NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: MUSCULOSKELETAL SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

OSTEOARTHRITIS: joint disorder characterized by degeneration of articular cartilage and formation of bony outgrowths at edges of weight-bearing joints.

A. Pathophysiology: excessive friction combined with risk factors → thinning of articular cartilage, narrowing of joint space, and loss of joint stability; cartilage erodes, producing shallow pits on articular surface and exposing bone in joint space. Bone responds by becoming denser and harder.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Aging (>50).
  • Rheumatoid arthritis.
  • Arteriosclerosis.
  • Obesity.
  • Trauma.
  • Family history.

C. Assessment:

  • Subjective data:

a. Pain; tender joints.

b. Fatigability, malaise.

c. Anorexia.

d. Cold intolerance.

e. Extremities: numbness, tingling.

  • Objective data:

a. Joints:

(1) Enlarged.
(2) Stiff, limited movement.
(3) Swelling, redness, and heat around affected joint.
(4) Shiny stretched skin over and around joint.
(5) Subcutaneous nodules.

b. Weight loss.

c. Fever.

d. Crepitation (creaking or grating of joints).

e. Deformities, contractures. f. Cold, clammy extremities.

g. Laboratory data: decreased Hgb, elevated WBC count.

h. Diagnostic tests: x-ray, thermography, arthroscopy.

D. Analysis/nursing diagnosis:

  • Pain related to friction of bones in joints.
  • Bathing/hygiene self-care deficit related to decreased mobility of involved joints.
  • Risk for injury related to fatigability.
  • Impaired physical mobility related to stiff, limited movement.
  • Impaired home maintenance management related to contractures.

E. Nursing care plan/implementation:

  • Goal: promote comfort: reduce pain, spasms, inflammation, swelling.

a. Medications as prescribed.

(1) Nonsteroidal antiinflammatory agents: aspirin (Ecotrin), acetaminophen (Tylenol), ibuprofen (Motrin), indomethacin (Indocin), corticosteroids, nabumetone (Relafen), naproxen (Naprosyn).
(2) Antimalarials: chloroquine (Aralen), hydroxychloroquine (Plaquenil), to relieve symptoms.

b. Heat to reduce muscle spasms, stiffness.

c. Cold to reduce swelling and pain.

d. Prevent contractures:

(1) Exercise.
(2) Bedrest on firm mattress during attacks.
(3) Splints to maintain proper alignment.

e. Elevate extremity to reduce swelling.  f. Rest.

g. Assistive devices to decrease weight-bearing of affected joints (canes, walkers).

  • Goal: health teaching to promote independence.

a. Encourage self-care with assistive devices for activities of daily living (ADLs).

b. Activity, as tolerated, with ambulation-assistive devices.

c. Scheduled rest periods.

d. Correct body posture and body mechanics.

  • Goal: provide for emotional needs.

a. Accept feelings of frustration regarding long-term debilitating disorder.

b. Provide diversional activities appropriate for age and physical condition to promote comfort and satisfaction.

F. Evaluation/outcome criteria:

  • Remains independent as long as possible.
  • No contractures.
  • States comfort has increased.
  • Uses methods that are successful in pain control.

RHEUMATOID ARTHRITIS: chronic, systemic, collagen inflammatory disease; etiology unknown; may be autoimmune, viral, or genetic; affects primarily women ages 20 to 40 years; present in 2% to 3% of total population; follows a course of exacerbations and remissions.

A. Pathophysiology: synovitis with edema → proliferation of various blood material (formation of pannus) → destruction and fibrosis of cartilage (fibrous ankylosis); calcification of fibrous tissue (osseous ankylosis) (Rheumatoid arthritis).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

B. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Joints: pain; morning stiffness; swelling.

b. Easily fatigues; malaise.

c. Anorexia; weight loss.

  • Objective data:

a. Subcutaneous nodules over bony prominences.

b. Bilateral symmetrical involvement of joints: crepitation, creaking, grating.

c. Deformities: contractures, muscle atrophy.

d. Laboratory data: blood: decreased—hemoglobin/hematocrit; RBCs; increased—WBCs (12,000 to 15,000), sedimentation rate (>20 mm/hr), rheumatoid factor. Positive antinuclear antibody titer.

C. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain related to joint destruction.
  • Impaired physical mobility related to joint contractures.
  • Risk for injury related to the inflammatory process.
  • Body image disturbance related to joint deformity.
  • Self-care deficit related to musculoskeletal impairment.
  • Risk for activity intolerance related to fatigue and stiffness.
  • Altered nutrition, less than body requirements, related to anorexia and weight loss.
  • Self-esteem disturbance related to chronic illness.

D. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent or correct deformities.

a. Activity:

(1) Bedrest during exacerbations.
(2) Daily ROM—active and passive exercises even in acute phase, 5- to 10-minute periods; avoid fatigue and persistent pain.
(3) Heat or pain medication before exercise.

b. Medications: aspirin (high dosages); nonsteroidals; steroids; antacids given for possible GI upset with ASA, steroids; disease-modifying antirheumatics (methotrexate, hydroxychloroquine, sulfasalazine).

c. Fluids: at least 1,500 mL liquid daily to avoid renal calculi; milk for GI upset.

  • Goal: health teaching.

a. Side effects of medications: tarry stools (GI bleeding); tinnitus (ASA).

b. Psychosocial aspects: possible need for early retirement; financial hardship; loss of libido; unsatisfactory sexual relations.

c. Prepare for joint repair or replacement if indicated.

E. Evaluation/outcome criteria:

  • Remains as active as possible; limited loss of mobility; performs self-care activities.
  • No side effects from drug therapy (e.g., GI bleeding).
  • Copes with necessary lifestyle changes; complies with treatment regimen.

TOTAL HIP REPLACEMENT: femoral head and acetabulum are replaced by a prosthesis, which is cemented into the bone with plastic cement. Performed to replace a joint with limited and painful function due to bony alkalosis and deformity, caused by degenerative joint disease or when vascular supply to femoral head is compromised from a fracture. Goal of the surgery: restore or improve mobilization of hip joint and prevent complications of extended immobilization.

A. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Rheumatoid arthritis.
  • Osteoarthritis.
  • Complications of femoral neck fractures— avascular necrosis and malunion (Fractures of the Hip).
  • Congenital hip disease.

B. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Risk for injury related to implant surgery.
  • Knowledge deficit (learning need) regarding joint replacement surgery.
  • Impaired physical mobility related to major hip surgery.
  • Pain related to surgical incision.
  • Risk for impaired skin integrity related to immobility.

C. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Preoperative:

a. Goal: prevent deep vein thrombosis or pulmonary emboli.

(1) Antiembolic stockings.
(2) Increase fluid intake.

b. Goal: prevent infection: antibiotics as ordered, given prophylactically (Cefazolin).

c. Goal: health teaching.

(1) Isometric exercises—gluteal, abdominal, and quadriceps-setting; dorsiflexion and plantar flexion of the feet.
(2) Use of trapeze.
(3) Explain position of operative leg and hip postoperatively to prevent adduction and flexion.
(4) Transfer techniques—bed to chair and chair to crutches; dangle at bedside first time out of bed.
(5) Assist client with skin scrubs with antibacterial soap.

  • Postoperative:

a. Goal: prevent respiratory complications.

(1) Turn, cough, and deep breathe.
(2) Incentive spirometry.

b. Goal: prevent complications of shock or infection.

(1) Check dressings for drainage q1h for first 4 hours; then q4h and prn; may have Hemovac or other drainage tubes inserted in wound to keep dressing dry.
(2) Monitor I&O and vital signs hourly for 4 hours, then q4h and prn.

c. Goal: prevent contractures, muscle atrophy: initiate exercises as soon as allowed: isometric quadriceps, dorsiflexion and plantar flexion of foot, and flexion and extension of the ankle—sequential compression device while in bed.

d. Goal: promote early ambulation and movement.

(1) Use trapeze.
(2) Transfer technique (pivot on unaffected leg); crutches/walker.
(3) Initiate progressive ambulation as ordered; ensure maximum extension of leg when walking.
(4) Administer anticoagulation therapy as ordered (warfarin immediately postoperatively) to prevent deep vein thrombosis and pulmonary emboli.
(5) Recognize early side effects of medications and report appropriately.

e. Goal: prevent constipation.

