s nodes (enlarged at the distal interphalaageal joints. • Bouchard’s nodes (proximal interphalangeal joints) may occur bilaterally.

5. Rheumatoid Arthritis • Synovial membrane inflammation resulting in cartilage destruction and bone erosion. • Inflammatory • Note for swelling, redness, warmth, pain at rest, after immobility (morning stiffness). • Involves all joints. • Usually may occur to client who are underweight. • Swan neck and Boutonniere deformities of hands. • Systematic involvement- lung, hearth, skin, extra-articular. • Symmetrical. • DX Test – X-rays, positive rheumatoid factor.

6. Rheumatoid Arthritis • Is an autoimmune disease that causes chronic inflammation of the joints. • Can cause inflammation of the tissue around the joints, as well as in other organs in the body. • Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. • Because it can affect multiple other organs, it is referred to as a systemic illness and is sometimes called rheumatoid disease. • Is a chronic illness, clients may experience long periods without symptoms. • Typically a progressive illness that has the potential to cause joint destruction and functional disability. • Characterized by exacerbation and remission.

7. Rheumatoid Arthritis • The cause is unknown. • Infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. • It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited. • It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals.

8. Rheumatoid Arthritis Complications • Inflammation of the glands of the eyes and mouth can cause dryness - Sjogren's syndrome. • Pleuritis - causes chest pain with deep breathing, shortness of breath, or coughing. • Lung tissue can become inflamed, scarred, and with nodules of inflammation. • Pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. • The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. • Decreased white cells can be associated with an enlarged spleen (Felty's syndrome) and can increase the risk of infections. • Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. • Nerves can become pinched in the wrists to cause carpal tunnel .

9. Osteoarthritis Tests & diagnosis • A physical exam can show: • Joint movement may cause a cracking (grating) sound • Joint swelling (bones around the joints may feel larger than normal) • Limited range of motion • Tenderness when the joint is pressed • Normal movement is often painful • No blood tests are helpful in diagnosing osteoarthritis. • An x-ray of affected joints will show a loss of the joint space. In advanced cases, there will be a wearing down of the ends of the bone and bone spurs.

10. Nurse to assess or monitor • Pain level 0 – 10, location, characteristics, quality, and severity. • Degree of functional limitation. • Levels of pain and pain after activity. • Range of motion. • Proper functional/joint alignment. • Home barriers. • Activity to perform activities of daily living (ADLs).

11. Treatment • The goals of treatment are to: - Increase the strength of the joints - Maintain or improve joint movement - Reduce the disabling effects of the disease - Relieve pain

12. Diagnostic Procedures and Nsg Interventions • Erythrocyte Sedimentation Rate (ESR) and high sensitivity C-reactive protein. Result may be slightly elevated secondary to synovitis. • Radiographs – can determine structural damage within the joint. • Computed Tomography (CT) – imaging scan to determine vertebral involvement. Rheumatoid Arthritis 1. Abnormal antibodies can be found in the blood of people with rheumatoid arthritis. An antibody called "rheumatoid factor“. 2. "antinuclear antibody" (ANA) is also frequently found in people with rheumatoid arthritis. 3. ESR

13. MEDICATIONS • Acetaminophen (Tylenol) first, because it has fewer side effects than other drugs. • Non-steroidal anti-inflammatory drugs (NSAIDs). These drugs help relieve pain and swelling. Types of NSAIDs include Aspirin, Ibuprofen, and Naproxen. • Long-term use of NSAIDs can cause stomach problems, such as ulcers and bleeding. • Corticosteroids injected right into the joint can also be used to reduce swelling and pain. However, relief only lasts for a short time.

14. MEDICATIONS • Capsaicin (Zostrix) skin cream may help relieve pain. Client may feel a warm, stinging sensation when first apply the cream. This sensation goes away after a few days of use. Pain relief usually begins within 1 - 2 weeks. • Glucosamine and chondroitin sulfate. There is some evidence that these supplements can help control pain, although they do not seem to grow new cartilage. Some doctors recommend a trial period of 3 months to see whether glucosamine and chondroitin work.

