Assignment #1 Musculoskeletal system disorders ( total 50points) Due Thursday 1/9 1. Differentiate among the etiology, pathophysiology, clinical manifestations, and collaborative care of soft tissue injuries; 4Pts A. strains B. sprains. 2. Relate the sequential events involved in fracture healing. 2Pts 3. describe complications, and nursing management of the following: 4Pts a. Cast b. Traction 4. describe factors involved in neurovascular assessment of an injured extremity. 2Pts 5. Explain common complications associated with fracture and fracture healing. 2Pts 6. Describe nursing management of the patient with amputation2Pts 7. Identify the preoperative and postoperative management of the patient having joint replacement surgery3Pts 8.Describe the pathophysiology, clinical manifestations, collaborative care, and nursing management of osteomyelitis. 3Pts 9. Differentiate between the causes and characteristics of acute and chronic low back pain. 2Pts 10. Explain the conservative and surgical therapy of intervertebral disc damage. 2Pts 11. Describe the postoperative nursing management of a patient who has undergone vertebral disc surgery. 2Pts 12. Describe the etiology, pathophysiology, clinical manifestations and collaborative and nursing management of: 6Pts a. osteomalacia b.osteoporosis c. Paget’s disease. 13. Compare and contrast osteoarthritis and rheumatoid arthritis. 4Pts 14. Summarize the pathophysiology, clinical manifestations, collaborative care, and nursing management of: 6Pts a. ankylosing spondylitis, b.psoriatic arthritis, c.Reactive arthritis. 15. Differentiate the pathophysiology, clinical manifestations, collaborative care, and nursing management of: 6Pts a. systemic lupus erythematosus, b.polymyositis, dermatomyositis, c. Sjorgen syndrome and Scleroderma. Fractures Chapter 62 Copyright © 2017, Elsevier Inc. All Rights Reserved. Fractures • Disruption or break in continuity of structure of bone • Majority of fractures from traumatic injuries • Some fractures secondary to disease process • Cancer or osteoporosis Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • L.G. , a 23-year-old man, is brought to ED following injury to his right arm during a rugby game. • A bone in his forearm is protruding through his skin. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • The ERS immobilized the arm at the scene. • L.G. rates his pain as a 9 on a scale of 0-10. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • How would you classify this fracture? Explain. Copyright © 2017, Elsevier Inc. All Rights Reserved. Classification According to External Environment Copyright © 2017, Elsevier Inc. All Rights Reserved. Classification • Complete or incomplete • Complete: break is completely through bone • Incomplete: bone is still in one piece Copyright © 2017, Elsevier Inc. All Rights Reserved. Classification • Based on direction of fracture line • Linear • Oblique • Transverse • Longitudinal • Spiral Copyright © 2017, Elsevier Inc. All Rights Reserved. Classification According to Location Copyright © 2017, Elsevier Inc. All Rights Reserved. Classification • Displaced or nondisplaced • Displaced: two ends separated from one another • Often comminuted or oblique • Nondisplaced: periosteum is intact and bone is aligned. • Usually transverse, spiral , or greenstick Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • For what other clinical manifestations associated with a fracture will you assess L.G.? Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations • Localized pain • Decreased function • Inability to bear weight or use • Guard against movement • May or may not have deformity Immobilize if suspect fracture!!!! Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • L.G. asks you how long it will take for his bone to heal. • You quickly review fracture healing so that you can answer his question better. • Describe the six stages of bone healing. Copyright © 2017, Elsevier Inc. All Rights Reserved. Fracture Healing • Multistage healing process (union) 1. Fracture hematoma 2. Granulation tissue 3. Callus formation 4. Ossification 5. Consolidation 6. Remodeling Copyright © 2017, Elsevier Inc. All Rights Reserved. Bone Healing Stages Copyright © 2017, Elsevier Inc. All Rights Reserved. FRACTURE HEALING • Factors influencing healing • Displacement and site of fracture • Blood supply to area • Immobilization • Internal fixation devices • Infection or poor nutrition • Age • Smoking . Copyright © 2017, Elsevier Inc. All Rights Reserved. Complications of Fracture Healing • • • • • • • Delayed union Nonunion Malunion Angulation Pseudoarthrosis Refracture Myositis ossificans Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Overall goals of fracture treatment • Anatomic realignment (reduction) • Immobilization • Restoration of normal or near-normal function Copyright © 2017, Elsevier Inc. All Rights Reserved. Fracture Reduction • Closed reduction • Nonsurgical, manual realignment of bone fragments • Traction and countertraction applied • Under local or general anesthesia • Immobilization afterwards Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • An x-ray confirms • Complete transverse break of the right radius • Oblique fracture of the right ulnar bone. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • L.G. is scheduled for an immediate debridement and open reduction/repair of these fractures. • How will you explain the planned treatment to L.G.? Copyright © 2017, Elsevier Inc. All Rights Reserved. Fracture Reduction • Open reduction • Surgical incision • Internal fixation • Risk for infection • Early ROM of joint to prevent adhesions • Facilitates early ambulation Copyright © 2017, Elsevier Inc. All Rights Reserved. Traction • Purpose • Prevent or ↓ pain and muscle spasm • Immobilize joint or part of body • Reduce fracture or dislocation • Treat a pathologic joint condition Copyright © 2017, Elsevier Inc. All Rights Reserved. Traction • Pulling force to attain realignment – countertraction pulls in opposite direction • Two most common types of traction • Skin traction • Skeletal traction Copyright © 2017, Elsevier Inc. All Rights Reserved. Traction • Skin traction • Short-term (48-72 hours) • Tape, boots, or splints applied directly to skin • Traction weights 5 to 10 pounds • Skin assessment and prevention of breakdown imperative Copyright © 2017, Elsevier Inc. All Rights Reserved. Buck’s Traction Copyright © 2017, Elsevier Inc. All Rights Reserved. Traction • Skeletal traction • Long-term pull to maintain alignment • Pin or wire inserted into bone • Weights 5 to 45 lbs • Risk for infection • Complications of immobility Copyright © 2017, Elsevier Inc. All Rights Reserved. Balanced Suspension Traction Copyright © 2017, Elsevier Inc. All Rights Reserved. Skeletal Traction • Maintain countertraction, typically the patient’s own body weight • Elevate end of bed • Maintain continuous traction • Keep weights off the floor Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • What type of immobilization would you expect L.G. to return from surgery with? Copyright © 2017, Elsevier