The Skeletal system, Integumentary system, and eyes & ears

1. The Skeletal system, Integumentary system, and eyes & ears Week 9 Chapters 20, 38, & 40

2. The Skeletal System

3. Calcium • One of the body’s most important minerals • Responsible for: • Muscle contraction • Nerve conduction • Bone formation

4. Blood Calcium levels are Controlled by three hormones • Calcitriol – a form of vitamin D that facilitates calcium absorption from the digestive tract • Increases blood calcium levels • Parathyroid Hormone (PTH) – secreted by the parathyroid gland • Stimulates osteoclasts • Accelerates bone resorption - breaking down of the bone • Calcium increases in the blood and can be used elsewhere in the body • Calcitonin – secreted by the Thyroid gland • Stimulates bone deposition - building • Removes calcium from the blood

5. Vitamin D • Enzymes in the kidneys metabolize Vitamin D to its active form- Calcitriol • Primary function of calcitriol is to increase calcium absorption from the GI tract • Dietary calcium is absorbed better in the presence of active vitamin D • Many foods are fortified with vitamin D

6. Parathyroid Hormones

7. Hypocalcemia • Causes: • Vitamin D deficiency • Thyroid tumors • Renal dialysis • hypoparathyroidism • Symptoms: • Spastic muscle contractions (including paresthesia) • Tetany – inability of muscles to relax - classic sign is Carpopedal spasm- picture page 654 in book • Treatment—calcium and vitamin D

8. Common calcium supplements • Calcium chloride • Calcium lactate • Calcium gluconate

9. Vitamin D supplements (active form) • Calcitriol (Rocaltrol) • Calcitriol (Vitamin D3)

10. Degenerative Bone Disease • Paget’s disease: • Hyperactive bone metabolism • Thick and weak bones • Osteoporosis: most common metabolic bone disease • Decreased bone mass: • Increased bone resorption • Decreased mineral deposition • Increased mineral excretion • Responsible for approximately 1.5 million fractures annually • Usually asymptomatic until bone becomes brittle and fractures • Several factors leave patient prone to osteoporosis

11. Risk Factors for Osteoporosis • Postmenopause - most common risk factor is onset of menopause • High alcohol or caffeine consumption • Anorexia nervosa • Tobacco use • Physical inactivity • Testosterone deficiency, particularly in elderly men • Lack of adequate vitamin D or calcium in the diet • Drugs that lower calcium levels in the blood (corticosteroids, some anti-convulsants, immunosuppressants)

12. Treatments • Calcitonin • Bisphosphonates • Calcium supplements • Vitamin D supplements

13. Calcitonin (Fortical, Miacalcin) • Hormonal agent (Class), extracted from Salmon • Nasal spray or SQ injection • SE nasal irritation; N/V • MOA: Increases bone density • USE: Reduces risk of vertebral fractures, to treat osteoporosis

14. Bisphosphonates • MOA: Inhibit bone resorption by suppressing osteoclast activity • This increases bone density • Profile Drugs: • Alendronate (Fosamax) • Ibandronate (Boniva)

15. Bisphosphonates • Side effects: nausea, vomiting, abdominal pain, back pain and esophageal irritation • Patient must sit upright for 30 min following administration • These drugs are poorly absorbed and interact with several foods (milk, orange juice, fortified water)so they need to be taken on an empty stomach with plain water

16. Question One • A client with osteoporosis is started on alendronate sodium (Fosamax). The client should be instructed to do which of the following? (Select all that apply) • 1. Take medication in the morning after arising and before eating • 2. Chew tablets to increase bioavailability • 3. Drink a full glass of water with each tablet • 4. Take Fosamax with an antacid if heartburn occurs • 5. Avoid lying down after taking this medication

17. Question Two • The nurse recognized that calcitonin-salmon (Miacalcin) may be given to a client with hypercalcemia to: • 1. Increase renal reabsorption of calcium • 2. Decrease intestinal absorption of calcium • 3. Increase parathyroid response to hypercalcemia • 4. Decrease bone resorption of calcium

18. Question Three • If calcium levels decrease below normal, which hormone would be released to compensate? • 1. calcitonin • 2. PTH • 3. TRH • 4. TSH

19. Arthritic and Joint Disorders Chapters 20

20. Arthritic Disorders • Osteoarthritis • Degenerative joint disease • Excessive wear and tear of weight-bearing joints • Rheumatoid arthritis • Degenerative joint disease • Systemic autoimmune disorder • Disfigurement and inflammation of multiple joints ( often red, warm, and limits in ROM) • Gout • Metabolic disorder