(1) Increase fluid intake.
(2) Use fracture bedpan.

f. Goal: prevent dislocation of prosthesis.

(1) Maintain abduction of the affected joint (prevent external rotation); elevate head of bed, turn according to physician’s order. When turning to unaffected side, turn with abduction pillow between legs to maintain abduction.
(2) Buck’s extension or Russell’s traction may be applied (temporary skin traction).                                                                                                                                                                     (3) Plaster booties with an abduction bar may be used.
(4) Wedge Charnley (triangle-shaped) pillow to maintain abduction between knees and lower legs.
(5) Provide periods throughout day when client lies flat in bed to prevent hip flexion and strengthen hip muscles.
(6) Report signs of dislocation: anteriorly—knee flexes, leg turns outward, leg looks longer than other, femur head may be felt in groin area; posteriorly—leg turns inward, appears shorter than other, greater trochanter elevated.

g. Goal: promote comfort.

(1) Initiate skin care; monitor pressure points for redness; back care q2h.
(2) Alternating pressure mattress; sheepskin when sitting in chair.

h. Goal: health teaching.

(1) Exercise program with written list of activity restrictions.
(2) Methods to prevent hip adduction.
(3) Avoid sitting for more than 1 hour: stand, stretch, and walk frequently to prevent hip flexion contractures.
(4) Advise not to exceed 90 degrees of hip flexion (dislocation can occur, particularly with posterior incisions); avoid low chairs.
(5) Teach alternative methods of usual selfcare activities to prevent hip dislocation (e.g., avoid: bending from waist to tie shoes, sitting up straight in a low chair, using a low toilet seat).   (6) Avoid crossing legs, driving a car for 6 weeks.
(7) Wear support hose for 6 weeks to enhance venous return and avoid thrombus formation.

D. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Participates in postoperative nursing care plan to prevent complications.
  • Reports pain has decreased.
  • Ambulates with assistive devices.
  • Complications of immobility avoided.
  • Able to resume self-care activities.
Physiological Integrity: Nursing Care of the Adult Client

TOTAL KNEE REPLACEMENT: both sides of the joint are replaced by metal or plastic implants.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Analysis/nursing diagnosis.

B. Nursing plan/implementation:

  • Goal: achieve active flexion beyond 70 degrees.

a. Immediately postoperatively: may have continuous passive motion (CPM) device for flexion-extension of affected knee. Maximum flexion 110 degrees.

b. Monitor drainage in Hemovac (q15 min for first 4 hours, q1h until 24 hours; q4h and prn while Hemovac in place).

c. Analgesics as ordered for pain.

d. While dressings are still on: quadricepssetting exercises for approximately 5 days (consult with physical therapist for specific instructions).

e. After dressings removed: active flexion exercises.

f. Avoid pressure on heel.

C. Evaluation/outcome criteria:

  • No complications of infection, hemorrhage noted.
  • ROM of knee increases with exercises.

AMPUTATION: surgical removal of a limb as a result of trauma or circulatory impairment (gangrene). The amount of tissue amputated is determined by the severity of disease or trauma and the ability of the remaining tissue to heal.

A. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Atherosclerosis obliterans.
  • Uncontrolled diabetes mellitus.
  • Malignancy.
  • Extensive and intractable infection.
  • Result of severe trauma.

B. Assessment (preoperative):

  • Subjective data: pain in affected part.
  • Objective data:

a. Soft tissue damage.

b. Partial or complete severance of a body part.

c. Lack of peripheral pulses.  d. Skin color changes, pallor → cyanosis → gangrene.

e. Infection, hemorrhage, or shock.

C. Analysis/nursing diagnosis:

  • Impaired physical mobility related to lower-limb amputation.
  • Body image disturbance related to loss of body part.
  • Pain related to interruption of nerve pathways.
  • Anxiety related to potential change in lifestyle.
  • Knowledge deficit (learning need) related to rehabilitation goals.