Inc. All Rights Reserved. Fracture Immobilization • Cast • Temporary • Allows patient to perform many normal activities of daily living • Made of various materials • Typically incorporates joints above and below fracture Copyright © 2017, Elsevier Inc. All Rights Reserved. Fracture Immobilization • Cast • Cover affected part with stockinette and padding • Immerse plaster of paris material in warm water, wrap and mold it • Sets in 15 minutes • 24-72 hours before weight bearing • Do not cover – risk for burn • No direct pressure; petal edges 2017, Elsevieran Inc. All Rights CopyrightCopyright © 2014©by Mosby, imprint ofReserved. Elsevier Inc. Fracture Immobilization • Cast • Synthetic casting materials • Lightweight, stronger, waterproof • Early weight bearing • Activated by submersion in cool or tepid water, then molded Copyright © 2017, Elsevier Inc. All Rights Reserved. Upper Extremity Immobilization • Types of casts • Sugar-tong splint • Posterior splint • Short arm cast • Long arm cast • Sling to elevate and support arm • Contraindicated with proximal humerus fracture Copyright © 2017, Elsevier Inc. All Rights Reserved. Upper Extremity Immobilization • Sling • To support and elevate arm • Contraindicated with proximal humerus fracture • Ensures axillary area is well padded • No undue pressure on posterior neck • Encourage movement of fingers and nonimmobilized joints Copyright © 2017, Elsevier Inc. All Rights Reserved. Vertebral Immobilization • Body jacket brace • Immobilization and support for stable spine injuries • Monitor for superior mesenteric artery syndrome (cast syndrome) • Assess bowel sounds • Treat with gastric decompression Copyright © 2017, Elsevier Inc. All Rights Reserved. Lower Extremity Immobilization • • • • Long leg cast Short leg cast Cylinder cast Robert Jones dressing Copyright © 2017, Elsevier Inc. All Rights Reserved. Lower Extremity Immobilization • Elevate extremity above heart • Do not place in a dependent position • Observe for signs of compartment syndrome and increased pressure Copyright © 2017, Elsevier Inc. All Rights Reserved. Knee Immobilizer Copyright © 2017, Elsevier Inc. All Rights Reserved. Lower Extremity Immobilization • Hip spica cast • Single spica • Double spica • Assess patient for same problems as body jacket brace Copyright © 2017, Elsevier Inc. All Rights Reserved. Common Types of Casts Copyright © 2017, Elsevier Inc. All Rights Reserved. External Fixation • • • • Metal pins and rods Applies traction Compresses fracture fragments Immobilizes and holds fracture fragments in place Copyright © 2017, Elsevier Inc. All Rights Reserved. External Fixation Copyright © 2017, Elsevier Inc. All Rights Reserved. External Fixation • Assess for pin loosening and infection • Patient teaching • Pin site care Copyright © 2017, Elsevier Inc. All Rights Reserved. Internal Fixation Copyright © 2017, Elsevier Inc. All Rights Reserved. Stabilization of Knee Injury Copyright © 2017, Elsevier Inc. All Rights Reserved. Electric Bone Growth Stimulation • Used to facilitate healing process • Increase calcium uptake • Activate intracellular calcium stores • Increase bone growth factor production • Non-invasive, semi-invasive, and invasive methods Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • What type of medication would you expect the health care provider to order for L.G. postoperatively? • What vaccination should he have received in the ED if he were not upto-date? Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy • Central and peripheral muscle relaxants • Carisoprodol (Soma) • Cyclobenzaprine (Flexeril) • Methocarbamol (Robaxin) • Tetanus and diphtheria toxoid • Bone-penetrating antibiotics Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • What will you teach L.G. about his nutritional needs related to bone healing? Copyright © 2017, Elsevier Inc. All Rights Reserved. Nutritional Therapy • ↑ Protein (1 g/kg of body weight) • ↑ Vitamins (B, C, D) • ↑ Calcium, phosphorus , and magnesium • ↑ Fluid (2000-3000 mL/day) • ↑ Fiber • Body jacket and hip spica cast patients: six small meals a day Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment • Subjective Data • Past medical history • Trauma • Bone or systemic diseases • Immobility • Osteopenia • Osteoporosis • Medications • Surgery or other treatments Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment • Subjective Data – Functional Health Patterns • Estrogen replacement therapy • Calcium supplementation • Loss of motion or weakness of affected part • Muscle spasms • Pain, numbness, tingling, loss of sensation Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment • Objective Data • Apprehension • Guarding • Skin lacerations, color changes • Hematoma, edema • ↓ or absent pulse, ↓ skin temperature • Delayed capillary refill Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment • Objective Data • • • • • • • Paresthesias Absent, ↓ or ↑ sensation Restricted or lost function Deformities; abnormal angulation Shortening, rotation, or crepitation Muscle weakness Imaging findings Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • L.G. returns to the orthopedic unit following an open reduction and fixation of his arm fractures. • His right arm has a split cast on it that is secured with an Ace wrap. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • It is elevated above the level of his heart. • The surgeon has written an order for hourly neurovascular checks. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • What will you assess when performing these checks? Copyright © 2017, Elsevier Inc. All Rights Reserved. Neurovascular Assessment • Peripheral vascular • • • • Color and temperature Capillary refill Pulses Edema Copyright © 2017, Elsevier Inc. All Rights Reserved. Neurovascular Assessment • Peripheral neurologic • Motor function • Upper and lower extremities • Sensory function • Paresthesia Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • What nursing diagnoses would be appropriate for L.G.? Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Diagnoses • Impaired physical mobility • Risk for peripheral neurovascular dysfunction • Acute pain • Readiness for enhanced health management Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Planning • Overall Goals • Healing with no associated complications • Satisfactory pain relief • Maximal rehabilitation Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation • Health Promotion • Teach safety precautions • Advocate to decrease injuries • Encourage moderate exercise • Safe environment to reduce falls • Calcium and vitamin D intake Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation • Acute Care • Patients with fractures can be treated in the emergency department or a physician’s office • Patients are released home, or they may require hospitalization Copyright © 2017, Elsevier Inc. All Rights Reserved. Preoperative Care • Patient Teaching • Immobilization • Assistive devices • Expected activity limitations • Assure that needs will be met • Pain medication Copyright © 2017, Elsevier Inc. All Rights Reserved. Postoperative