15. Medications • NSAIDS Ex. • Toradol(ketorolactromethamine) is a prescription medication for short-term relief of moderate to severe pain. "Short-term" is defined as no longer than five days for adults. Children should not receive more than one dose of Toradol. • The medication is most often used to treat pain following a procedure, but may also be used for such things as pain caused by kidney stones, back pain, or cancer pain. • Belongs to a class of drugs called nonsteroidal anti-inflammatory drugs.

16. Toradol • Toradol side effects include: Headache, Abdominal pain (or stomach pain) , Nausea, Heartburn or indigestion, Diarrhea, Dizziness, Drowsiness, Swelling. • Other side effects with Toradol occurring in more than 1 percent of people include but are not limited to: High blood pressure (hypertension), Itching, Unexplained rash, Gas , Constipation , Vomiting, Sweating Pain at the injection site if injection.

17. Toradol – Serious Side Effects • Allergic reactions • Stomach or intestinal problems, including bleeding, ulcers(known as a perforation). • Liver damage, which can cause nausea, fatigue, yellowing of the skin or whites of the eyes, and excessive tiredness. • Kidney problems, including kidney failure • Fluid retention or unexplained weight gain

18. Nursing Interventions 1. Conservative Therapy: • Balance rest with activity. • Use bracing or splints. • Apply therapies (heat or cold) • Analgesic therapy – Acetaminophen, NSAIDS, Topical salicylates, Glucosamine rebuild cartilage. • Intra-articular injections of glucocorticoids (treat localized inflammation). 2. Joint Replacement Surgery – to relieve the pain and improve mobility and quality of life. Osteotomyis done to remove damaged cartilage and correct the deformity.

19. Nursing Interventions • Instruct the client on the use of analgesics and NSAIDS prior to activity and around the clock as needed. • Balance rest with activity. • Instruct the client on proper body mechanics. • Encourage use of thermal applications. Heat to alleviate pain; ice for acute inflammation. • Encourage use of complementary and alternative therapies. E.g. acupuncture, tai chi, magnets, and music therapy. • Encourage use of splinting. For protection. • Encourage use of assistive device to promote independence. E.g. elevated toilet seat, shower bench, long handled reacher. • Encourage use of a daily schedule of activities. • Encourage a well balanced diet and ideal body weight.

20. Prevention OSTEOARTHRITIS • Weight loss can reduce the risk of knee osteoarthritis in overweight client. Complications • Adverse reactions to drugs used for treatment • Decreased ability to perform everyday activities, such as personal hygiene, household chores, or cooking. • Decreased ability to walk. • Surgical complications.

21. Fracture • Fracture is a break or disruption in the continuity of a bone. TYPES • Closed or simple – does not break through the skin. • Open or compound – disrupt the skin integrity. Concern - risk for infection Grade 1 – minimal skin damage Grade 11 – damage includes skin and muscle contusions. Grade 111 – damage to skin, muscles, nerves, and blood vessels.

22. TYPES of FRACTURES cont. • Complete fracture – goes through entire bone. • Incomplete fracture – goes through part of the bone. OTHER COMMON TYPES OF FRACTURES • Displace – bone fragments are not in alignment. • Non-displace – Bone fragments remains in alignment. • Comminuted – Bone is fragmented. • Oblique – Fracture occurs at oblique angle. • Spiral – Fx occurs from twisting motion (physical abuse type) • Impacted – Fracture bone is wedge inside opposite fractured fragment. • Greenstick – Fracture in only one cortex of the bone. • Pathological – Fracture resulting from a tumor or lesion that has weakened the bone. • Segmented – Fracture resulting in two or more bone pieces.

23. Risk Factors for Fractures • Osteoporosis • Falls • Motor Vehicle crashes • Substance Abuse • Diseases ( Bone Cancer, Paget’s Disease) Paget's disease of the bone. It is a chronic disorder that typically results in enlarged and deformed bones. • Contact sports and hazardous recreational activities (football, skiing). • Physical Abuse

24. Diagnostic Procedures • X-Ray • Computed Tomography (CT)imaging scan • Magnetic Resonance

25. Nursing Assessments • Signs and symptoms of fracture; 1. Pain, Swelling and Tenderness 2. Deformity, loss of functional ability. May observe internal rotation of extremity, shortened extremity, visible bone with open fracture. 3. Discoloration, bleeding at the site through an open wound. 4. Crepitus: crackling sound between two broken bones. Created by the rubbing of bone fragments. 5. Muscle spasms: due to pulling forces of the bone when not aligned. 6. Edema: Swelling from trauma. 7. Ecchymosis: Bleeding into underlying soft tissues from trauma.