D. Nursing care plan/implementation:

  • Goal: prepare for surgery, physically and emotionally.

a. Validate that client and family are aware that amputation of body part is planned.

b. Validate that informed consent is signed.

c. Allow time for grieving.

d. If time allows, prepare client for postoperative phase (e.g., teach arm-strengthening exercises if lower limb is to be amputated; teach alternative methods of ambulation).

e. Provide time to discuss feelings.

f. Prepare surgical site to decrease possibility of infection (e.g., shave, scrub as ordered).

g. Discuss postoperative expectations.

  • Goal: promote healing postoperatively.

a. Monitor respiratory status q1–4h and prn: rate, depth of respiration; auscultate for signs of congestion; and question client about chest pain (pulmonary emboli common complication).

b. Monitor for hemorrhage; keep tourniquet at bedside.

c. Medicate for pain as ordered—client may have phantom limb pain.

d. Support stump on pillow for first 24 hours; remove pillow after 24 hours to prevent contracture.

e. Position: turn client on to stomach to prevent hip contracture.

f. ROM exercises for joint above amputation to prevent joint immobilization; strengthening exercises for arms, nonaffected limbs, abdominal muscles.

g. Stump care:

(1) Early postoperative dressings changed prn.
(2) As incision heals, bandage is applied in cone shape to prepare stump for prosthesis.
(3) Inspect for blisters, redness, abrasions.
(4) Remove stump sock daily and prn.

h. Assist in rehabilitation program.

E. Evaluation/outcome criteria:

  • Begins rehabilitation program.
  • No hemorrhage, infection.
  • Adjusts to altered body image.

GOUT: disorder of purine metabolism; genetic disease believed to be transmitted by a dominant gene, characterized by recurrent attacks of acute pain and swelling of one joint (usually the great toe).

A. Pathophysiology: urate crystals and infiltrating leukocytes appear to damage the intracellular phagolysosomes, resulting in leakage of lysomal enzymes into the synovial fluid, causing tissue damage and joint inflammation.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Men.
  • Age (>50).
  • Genetic/familial tendency.
  • Prolonged hyperuricemia (elevated serum uric acid).
  • Obesity.
  • Moderate to heavy alcohol intake.
  • Hypertension.
  • Abnormal kidney function.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Pain: excruciating

b. Fatigue

c. Anorexia.

  • Objective data:

a. Joint: erythema (redness), hot, swollen, difficult to move; skin stretched and shiny over joint.

b. Subcutaneous nodules, tophi (deposits of urate) on hands and feet.

c. Weight loss.

d. Fever.

e. Sensory changes, with cold intolerance.

f. Laboratory data:

(1) Serum uric acid: increased significantly (6.5 mg/100 mL in women, 7.5 mg/100 mL in men) in chronic gout; only slightly increased in acute gout.
(2) WBC count: 12,000 to 15,000/mm3.
(3) Erythrocyte sedimentation rate: >20 mm/hr.
(4) 24-hour urinary uric acid: slightly elevated.
(5) Proteinuria (chronic gout).
(6) Azotemia (presence of nitrogen-containing compounds in blood) in chronic gout.

g. Diagnostic tests: arthrocentesis, x-rays.

D. Analysis/nursing diagnosis:

  • Pain related to inflammation and swelling of affected joint.
  • Impaired physical mobility related to pain.
  • Knowledge deficit (learning need) related to diet restrictions and increased fluid needs.
  • Altered urinary elimination related to kidney damage.

E. Nursing care plan/implementation:

  • Goal: decrease discomfort.

a. Administer antigout medications as ordered:

(1) Treatment of acute attacks: colchicine, phenylbutazone (Butazolidin), indomethacin (Indocin), allopurinol (Zyloprim), naproxen (Naprosyn), corticosteroids (prednisone).
(2) Preventive therapy: probenecid (Benemid), sulfinpyrazone (Anturane). These drugs are not used during acute attacks.

b. Absolute rest of affected joint → gradual increase in activities, to prevent complications of immobilization; at the same time, rest for comfort.