21. Osteoarthritis • Goal: reduction of pain and inflammation • Analgesics and anti-inflammatory drugs • Cox – 2 inhibitors • Topical medications • NSAIDs • hyaluronate (Hyalgan Euflexxa) • Injection directly into the knee joint

22. Rheumatoid Arthritis • Analgesics and anti-inflammatories • Glucocorticoids • Immunosuppressants • Methotrexate (Rheumatrex) • Disease-modifying antirheumatic drugs (DMARDs): • hydroxychloroquine (Plaquenil), gold salts, sulfasalazine (Azulfidine), D-penicillamine (Cuprimine)

23. Gout • Gout is an inflammatory disease caused by uric acid crystal formations in the joints and soft tissue. • Some foods with high purine content precipitate gouty attacks. • Processed, high sodium foods (i.e. canned meats) • Inflammation of the joint is caused by phagocytes trying to remove the uric acid deposits.

24. Acute Gouty Arthritis Uric acid crystals accumulate quickly in the joints Red, swollen, inflamed tissue Sudden attacks often occur at night Triggered by diet, injury, or other stresses Often occurs in big toes, heels, ankles, wrists, fingers, knees, elbows

25. Medications for the Treatment of Gout Goals: Termination of acute attacks By relieving the acute inflammatory response Prevention of future attacks Reducing uric acid levels NSAIDs are the drugs of choice for treating pain and inflammation Indomethacine (Indocin) - NSAID that is widely used for gout

26. Medications for treatment of Acute Gout • Class: Anti-Gout • MOA: alters the phagocytes’ ability to attack the uric acid crystals. • SE: causes nausea, vomiting, diarrhea, thrombocytopenia, and hematuria. • NC: diarrhea will show effectiveness • Colchicine (Colcrys)

27. Medications Useful in Treating Gout • Two major classes of drugs used in long-term prophylaxis of gout: • Hypouricemic agents • allopurinol (Zyloprim) • febuxostat (Uloric) • Uricosuric agents • Probenecid

28. Medications for the Treatment of Gout Uric acid inhibiting drugs; Hypo-uricemics MOA: Block the accumulation of uric acid in the blood Block the accumulation of uric acid crystals in the joints USE: prophylaxis for gout, doesn’t stop acute attacks Glucocorticoids Useful for short-term, single joint gout Delivered intra-articularly

29. Question One • A nurse is caring for a client who is beginning a new prescription for etanercept (Enbrel) for rheumatoid arthritis. Based on the route of administration of etanercept, which of the following should the nurse plan to monitor? • 1. The client’s vein for thrombophlebitis during IV administration • 2. The client’s subcutaneous site for redness following injection • 3. The client’s oral mucosa for ulceration after oral administration • 4. The client’s skin for irritation following removal of transdermal patch

30. Question Two • Choose the reasons why allopurinol is useful in treating gout. • 1. blocks the accumulation of uric acid in the blood • 2. decreases the uric acid clearance from the blood • 3. blocks the accumulation of uric acid crystals in the joints • 4. alters the formation of uric acid

31. Question Three • A nurse is providing teaching to a client who is to start Colchicine (Colgout) for acute gouty arthritis. The nurse should advise the client to do which of the following? (Select all that apply) • 1. decrease fluid intake • 2. avoid alcohol use • 3. take the medication on a empty stomach to increase absorption • 4. notify the provider of bleeding, bruising, or sore throat • 5. Avoid aspirin or products containing salicylates

32. Question Four • Sodium hyaluronate (Hyalgan) is a therapy for patients with moderate osteoarthritis. Which of the following statements about this drug is false? • 1. It is injected directly into the knee joint • 2. It coats the articulating cartilage surface • 3. Patients should avoid strenuous activity for 48 hours after it is administered • 4. It is used prior to treatments with COX-2 inhibitors and nonsteroidal anti-inflammatory drugs (NSAIDs)

33. Integumentary System

34. Classifications of skin conditions • Infectious disease • ie. Athlete’s foot, lice • Inflammatory disorders • ie. Sunburn, contact dermatitis • Skin cancer • ie. Squamous cell carcinoma

35. Acne • Common skin disorder of adolescents and young adults • Treatment • Benzoyl Peroxide (Benzaclin) – OTC (sometimes combined with antibiotics) • Retinoids – Vitamin A – like compounds (cause sensitivity to light, don’t use when pregnant) • Antibiotics (tetracycline, doxycycline) • Birth control pills • MOA for antiacne drugs • Slow down turnover of skin cells • Inhibit bacterial growth