26. Nursing Interventions • Assess/monitor - Hx of trauma, metabolic bone disorders, chronic conditions (use of steroid therapy). - Neurovascular assessment: (Priority) Pain- Early sign, increasing pain not relieved with elevation or pain medication. Paresthesia – Early sign, teach client to report any numbness or tingling, pins and needle. Pallor– Late, assess cap refill, check for increased cap. Refill time > 3 sec. , blue fingers or toes. Polar – Late, cool/cold fingers or toes. Paralysis – Late, assess mobility, moves fingers or toes, check for inability to move fingers or toes. Pulses– Late, weak palpable pulses, unable to palpate pulses, pulses detected only with Doppler.

27. Diagnostic Procedure of Hip Fracture • A hip fracture is a fracture in the proximal end of the femur (the long bone running through the thigh), near the hip joint. • X-rays of the affected hip usually make the diagnosis obvious; AP and lateral views should be obtained. • In situations where a hip fracture is suspected but is not obvious on x-ray, a CT scan with 3D reconstruction may be helpful. MRI has gained importance in the diagnosis of occult fractures of the femoral neck. Within 24 hours changes can be seen on MRI. • As the client most often require an operation (surgery), full pre-operative general investigation is required. This would normally include blood tests, ECG and chest x-ray.

28. X-Ray of Hip Fracture Hip Fx treated screws

29. Types of Hip Fractures and Treatment • Femoral neck - Femoral neck fractures involve the narrow neck between the round head of the femur and the shaft. This fracture often disrupts the blood supply to the head of the femur. • Treatment for this type of fracture by replacing the fractured bone with a prosthesis arthroplasty. • Alternative treatment is to reduce the fracture (manipulate the fragments back into a good position) and fix them in place with three metal screws. • ORIF – Open Reduction Internal Fixation • A serious but common complication of a fractured femoral neck is avascular necrosis.

30. NANDA NURSING Diagnosis • Risk for peripheral neurovascular dysfunction. • Acute pain • Risk for infection • Impaired physical mobility

31. Nursing Interventions for Fracture • Preoperative Nursing Care A. First address life-threatening complications of injury. - Maintain ABC’s , monitor V/S, Monitor Neuro status, digital pressure to proximal artery nearest the fx., position in supine position, keep client warm. B. Risk for impaired skin integrity. - Monitor pressure points - Perform ROM to unaffected joints to prevent contracture (fx to hip requires ROM to ankles and toes).

32. Nursing Interventions for Fracture • C. Risk for hypovolemic shock- assess fx, assess abdomen, bladder for bleeding. - Monitor V/S, monitor I and O, Promote hydration (IV therapy), Keep client in supine position. D. Stabilization of injured area (Cast, splints and traction). E. Risk for peripheral vascular dysfunction. - Perform neurovascular assessments ( Assess the 5 P’s). F. Risk for compartment syndrome. Compartment syndrome is the compression of nerves and blood vessels within an enclosed space. This leads to muscle and nerve damage and problems with blood flow.

33. Compartment Syndrome • Hallmark symptom of compartment syndrome is • Severe pain that does not go away when you take pain medicine or raise the affected area. • Symptoms may include: Decreased sensation , Paleness of skin, Weakness. • A physical exam will reveal: • Severe pain when moving the affected area (for example, a person with compartment syndrome in the foot or lower leg will experience severe pain when moving the toes up and down) • Tensely swollen and shiny skin • Pain when the compartment is squeezed • Confirming the diagnosis involves directly measuring the pressure in the compartment.