  • Goal: prevent kidney damage.

a. Increase fluid intake to 2,000 to 3,000 mL/day.

b. Monitor urinary output.

  • Goal: health teaching.

a. Need for low-purine diet during acute attack

b. Importance of increased fluid in diet.

c. Signs and symptoms of increased progression of disease.

d. Dosage and side effects of prescribed medications.

F. Evaluation/outcome criteria:

  • Swelling decreased.
  • Discomfort alleviated.
  • Mobility returned to status before attack.
  • Laboratory values return to normal.

LUPUS ERYTHEMATOSUS (LE): chronic inflammatory disease of connective tissue; may affect or involve any organ; vague etiology, but genetic factors, viruses, hormones, and drugs are being investigated; occurs primarily in women ages 18 to 35 years. Two forms: discoid lupus erythematosus (DLE) affects skin only, and systemic lupus erythematosus (SLE) affects multiple organs.

A. Pathophysiology: possible toxic effects from immune complexes deposited in tissue (antibodyantigen trapping in organ capillaries)—fibrinoid necrosis of collagen in connective issue, small arterial walls (kidneys and heart  particularly) →cellular death, obstructed blood flow.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Assessment:

  • Subjective data:

a. Pain: joints.

b. Anorexia; weight loss.

c. Photophobia; sensitivity to sun.

d. Weakness.

e. Nausea, vomiting.

  • Objective data:
  • a. Fever.

b. Rash: butterfly distribution across nose, cheeks.

c. Lesions: raised, red, scaling plaques—coinlike (discoid).

d. Ulceration: oral or nasopharyngeal.

e. Laboratory data:

(1) Blood: increased LE cells; decreased— RBCs, WBCs, thrombocytes. Positive antinuclear antibody (ANA) titer.
(2) Urine—hematuria, proteinuria (nephritis).

C. Analysis/nursing diagnosis:

  • Risk for injury related to possible autoimmune disorder.
  • Pain related to joint inflammation.
  • Risk for activity intolerance related to extreme fatigue, anemia.
  • Body image disturbance related to chronic skin eruptions.
  • Altered nutrition, less than body requirements, related to anorexia, nausea, vomiting.
  • Altered oral mucous membrane related to ulcerations.

D. Nursing care plan/implementation:

  • Goal: minimize or limit immune response and complications.

a. Activity: rest; 8 to 10 hours’ sleep; unhurried environment; assist with stressful activities; ROM to prevent joint immobility and stiffness.

b. Skin care: hygiene; topical steroid cream as ordered for inflammation, pruritus, scaling.

c. Mouth care: several times daily if stomatitis present; soft, bland, or liquid diet to prevent irritation.

d. Diet: low sodium if edematous; low protein with renal involvement.

e. Observe for signs of complications:

(1) Cardiac/respiratory (tachycardia, tachypnea, dyspnea, orthopnea).
(2) GI (diarrhea, abdominal pain, distention).
(3) Renal (increased weight, oliguria, decreased specific gravity).
(4) Neurological (ptosis, ataxia).
(5) Hematological (malaise, weakness, chills, epistaxis); report immediately.

f. Medications, as ordered:

(1) Analgesics.
(2) Anti-inflammatory agents (aspirin, prednisone) and immunosuppressive drugs (azathioprine [Imuran], cyclophosphamide [Cytoxan]) to control inflammation.
(3) Antimalarials for skin and joint manifestations.

  • Goal: health teaching.

a. Disease process: diagnosis, prognosis, effects of treatment.

b. Avoid precipitating factors:

(1) Sun (aggravates skin lesions; thus, cover body as much as possible).

(2) Altering dosage of medications.

(3) Pregnancy (requires medical clearance).

(4) Fatigue, stress.

(5) Infections.

c. Medications: side effects of immunosuppressives and corticosteroids.

d. Regular exercise: walking, swimming; but avoid fatigue.

e. Wear Medic Alert bracelet.

E. Evaluation/outcome criteria:

  • Attains a state of remission.
  • No organ involvement (e.g., no cardiac, renal complications).
  • Keeps active within limitations.
  • Continues follow-up medical care—recognizes symptoms requiring immediate attention.
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