36. isotretinoin (Accutane) • Treatment - most severe cases, strongest Retinoid • Isotretinoin (Accutane) • MOA: provides improved resistance to bacterial infection by reducing oil production and the occurrence of clogged pores • SE: sensitivity to sunlight, teteragenic, hepatotoxic • NC: Pregnancy category X • iPLEDGE system • Pregnancy test prior to initiation of treatments • Monitor liver enzymes and triglyceride levels • Avoid direct sunlight

37. Eczema and Dermatitis • Eczema- skin disorder that resembles allergic reaction • Inflammation, itching, rash • Contact dermatitis • Delayed type of allergic reaction • Contact with specific allergens - cosmetic, detergents, jewelry, latex • Inflammation, varying degrees of cracking, bleeding, or small blisters • Treat with Topical Steroids • Best way to treat symptoms of dermatitis • Help relieve inflammation and itching • Available in different levels of potency • Different preparations available - creams, lotions, solutions, gels, pads

38. PsoriasisDisorder • Symptoms - red patches of skin covered with flaky, silver-colored scales (called plaques) • Reason for plaques - extremely fast skin turnover rate • Cause - may be genetic immune reaction • Topical and Systemic Medications for Psoriasis • Emollients- soften and soothe skin • Topical glucocorticoids • Immunosuppressant medications

39. Question One • An 18 – year – old female client has severe acne. There has been no improvement from the use of various preparations and isotretinoin (Accutane) is being prescribed. The nurse evaluates that the client understood medication instructions, if the client stated to do which of the following? • 1. Apply a thick layer of isotretinoin twice a day • 2. Increase exposure to the sun for added benefits • 3. Have a pregnancy test prior to beginning therapy and use contraception • 4. Have blood drawn for hormonal studies monthly for the first 6 months

40. Glaucoma and Other Eye Disorders

41. Forms and Routes Eye Drop Instillations

42. Eye Drop Instillation • Expose the conjunctiva sac by gently pulling down and having the pt look up. • Administer prescribed # of drops into center of sac without touching dropper. • Press the lacrimal duct with cotton or tissue 1-2 min to prevent systemic absorption. • Client should keep eye closed 1-2 min after to increase absorption.

43. General Considerations for Topical Ophthalmic Drug Therapy • Topical application • Check which eye is being medicated • Proper administration • One drop at a time • If more than one drug at about the same time, separate administration by at least 5 minutes • Minimize systemic absorption • Ointments

44. Anatomy and Physiology of the Eye Slide 44

45. Glaucoma • One of the leading causes of blindness • Causes • Some cases genetic • Nongenetic factors • Eye injury and disease • Medications • Major risk factors • High blood pressure • Migraine headaches • Refractive illnesses • Old age

46. Increase in Intraocular Pressure (IOP) • Reason is the flow of aqueous humor is blocked • Pressure on optic nerve builds • Can result in blindness • In some cases, can be sudden, but in most cases is a gradual increase in IOP • Two Types • Closed-angle glaucoma • Open-angle glaucoma • Both types result from buildup of aqueous humor • Difference comes from how quickly the increased intraocular pressure develops

48. Glaucoma Drug Therapy • 2 approaches • Drugs that increase the outflow of aqueous humor at the Canal of Schlemm • Cholinergic agents (Miotics) • Prostaglandins • Drugs that decrease formation of aqueous humor at the ciliary body • Beta adrenergic blockers • Carbonic anhydrase inhibitors • Osmotic diuretics

49. Cholinergic Agents (Miotics) • MOA: • Activate cholinergic receptors • This produces a variety of responses in the eye including dilation of the trabecular meshwork so that the canal of Schlemm can absorb more aqueous humor • Direct or indirect acting • USE: increase outflow of aqueous humor to reduce IOP in glaucoma • SE/NC: rest and digest is absorbed systemically; hold lacrimal duct and may need a stronger dose for darker eyes • Example • Pilocarpine (IsoptoCarptine)- direct acting • Demecarium bromide (Humorsol)-indirect acting

50. Prostaglandins • MOA: Increase aqueous humor outflow by reducing congestion in trabecular meshwork • USE: reduces IOP in glaucoma • Major SE of prostaglandins- • cause hyperpigmentation of the eye • Can be irritating to the eyes • NC: • Give at HS to decrease irritation • Instruct pt eye color may change • Latanoprost (Xalatan)