34. Compartment Syndrome Management • Perform neurovascular assessment. • Assess pain or massive stretch. • Do not elevate extremity further to avoid further ischemia. • Looses bandage or immobilizer/bivalve cast G. Pain – Assess on scale 0f 0-10 - Provide analgesics and assess relief - Position for comfort. H. Open fractures or fracture blister. - Monitor V/S - Monitor lab. Values: WBC, ESR, - Provide aseptic wound care.

35. Nursing Interventions for Fracture • Post- Operative Nursing Care A. Risk for peripheral vascular compromise. - Perform neurovascular assessment. B. Acute Pain - Assess pain on scale of 1-10. Provide analgesics/antispasmodic and assess relief. - Position for comfort. C. Risk for infection – Assess s/s of infection:Monitor V/S (temp). - Monitor lab. Values – WBC, ESR - Provide surgical aseptic wound care. D. Impaired physical mobility – consult PT/OT for ambulation and ADLs. - Monitor orthostatic BP when getting out of bed for the first time. - Turn and position q 2 Hours. - Instruct to get out of bed from unaffected side. - Position for comfort.

36. Nursing Interventions for Fracture Post – Op Nursing Management E. Imbalance Nutrition – Encourage increased calorie intake. - Ensure use of Calcium supplements. - Encourage small, frequent meals with snack. - Monitor for Constipation.

37. Hip Fracture Post-Op Activity • It is important to start some activities immediately to offset the effects of the anesthetic, help the healing, and keep blood clots from forming in the leg veins. • The MD, PT and OT can provide specific instructions on wound care, pain control, diet, and exercise. • They should also indicate how much weight you can put on your affected leg. • Pain management is important in early recovery. Initially, client may get pain medication through an IV (intravenous) using a PCA machine.

38. Hip Fracture Post-Op Activity • It is easier to prevent pain than to control it and client do not have to worry about becoming addicted to the medication; after a day or two, injections or pills will replace the IV tube. • Besides the pain medication, client will also need antibiotics and blood-thinners to help prevent blood clots from forming in the veins of your thigh and calf. • Client may lose appetite and feel nauseous or constipated for a couple of days. These are ordinary reactions.

39. Hip Fracture Post-Op Activity • Client may have a urinary catheter inserted during surgery and be given stool softeners or laxatives to ease the constipation caused by the pain medication after surgery. • Client will be taught to do breathing exercises to keep chest and lungs clear. • A physical therapist will visit client, usually on the day after your surgery, and teach client how to use your new joint. • It is important that client get up and about as soon as possible after hip replacement surgery. • Even in bed, client can pedal his/her feet and pump ankles regularly to keep blood flowing in your legs. • Client may have to wear elastic stockings and/or a pneumatic sleeve to help keep blood flowing freely. Pedaling may done via CPM machine.

40. Hip Surgery – Home Activity that are safe. • Do not have to reach up or bend down. • Rearrange furniture so can get about on a walker or crutches. • May want to change rooms (make the living room the bedroom, for example) to stay off the stairs. • Get a good chair—one that is firm and has a higher-than-average seat. • Remove any throw rugs or area rugs that could cause you to slip. • Securely fasten electrical cords around the perimeter of the room. • Install a shower chair, grab bar, and raised toilet in the bathroom. • Use assistive devices such as a long-handled shoehorn, a long-handled sponge, and a grabbing tool or reacher to avoid bending too far over.

41. Activities Post Hip Replacement • Dos and Don't: These precautions will help to prevent the new joint from dislocating and to ensure proper healing. Here are some of the most common precautions: The Don'ts • Don't cross your legs at the knees for at least 8 weeks. • Don't bring your knee up higher than your hip. • Don't lean forward while sitting or as you sit down. • Don't try to pick up something on the floor while you are sitting. • Don't turn your feet excessively inward or outward when you bend down. • Don't reach down to pull up blankets when lying in bed. • Don't bend at the waist beyond 90°. • Don't stand pigeon-toed. • Don't kneel on the knee on the unoperated leg (the good side). • Don't use pain as a guide for what you may or may not do.