Care • • • • • Monitor vitals General principles of nursing care Frequent neurovascular assessments Minimize pain and discomfort Monitor for bleeding or drainage • Aseptic technique • Blood salvage and reinfusion Copyright © 2017, Elsevier Inc. All Rights Reserved. Other Measures • Prevent complications of immobility • Constipation • Renal calculi • Cardiopulmonary deconditioning • DVT/pulmonary emboli Copyright © 2017, Elsevier Inc. All Rights Reserved. Traction • • • • • • Inspect exposed skin Monitor pin sites for infection Pin site care per policy Proper positioning Exercise as permitted Psychosocial needs Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Pixland/Thinkstock) • L.G. recuperates well and is scheduled for discharge the following day. • What will you teach L.G. regarding care of his cast? Copyright © 2017, Elsevier Inc. All Rights Reserved. Ambulatory Care Cast Care • Do • • • • • Frequent neurovascular assessments Apply ice for first 24 hours Elevate above heart for first 48 hours Exercise joints above and below Use hair dryer on cool setting for itching • Check with health care provider before getting wet Copyright © 2017, Elsevier Inc. All Rights Reserved. Ambulatory Care Cast Care • Do • Dry thoroughly after getting wet • Report increasing pain despite elevation, ice, and analgesia • Report swelling associated with pain and discoloration OR movement • Report burning or tingling under cast • Report sores or foul odor under cast Copyright © 2017, Elsevier Inc. All Rights Reserved. Ambulatory Care Cast Care • Do not • • • • • • Elevate if compartment syndrome Get plaster cast wet Remove padding Insert objects inside cast Bear weight for 48 hours Cover cast with plastic for prolonged period Copyright © 2017, Elsevier Inc. All Rights Reserved. Ambulatory Care Cast Care • Validate understanding of cast care instructions • Follow-up phone call • Teach cast removal and possible alterations in appearance of extremity Copyright © 2017, Elsevier Inc. All Rights Reserved. Ambulatory Care • Psychosocial problems • Dependence in performing ADLs • Family separation • Finances • Inability to work • Potential disability Copyright © 2017, Elsevier Inc. All Rights Reserved. Ambulatory Care • Ambulation • Reinforce physical therapist’s instructions • Mobility training • Instruction in use of assistive aids • Pain management Copyright © 2017, Elsevier Inc. All Rights Reserved. Ambulation • Degrees of weight-bearing • Non–weight-bearing • Touch-down/toe-touch weight-bearing • Partial–weight-bearing • Weight bearing as tolerated • Full–weight-bearing ambulation Copyright © 2017, Elsevier Inc. All Rights Reserved. Assistive Devices • Devices for ambulation range from a cane to a walker or crutches • Technique for use varies • Use transfer belt for stability when teaching how to use • Discourage from reaching for support • Upper arm strength required Copyright © 2017, Elsevier Inc. All Rights Reserved. Evaluation • Report satisfactory pain management • Appropriate care of cast or immobilizer • No peripheral neurovascular dysfunction • Uncomplicated bone healing Copyright © 2017, Elsevier Inc. All Rights Reserved. Complications of Fractures • Majority heal without complication • Death is usually the result of • Damage to underlying organs and vascular structures • Complications of fracture or immobility • May be direct or indirect Copyright © 2017, Elsevier Inc. All Rights Reserved. Infection • High incidence in open fractures and soft tissue injuries • Devitalized and contaminated tissue an ideal medium for pathogens • Prevention key • Can lead to chronic osteomyelitis Copyright © 2017, Elsevier Inc. All Rights Reserved. Infection • • • • • Aggressive surgical debridement Wound may or may not be closed Closed suction drainage Skin grafting Antibiotics – irrigation, impregnatedbeads, and IV Copyright © 2017, Elsevier Inc. All Rights Reserved. Compartment Syndrome • Swelling and increased pressure within a confined space • Compromises neurovascular function of tissues within that space • Usually involves the leg but can occur in any muscle group Copyright © 2017, Elsevier Inc. All Rights Reserved. Compartment Syndrome • Two basic types of compartment syndrome • ↓ Compartment size • ↑ Compartment contents • Arterial flow compromised → ischemia → cell death → loss of function Copyright © 2017, Elsevier Inc. All Rights Reserved. Compartment Syndrome Clinical Manifestations • Early recognition and treatment essential • May occur initially or may be delayed several days • Ischemia can occur within 4 to 8 hours after onset Copyright © 2017, Elsevier Inc. All Rights Reserved. Compartment Syndrome Clinical Manifestations • Six Ps • Pain • Pressure • Paresthesia • Pallor • Paralysis • Pulselessness Copyright © 2017, Elsevier Inc. All Rights Reserved. Compartment Syndrome Interprofessional Care • Prompt, accurate diagnosis via regular neurovascular assessments • Notify of pain unrelieved by drugs and out of proportion to injury • Paresthesia is also an early sign • Assess urine output and kidney function Copyright © 2017, Elsevier Inc. All Rights Reserved. Compartment Syndrome Interprofessional Care • NO elevation above heart • NO ice • Surgical decompression (fasciotomy) Copyright © 2017, Elsevier Inc. All Rights Reserved. Fasciotomy for Compartment Syndrome Fasciotomy associated with compartment syndrome. Stabilization of fracture with external fixator. (From Browner BD, Jupiter JB, Levine AM, Trafton P: Skeletal trauma: fractures, dislocations, ligamentous injuries, ed 4, Philadelphia, 2009, Saunders.) Copyright © 2017, Elsevier Inc. All Rights Reserved. Venous Thromboembolism • High susceptibility aggravated by inactivity of muscles • Prophylactic anticoagulant drugs • Antiembolism stockings • Sequential compression devices • ROM exercises Copyright © 2017, Elsevier Inc. All Rights Reserved. Fat Embolism (FES) • Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury • Contributory factor in many deaths associated with fracture • Most common with fracture of long bones, ribs, tibia, and pelvis Copyright © 2017, Elsevier Inc. All Rights Reserved. Fat Embolism (FES) • Mechanical theory • Fat released from marrow and enters circulation where it can obstruct • Biochemical theory • Hormonal changes caused by trauma stimulate release of fatty acids to form fat emboli Copyright © 2017, Elsevier Inc. All Rights Reserved. Fat Embolism (FES) Clinical Manifestations • Early recognition of FES is crucial • Symptoms 24 to 48 hours after injury • Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis. • Respiratory and neurologic symptoms • Petechiae – neck, chest wall, axilla, buccal membrane, conjunctiva Copyright © 2017, Elsevier Inc. All Rights Reserved. Fat Embolism (FES) Clinical Manifestations • Clinical course of fat embolus may be rapid and acute • Patient frequently expresses a feeling of impending disaster • In a short time skin color changes from pallor to cyanosis • Patient may become comatose Copyright © 2017, Elsevier Inc. All Rights Reserved. Fat Embolism (FES) Clinical Manifestations • • • • • • Fat cells in blood, urine, or sputum ↓ PaO2 < 60 mm Hg ST segment and T-wave changes ↓ Platelet count, hematocrit levels Elevated ESR Chest x-ray →bilateral pulmonary infiltrates Copyright © 2017, Elsevier Inc. All Rights Reserved. Fat Embolism (FES) Interprofessional Care • Treatment is directed at prevention • Careful immobilization and handling of a long bone fracture probably the most important factor in prevention • Management is supportive and related to symptom management Copyright © 2017, Elsevier Inc. All Rights Reserved. Fat Embolism (FES) Interprofessional Care • Coughing and deep breathing • Administer O2 • Intubation/ intermittent positive pressure ventilation Copyright © 2017, Elsevier Inc. All Rights Reserved. Audience Response Question A plaster splint is applied with an elastic bandage to the leg of a patient with a fractured tibia in preparation for open reduction and internal fixation. The patient complains of increasing pain in the affected leg and foot that is not relieved by loosening of the elastic bandage. The most appropriate action by the nurse is to a. elevate the leg on two pillows. b. apply ice over the fracture site. c. notify the health care provider. d. perform neurovascular assessment of the foot. Copyright © 2017, Elsevier Inc. All Rights Reserved. Audience Response Question A patient has a severely sprained ankle from a sports injury. What should the nurse teach the patient prior to discharge from the urgent care center? a. Alternate cold and heat for 30 minutes each until symptoms are relieved. b. Apply cold for 20 to 30 minutes with breaks of 10 to 15 minutes during the first 2 days. c. Use continuous cold for the first 24 hours and then continuous heat until the symptoms are relieved. d. Apply continuous heat to the ankle for the first 24 hours and then continuous cold until the symptoms are relieved. Copyright © 2017, Elsevier Inc. All Rights Reserved. Low Back Pain and Intervertebral Disc Disease Chapter 63 Copyright © 2017, Elsevier Inc. All Rights Reserved. LOW BACK PAIN Copyright © 2017, Elsevier Inc. All Rights Reserved. Incidence • Affects ~80% of adults in United States at least once • Second only to headache as most common pain complaint • Leading cause of job-related disability • Major contributor to missed work days Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Most often due to musculoskeletal problem • Localized or diffuse • Radicular pain- irritation of nerve root • Referred pain- source of pain is another location Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Low back pain common because lumbar region • • • • Bears most of body weight Is most flexible Contains nerve roots Has poor biomechanical structure Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study • D.M., a 54-year-old man, visits his primary care physician complaining of lower back pain that has persisted for 3 weeks. Copyright © 2017, Elsevier Inc. All Rights Reserved. (©Monkey Business/Thinkstock) Case Study (©Monkey Business/Thinkstock) • He states that the pain prevents him from doing certain activities, such as his regular golf game. • D.M. claims to have had some minor back pain before but has not had pain like this before. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Monkey Business/Thinkstock) • D.M. has been taking ibuprofen for the pain when he feels that he “really needs it.” • He tried using an ice pack and that provided little relief. • When obtaining a history on D.M., what risk factors for low back pain will you ask him about? Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Risk factors • • • • • • • • • Lack of muscle tone Excess body weight Pregnancy Stress Poor posture Cigarette smoking Prior compression fractures Congenital spinal problems Family history of back pain Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Occupational risk factors • • • • Repetitive lifting Vibration Extended periods of sitting Health care personnel engaged in patient care Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Causes • Lumbosacral strain/instability • Osteoarthritis • Degenerative disc disease/herniation Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Monkey Business/Thinkstock) • Would you classify D.M.’s back pain as acute or chronic? • Explain your answer. Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain • Lasts 4 weeks or less • Caused by trauma or undue stress • Symptoms usually appear within 24 hours • Muscle ache to shooting/stabbing pain • Limited flexibility/ROM • Inability to stand upright Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study • D.M. tells you that he had spent a weekend shoveling and spreading a truckload of mulch. • He recalls the pain started the following day. • What diagnostic testing would you expect the health care provider to perform or order for D.M.? Copyright © 2017, Elsevier Inc. All Rights Reserved. (©Monkey Business/Thinkstock) Acute Low Back Pain • Few definitive diagnostic abnormalities • Straight-leg raising test • Positive for disc herniation when radicular pain occurs • MRI and CT scan only for trauma or suspected systemic disease Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Nursing Assessment • Subjective Data • Acute or chronic lumbosacral strain/ trauma, osteoarthritis, degenerative disc disease • Use of opioid analgesics and NSAIDs, muscle relaxants, corticosteroids, OTC remedies • Previous back surgery, epidural injections Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Nursing Assessment • Subjective Data • Smoking, lack of exercise • Obesity • Poor posture, muscle spasms, activity intolerance • Constipation Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Nursing Assessment • Subjective Data • • • • Interrupted sleep Pain in back, buttocks, or leg Numbness or tingling Occupational risks and impact on family Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Monkey Business/Thinkstock) • D.M. undergoes an MRI. • He is diagnosed with herniated discs at L3/L4 and L4/L5. • For what additional clinical manifestations will you assess D.M.? Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Nursing Assessment • Objective Data • Guarded movement • Depressed or absent Achilles tendon or patellar reflex • + Straight leg raise test • + Crossover straight leg test • + Trendelenburg test • Tense, tight paravertebral muscles • ↓ Range of motion in spine Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Nursing Assessment • Objective Data • Lesion or disorder on myelogram, CT scan, or MRI • Nerve root impingement on electromyography (EMG) Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Monkey Business/Thinkstock) • When developing a plan of care, what nursing diagnoses would you identify for D.M.? Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Nursing Diagnoses • • • • Acute pain Impaired physical mobility Ineffective coping Ineffective health management Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Planning • Overall Goals • • • • • Satisfactory pain relief Return to previous level of activity Correct performance of exercises Adequate coping Adequate self-help management Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Health Promotion • • • • • • Proper body mechanics “Back School” Appropriate body weight Proper sleep positioning Firm mattress Stop smoking Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Monkey Business/Thinkstock) • D.M. is advised to use conservative therapies for his pain management. • What are some of these measures? Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Acute Care • Treat as outpatient if not severe • • • • • NSAIDs, muscle relaxants Massage Back manipulation Acupuncture Cold and hot compresses • Severe pain - corticosteroids, opioids Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Acute Care • Brief period of rest at home may be necessary • Avoid prolonged bed rest • Avoid activities that increase pain • Lifting, bending, twisting • Prolonged sitting Copyright © 2017, Elsevier Inc. All Rights Reserved. Acute Low Back Pain Acute Care • Teach patients • Cause of their pain • Ways to prevent additional episodes • Strengthening and stretching exercises Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Ambulatory and Home Care • Goal is to make an episode of acute low back pain an isolated incident • Patient teaching imperative • Occupational counseling • Emotional support Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Monkey Business/Thinkstock) • D.M. wants to know if he will ever be pain-free again. • What patient teaching will you provide D.M. to help him achieve and maintain a healthy back? Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Patient Teaching • Do • Sleep in a side-lying position with knees and hips bent • Sleep on back with a lift under knees and legs or back with 10-inchhigh pillow under knees to flex hips and knees Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Patient Teaching • Do • Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing • Maintain appropriate body weight Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Patient Teaching • Do • Exercise 15 minutes in the morning and evening regularly • Carry light items close to body • Use local heat and cold application • Use a lumbar roll or pillow for sitting Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation Patient Teaching • Do Not • • • • Lean forward without bending knees Lift anything above level of elbows Stand in one position for prolonged time Sleep on abdomen or on back or side with legs out straight • Exercise without consulting health care provider if having severe pain Copyright © 2017, Elsevier Inc. All Rights Reserved. Chronic Low Back Pain • Lasts longer than 3 months or involves a repeated incapacitating episode • Often progressive • Various causes • • • • Degenerative or metabolic disease Weakness from scar tissue Chronic strain Congenital spine problems Copyright © 2017, Elsevier Inc. All Rights Reserved. Chronic Low Back Pain • Spinal stenosis • Narrowing of spinal canal • Acquired conditions • Osteoarthritis most common • Rheumatoid arthritis, tumors, Paget’s disease, trauma • Inherited conditions • Congenital spinal stenosis • Scoliosis Copyright © 2017, Elsevier Inc. All Rights Reserved. Chronic Low Back Pain • Spinal stenosis – lumbar • Pain in low back and radiates to buttock and leg • ↑ With walking/ prolonged standing • Numbness, tingling, weakness, heaviness in legs and buttocks • Pain ↓ when bends forward or sits down Copyright © 2017, Elsevier Inc. All Rights Reserved. Chronic Low Back Pain Interprofessional Care • Similar to acute low back pain • Drug therapy • Mild analgesics • Antidepressants • Gabapentin (Neurontin) Copyright © 2017, Elsevier Inc. All Rights Reserved. Chronic Low Back Pain Interprofessional Care • • • • • • • Weight reduction Sufficient rest periods Local heat and cold application Physical therapy Exercise and activity throughout day Complementary and alternative therapies Back School Copyright © 2017, Elsevier Inc. All Rights Reserved. Chronic Low Back Pain Interprofessional Care • Minimally invasive treatments • Epidural corticosteroid injections • Implanted devices to deliver analgesia • Surgery Copyright © 2017, Elsevier Inc. All Rights Reserved. INTERVERTEBRAL DISC DISEASE Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Etiology and Pathophysiology • Intervertebral discs separate vertebrae and help absorb shock • Disease involves deterioration, herniation, or other dysfunction • Involves all levels Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Etiology and Pathophysiology • Degenerative disc disease (DDD) • Loss of elasticity, flexibility, and shock-absorbing capabilities • Disc becomes thinner as nucleus pulposus dries out → load shifted to annulus fibrosus → progressive destruction →pulposus seeps out (herniates) Copyright © 2017, Elsevier Inc. All Rights Reserved. Degenerative Disc Disease Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Etiology and Pathophysiology • Radiculopathy • • • • Radiating pain Numbness Tingling ↓ Strength and/or range of motion • Osteoarthritis Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Clinical Manifestations • • • • • • Low back pain most common Radicular pain + Straight leg raise ↓ or absent reflexes Paresthesia Muscle weakness Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Clinical Manifestations • Multiple nerve root (cauda equina) compression • • • • • Sever low back pain Progressive weakness Increased pain Bowel and bladder incontinence Medical emergency Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Clinical Manifestations • Cervical disc disease • Pain radiates to arms and hands. • ↓ Reflexes and handgrip • May include shoulder pain and dysfunction Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Diagnostic Studies • • • • X-rays Myelogram, MRI, or CT scan Epidural venogram or discogram EMG Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Interprofessional Care • Conservative Therapy • • • • • Limitation of movement Local heat or ice Ultrasound and massage Skin traction Transcutaneous electrical nerve stimulation (TENS) Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Interprofessional Care • Conservative Therapy • Drug therapy • NSAIDs • Short-term corticosteroids • Opioids • Muscle relaxants • Antiseizure drugs, antidepressants • Epidural corticosteroid injections Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Interprofessional Care • Back-strengthening exercises • Twice a day • Encouraged for a lifetime • Teach good body mechanics • Avoid extremes of flexion and torsion • Most patients heal in 6 months Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Surgical Therapy • Indicated when • • • • • Conservative treatment fails Radiculopathy worsens Loss of bowel or bladder control Constant pain Persistent neurologic deficit Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Monkey Business/Thinkstock) • D.M. develops radiculopathy and has persistent back pain despite conservative treatment for 4 months. • His primary care physician consults a surgeon. • D.M. asks you what his options are. • How will you respond to D.M.? Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Surgical Therapy • Intradiscal electrothermoplasty (IDET) • Minimally invasive outpatient procedure • Needle inserted into affected disc • Wire threaded into disc and heated → denervates nerve fibers Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Surgical Therapy • Radiofrequency discal nucleoplasty (coblation nucleoplasty) • Needle inserted similar to IDET • Radiofrequency probe generates energy → breaks up nucleus pulposus • Up to 20% of nucleus is removed • Decompresses disc Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Surgical Therapy • Interspinous process decompression system (X Stop) • Titanium →fits into mount placed on vertebrae • To treat lumbar spinal stenosis • Lifts vertebrae off pinched nerve Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Surgical Therapy • Laminectomy • Surgically remove disc through excision of part of vertebra • Diskectomy • Surgically decompress nerve root • Microsurgical or percutaneous technique Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Surgical Therapy • Artificial disc replacement • Charité or Prodisc-L disc for lumbar DDD • Prestige cervical disc system • Surgically placed in spine through small incision after damaged disc is removed • Allows for movement at level of implant Copyright © 2017, Elsevier Inc. All Rights Reserved. Charite Disc Copyright © 2017, Elsevier Inc. All Rights Reserved. Intervertebral Disc Disease Surgical Therapy • Spinal fusion • Spine is stabilized by creating an ankylosis (fusion) of contiguous vertebrae • Uses a bone graft from patient’s fibula or iliac crest or from a donated cadaver bone • Metal fixation can add to stability • Bone morphogenetic protein (BMP) to stimulate bone grown of graft Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study • D.M. undergoes a lumbar laminectomy with spinal fusion. • What nursing interventions will you plan for D.M.’s postoperative care? Copyright © 2017, Elsevier Inc. All Rights Reserved. (©Monkey Business/Thinkstock) Nursing Management Vertebral Disc Surgery • Maintain proper alignment • Allowed activity varies • Post lumbar fusion • Pillows under thighs when supine • Between legs when side-lying • Reassure patient Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Spinal Surgery: Postoperative • • • • • Opioids for 24 to 48 hours Patient-controlled analgesia (PCA) Switch to oral drugs when able Muscle relaxants Assess and document pain intensity, and pain management effectiveness Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Spinal Surgery: Postoperative • Potential for cerebrospinal fluid (CSF) leakage • Monitor for and report severe headache or leakage of CSF • Clear or slightly yellow drainage on dressing • + For glucose Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Spinal Surgery: Postoperative • Frequently assess peripheral neurologic signs • Every 2 to 4 hours during first 48 hours post surgery • Compare with preoperative status • Assess circulation (temp, capillary refill, pulses) Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Spinal Surgery: Postoperative • Monitor GI and bowel function • Administer stool softeners • Monitor and assist with bladder emptying • Loss of tone may indicate nerve damage • Notify surgeon immediately if bowel or bladder incontinence Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Spinal Fusion: Postoperative • Prolonged limited activity • Rigid orthosis • Verify and teach how to apply • Cervical spine • Observe for spinal cord edema • Immobilize neck Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Spinal Fusion: Postoperative • Regularly assess bone graft donor site • Posterior iliac crest • Fibula • Usually more painful than fusion area • Pressure dressing • Neurovascular assessments if fibula is donor site Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Spinal Fusion: Postoperative • Teaching regarding activity • Proper body mechanics • Avoid prolonged sitting or standing. • Encourage walking, lying down, shifting weight • No lifting, twisting • Use thighs and knees to absorb shock • Firm mattress or bed board Copyright © 2017, Elsevier Inc. All Rights Reserved. Audience Response Question When caring for a patient following a lumbar laminectomy, the nurse should a. place a pillow between the patient’s legs before turning to the side. b. elevate the head of the bed 30 degrees and then turn the patient to the side. c. ask the patient to flex the knees and push the heels into the bed during turning. d. have the patient grasp the side rail on the opposite side of the bed to help with turning. Copyright © 2017, Elsevier Inc. All Rights Reserved. Osteomyelitis Chapter 63 Copyright © 2017, Elsevier Inc. All Rights Reserved. Osteomyelitis • Severe infection of bone, bone marrow, and surrounding soft tissue • Most common microorganism is Staphylococcus aureus, but can be caused by variety of organisms Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study • V.R. is a 74-year-old man who is brought into the ED by his daughter. • He is complaining of a fever, nausea, and constant pain in his left leg. • He has a history of diabetes mellitus and foot ulcers. Copyright © 2017, Elsevier Inc. All Rights Reserved. (©Jupiterimages/Polkadot/Thinkstock) Case Study (©Jupiterimages/Polkadot/Thinkstock) • Examination of V.R.’s left leg indicates inflammation with restricted movement secondary to pain. • He is admitted to the hospital. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Polkadot/Thinkstock) • V.R.’s WBC count is elevated. • CT scan reveals severe inflammation of his tibia and surrounding soft tissue. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Polkadot/Thinkstock) • V.R.’s daughter asks how his bone could get an infection. • How would you explain the disease process and likely cause? Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Indirect entry (hematogenous) • Young boys • Blunt trauma • GU and respiratory infections • Vascular insufficiency disorders • Direct entry • Via open wound • Foreign body presence Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Microorganisms grow → increase pressure in bone → ischemia and vascular compromise • Infection spreads through bone → cortex devascularization and necrosis Copyright © 2017, Elsevier Inc. All Rights Reserved. Development of Osteomyelitis Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Acute Osteomyelitis • Infection of < 1 month in duration • Local manifestations • Pain that worsens with activity; is unrelieved by rest • Swelling, tenderness, warmth • Restricted movement Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Acute Osteomyelitis • Systemic manifestations • • • • • • • Fever Night sweats Chills Restlessness Nausea Malaise Drainage (late) Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Chronic Osteomyelitis • Infection lasting > 1 month or has failed to respond to initial antibiotic treatment • Continuous and persistent or process of exacerbations and remissions Copyright © 2017, Elsevier Inc. All Rights Reserved. Chronic Osteomyelitis of Femur Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Chronic Osteomyelitis • Systemic manifestations reduced • Local signs of infection more common • Pain, swelling, warmth • Granulation tissue turns to scar tissue → avascular → ideal site for microorganism growth → cannot be penetrated by antibiotics Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Long-term and mostly rare complications • • • • Septicemia Septic arthritis Pathologic fractures Amyloidosis Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Polkadot/Thinkstock) • Based on V.R.’s history and presentation, how would you classify his osteomyelitis? • What additional lab tests would you expect the health care provider to order? Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies • • • • • • • Bone or soft tissue biopsy Blood and/or wound cultures WBC count Erythrocyte sedimentation rate (ESR) C reactive protein X-rays/ MRI/ CT scans Bone scans Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Polkadot/Thinkstock) • What treatment would you expect the health care provider to order to treat V.R.’s osteomyelitis? Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Osteomyelitis • Aggressive, prolonged IV antibiotic therapy • Cultures or bone biopsy • Surgical debridement and decompression Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Polkadot/Thinkstock) • How long does V.R. need to stay on IV antibiotics? Why? Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Osteomyelitis • IV antibiotics via CVAD • May be started in hospital, continued at home/ skilled nursing facility • IV antibiotics 4-6 weeks or longer • Variety of antibiotics depending on microorganism Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Polkadot/Thinkstock) • If V.R.’s infection turns into a chronic osteomyelitis, what treatment options would be available for him? Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Chronic Osteomyelitis • Surgical removal • Extended use of antibiotics • Acrylic bead chains containing antibiotics • Intermittent or constant antibiotic irrigation of bone Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Chronic Osteomyelitis • • • • • • Casts or braces Negative-pressure wound therapy Hyperbaric oxygen therapy Removal of prosthetic devices Muscle flaps, skin grafts, bone grafts Amputation Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment • Subjective Data • Past health history • Bone trauma, open fracture, open or puncture wounds, other infections • Medications • Use of analgesics or antibiotics • Surgery or other treatments • Bone surgery Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment • Subjective Data • • • • • IV drug and alcohol abuse, malaise Anorexia, weight loss, chills Weakness, paralysis, muscle spasms Local tenderness, increase in pain Irritability, withdrawal, dependency, anger Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Assessment • Objective Data • Restlessness, high spiking temperature, night sweats • Diaphoresis, erythema, warmth, edema • Restricted movement, wound drainage, spontaneous fractures • ↑ WBC, + cultures, ↑ ESR, presence of sequestrum and involucrum Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Diagnoses • Acute pain • Ineffective health management • Impaired physical mobility Copyright © 2017, Elsevier Inc. All Rights Reserved. Planning • Overall Goals • Have satisfactory pain and fever management • Do not experience any complications associated with osteomyelitis • Adhere to treatment plan • Maintain a positive outlook on outcome of disease Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation • Health Promotion • Control other current infections • Persons at risk • Are immunocompromised • Have diabetes, orthopedic prosthetic devices, vascular insufficiencies • Encourage to call HCP about local signs Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Polkadot/Thinkstock) • During V.R.’s hospitalization, what specific nursing interventions would be appropriate related to his left leg? Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation • Acute Care • Immobilization and careful handling of affected limb • Assess and treat pain • Dressing care - sterile technique • Proper positioning/support of extremity Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation • Acute Care • Patient teaching adverse and toxic reactions to antibiotic therapy • Ototoxicity, impaired renal function, neurotoxicity • Hives, severe or watery diarrhea, bloody stools, throat and mouth sores • Tendon rupture • Monitor peak and trough levels Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation • Acute Care • Lengthy antibiotic therapy can cause an overgrowth of Candida albicans and Clostridium difficile • Patient and family are often frightened and discouraged • Continued psychologic and emotional support Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©Jupiterimages/Polkadot/Thinkstock) • V.R. is discharged to home to complete his IV antibiotic therapy. • What important teaching must be done before he is discharged? • What resources might be helpful for him at his home? Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Implementation • Ambulatory Care • Patient/caregiver teaching regarding antibiotic administration and management of CVAD • Wound care/dressing changes • Physical and psychologic support Copyright © 2017, Elsevier Inc. All Rights Reserved. Evaluation • The patient will • Have satisfactory pain management • Follow treatment regimen • Verbalize confidence in ability to implement treatment plan • Demonstrate increase in mobility/ range of motion Copyright © 2017, Elsevier Inc. All Rights Reserved. Osteoporosis Chapter 63 Copyright © 2017, Elsevier Inc. All Rights Reserved. Osteoporosis • Chronic, progressive metabolic bone disease marked by • Low bone mass • Deterioration of bone tissue • Leads to increased bone fragility Copyright © 2017, Elsevier Inc. All Rights Reserved. Osteoporosis • Over 54 million people in the United States • One in 2 women and 1 in 4 men over 50 will sustain an osteoporosis-related fracture • Known as the “silent thief” Copyright © 2017, Elsevier Inc. All Rights Reserved. Osteoporosis • Why more common in women? • Lower calcium intake • Less bone mass • Bone resorption begins earlier and becomes more rapid at menopause • Pregnancy and breastfeeding • Longevity Copyright © 2017, Elsevier Inc. All Rights Reserved. Osteoporosis • Screening guidelines • Initial bone density test in women over age 65 • Repeat in 15 years if normal • Earlier and more frequent if high risk • Currently no evidence of benefit for screening in men Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • A.L. is a 67-year-old white woman who visits her primary care physician for an annual check-up. • She states “I feel that I am in good health.” Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • She recently began taking a multivitamin because she said claims she was starting to “feel old.” • She is a retired secretary. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study Copyright © 2014 by Mosby, an imprint of Elsevier Inc. (©iStockphoto/Thinkstock) • A.L. has a history of smoking for 20 years, but she quit 10 years ago. • She has been postmenopausal for 13 years. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • A.L. has a small frame and is at a healthy weight. • Her height is 1.5 inches less than her last recorded height taken 2 years ago. • She has slight kyphosis. Copyright © 2017, Elsevier Inc. All Rights Reserved. Inc. Case Study (©iStockphoto/Thinkstock) • What risk factors for osteoporosis does A.L. have? Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Risk factors • • • • • • • Advancing age (>65 yr) Female gender Low body weight White or Asian Current cigarette smoking Prior fracture Sedentary lifestyle Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Risk factors • • • • • • • Estrogen deficiency Family history Diet low in calcium/vitamin D deficiency Excessive use of alcohol (>2 drinks/day) Low testosterone in men Specific diseases Certain drugs Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Preventive factors • • • • Regular weight-bearing exercise Fluoride Calcium Vitamin D Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Peak bone mass (by age 20) determined by heredity, nutrition, exercise, and hormone function • Bone loss after age 35-40 inevitable, rate of loss variable • Rapid bone loss for women at menopause Copyright © 2017, Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Remodeling • Osteoblasts – deposit bone • Osteoclasts – resorb bone • In osteoporosis, bone resorption exceeds bone deposition Copyright © 2017, Elsevier Inc. All Rights Reserved. Normal vs. Osteoporotic Bone Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • In addition to loss of height and kyphosis, what other clinical manifestations of osteoporosis would you question A.L. about? Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations • Occurs most commonly in spine, hips, and wrists • Back pain • Spontaneous fractures • Gradual loss of height • Kyphosis or “dowager’s hump “ Copyright © 2017, Elsevier Inc. All Rights Reserved. Effects of Osteoporosis Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • What diagnostic study will you expect the health care provider to order for A.L.? Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies • History and physical exam • X-ray and lab studies not diagnostic • Bone mineral density (BMD) • Quantitative ultrasound (QUS) • Dual-energy x-ray absorptiometry (DXA) Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • What results of the DXA scan would confirm that A.L. has osteoporosis? Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies • T-scores • T-score between +1 and -1 = normal bone density • T-score between -1 and -2.5 = osteopenia • T-score -2.5 or lower = osteoporosis • Z-score compares with someone own age and ethnicity Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Focus on • • • • • Proper nutrition Calcium supplements Exercise Prevention of fractures Drug therapy Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Treat if • T-score less than -2.5 • T-score between -1 and -2.5 with additional risk factors • Prior history of hip or vertebral fracture • Risk assessment • www.shef.ac.uk/FRAX Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • When A.L. is advised to take calcium supplements, she states she is already taking a multivitamin and drinks milk regularly. • Therefore she doesn’t see the need. • What can you tell her? Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Adequate calcium intake • 1000 mg/day for • women ages 19-50 years • Men ages 19-70 years • 1200 mg/day for • Women 51 years or older • Men 71 years or older Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Good sources of calcium • • • • • • • Milk Yogurt Turnip greens Cottage cheese Ice cream Sardines Spinach Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Supplemental calcium • Take in divided doses • Calcium carbonate • 40% elemental calcium • Take with meals • Calcium citrate • 20% elemental calcium • Less dependent on stomach acid Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • What other lifestyle changes will you teach A.L. about to prevent progression of her osteoporosis? Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Vitamin D necessary for calcium absorption/function; bone formation • Sunlight for 20 minutes adequate • Supplemental (800-1000 IU/day) • • • • Postmenopausal Older adults Homebound/long-term care Minimal sun exposure Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care • Weight-bearing exercise • Build up and maintain bone mass • Increase strength, coordination, balance • Walking, hiking, weight training, stair climbing, tennis, dancing • Quit smoking • Decrease alcohol intake Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study (©iStockphoto/Thinkstock) • A.L.’s health care provider prescribes alendronate (Fosamax) 70 mg po once/week. • What will you teach A.L. about this medication and how to take it? Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy • Bisphosphonates • Inhibit bone resorption • Side effects: anorexia, weight loss, gastritis • Proper administration • Take with full glass of water • Take 30 minutes before food or other meds • Remain upright for at least 30 minutes Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy • Calcitonin • Inhibits bone resorption • Give IM form at night to minimize side effects • Alternate nostrils when using nasal form • Calcium supplementation is needed Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy • Selective estrogen receptor modulators • Raloxifene (Evista) • Reduces bone resorption • Teriparatide (Forteo) • Portion of parathyroid hormone • First drug to stimulate new bone formation Copyright © 2017, Elsevier Inc. All Rights Reserved. Drug Therapy • Denosumab (Prolia) • Monoclonal antibody for postmenopausal women • Subcutaneous injection every 6 months • Management of patients receiving corticosteroids Copyright © 2017, Elsevier Inc. All Rights Reserved. Audience Response Question Alendronate (Fosamax) is prescribed for a patient with osteoporosis. The nurse teaches the patient that a. the drug must be taken with food to prevent GI side effects. b. bisphosphonates prevent calcium from being taken from the bones. c. lying down after taking the drug prevents lightheadedness and dizziness. d. taking the drug with milk enhances the absorption of calcium from the bowel. Copyright © 2017, Elsevier Inc. All Rights Reserved. Audience Response Question Which patient would be at greatest risk for developing osteoporosis? a. A 73-year-old man who has five alcoholic drinks per week and limits sun exposure to prevent recurrence of skin cancer. b. An 84-year-old man who has recently been diagnosed with hypothyroidism and is prescribed levothyroxine (Synthroid). c. A 69-year-old woman who had a renal transplant 5 years ago and has been taking prednisone to prevent organ rejection. d. A 55-year-old woman who recently had a hysterectomy with bilateral salpingo-oophorectomy and refuses estrogen therapy. Copyright © 2017, Elsevier Inc. 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