42. Activities Post Hip Replacement The Dos • Do keep the leg facing forward. • Do keep the affected leg in front as you sit or stand. • Do use a high kitchen or barstool in the kitchen. • Do kneel on the knee on the operated leg (the bad side). • Do use ice to reduce pain and swelling, but remember that ice will diminish sensation. Don't apply ice directly to the skin; use an ice pack or wrap it in a damp towel. • Do apply heat before exercising to assist with range of motion. Use a heating pad or hot, damp towel for 15 to 20 minutes. • Do cut back on your exercises if your muscles begin to ache, but don't stop doing them!

43. Fracture Complications and Nursing Implications • Compartment Syndrome – pressure in one or more muscle compartments of the extremity compromises circulation resulting in an ischemia-edema cycle. - capillaries dilates to attempt to pull O2 into the tissues. - Increase capillary permeability from the release of histamine leads to edema from plasma proteins leaking into interstitial space. - increased edema causes pressure to the nerve endings resulting to pain. - Blood flow is reduced and ischemia persist.

44. Compartment Syndrome Causes – External Sources • Tight cast • Constrictive bulky dressing Causes – Internal Source • Accumulation of blood or fluid within muscle compartment. S/S – increased pain unrelieved with elevation, paresthesia and pallor. - If untreated, tissue necrosis can result. Neuromuscular damage occurs within 4-6 hours. Normal compartment pressure is 0-8 mmHg. Pressure greater than 8 requires FASCIOTOMY. Prevention: • Cutting the cast on one side (univalve) or both sides (bivalve). • Loosening constrictive dressing or cutting the bandage or tape.

45. Surgical Treatment - Fasciotomy • A surgical incision is made through the subcutaneous tissue and fascia of the affected compartment to relieve the pressure and restore circulation. • Post fasciotomy – open wounds require sterile packings and dressing until secondary closure occurs. Skin graft maybe necessary. COMPLICATIONS OF COMPARTMENT SYNDROME • Infection from tissue necrosis • Persistent motor weakness or contracture from injured nerves • Myoglobinuric renal failure from muscle tissue breakdown (rhabdomyolysis). Myoglobin can occlude distal tubules of kidneys resulting in acute renal failure.

46. Fracture Complications and Nursing Implications • SHOCK – can occur as bone trauma may lead to hemorrhage. Treatment: same as shock prevention and treatment. • FAT EMBOLISM – can occur usually within 48 hour following long bone fracture. Fat globules from the bone marrow are released into the vasculature and travel to the small blood vessels including those in the LUNGS resulting in acute respiratory insufficiency. • Careful differentiation between fat embolism and pulmonary embolism is very important.

47. Clinical Manifestation of Fat Embolism • Earliest Sign – Altered Mental Status due to low O2 level. • Respiratory distress • Tachycardia • Tachypnea • Fever • Cutaneouspetechia – flat red marks that occur on the neck, chest, upper arm, and abdomen. Treatment: • Adequate splinting following fracture, bedrestandhydration to avoid hypovolemic shock, analgesia, oxygenation, and blood transfucion.

48. Fracture Complications and Nursing Implications • DEEP VEIN THROMBOSIS – is the most common complication following trauma, surgery, or disability related to immobility. Early mobilization is the prevention. • OSTEOMYELITIS – inflammation within the bone secondary to penetration of organism (trauma/surgery) • S/S – bone pain that is worse with movement. initially, erythema, edema, and fever may occur. • Diagnostic procedure – BONE BIOPSY, Cultures performed to possible aerobic and anaerobic organisms. • Treatment : LONG COURSE (e.g. 3 months) of IV and oral antibiotic therapy. Surgical Debridement may also be indicated Unsuccessful treatment can result in amputation.

49. Osteomyelitis

50. Fracture Complications and Nursing Implications • AVASCULAR NECROSIS – results from the circulatory compromise that occurs after a fracture. Blood flow is disrupted to the fracture site and the resulting ischemia leads to tissue necrosis. • FAILURE OF FRACTURE TO HEAL - Delayed union: fracture that has not healed within 6 months of injury. - Non union: Fracture that never heals (electrical bone stimulation and bone grafting can be used to treat nonunion. - Malunion: Fracture heals incorrectly.