NCLEX: MUSCULOSKELETAL DISORDERS

MUSCULOSKELETAL DISORDERS: Common musculoskeletal disorders

Focus topic: Musculoskeletal disorders

Nothing fake about the symptoms

Focus topic: Musculoskeletal disorders

Pseudogout also causes abrupt joint pain and swelling but results from an accumulation of calcium pyrophosphate in periarticular joint structures.

What tests tell you

  • Urate monohydrate crystals in synovial fluid taken from an inflamed joint or tophus establish the diagnosis. Arthrocentesis(aspiration of synovial fluid) or aspiration of tophaceous material reveals needle like intracellular crystals of sodium urate.
  • Although hyperuricemia isn’t specifically diagnostic of gout, tests reveal above-normal serum uric acid levels. Uric acid levels are usually higher in secondary gout than in primary gout.
  • Initially, X-ray examinations are normal. However, in chronic gout, X-rays show a punched-out look when urate acids replace bony structures. As the disorder destroys cartilage, the joint space narrows and degenerative changes become evident. Outward displacement of the overhanging margin from the bone contour characterizes gout.

How it’s treated

Management goals are to terminate an acute attack, reduce hyperuricemia, and prevent recurrence, complications, and calculi formation. Treatment of the patient with acute gout consists of bed rest; immobilization and protection of inflamed, painful joints; and local application of heat or cold.

A medley of meds

Focus topic: Musculoskeletal disorders

Analgesics, such as acetaminophen (Tylenol) or ibuprofen (Motrin), relieve the pain associated with mild attacks. Acute inflammation requires concomitant treatment with oral colchicine (Colcrys) at the first sign of a gout flare.
Indomethacin (Indocin) in therapeutic doses may be used instead but are less specific. Resistant inflammation may require corticosteroids or I.V. drip or I.M. corticotropin or joint aspiration and an intra-articular corticosteroid injection.

Down with serum uric acid!

Focus topic: Musculoskeletal disorders

Treatment of chronic gout aims to decrease serum uric acid levels. The doctor may order a continuing maintenance dosage of allo purinol to suppress uric acid formation or control uric acid levels and prevent further attacks. However, use this powerful drug cautiously in a patient with renal failure. Colchicine prevents recurrent acute attacks until uric acid returns to its normal level, but the drug doesn’t affect the acid level.
Uricosuric agents — such as probenecid — promote uric acid excretion and inhibit accumulation of uric acid, but their value is limited in a patient with renal impairment. Don’t administer these drugs to patients with calculi. Encourage patients taking these drugs to maintain adequate fluid intake to prevent complications.
Adjunctive therapy emphasizes a few dietary restrictions, primarily avoiding alcohol and high-purine foods. Obese patients should try to lose weight because obesity puts additional stress on painful joints.

Say good-bye to tophi

Focus topic: Musculoskeletal disorders

In some cases, surgery may be necessary to improve joint function or correct deformities. Tophi must be excised and drained if they become infected or ulcerated. They can also be excised to prevent ulceration, improve the patient’s appearance, or make it easier for him to wear shoes or gloves.

What to do

  • Encourage bed rest, but use a bed cradle to keep covers off extremely sensitive, inflamed joints.
  • Give pain medication as needed, especially during acute attacks. Administer anti-inflammatory medication and other drugs as ordered. Watch for adverse effects. Be alert for GI disturbances with colchicine.
  • Apply hot or cold packs to inflamed joints.
  • Unless contraindicated, urge the patient to drink plenty of fluids (up to 2 qt [2 L] per day) to prevent calculi formation. When forcing fluids, record intake and output accurately. Be sure to monitor serum uric acid levels regularly. Alkalinize urine with sodium bicarbonate or another agent if ordered.
  • Watch for acute gout attacks that may occur 24 to 96 hours after surgery. Even minor surgery can precipitate an attack. Before and after surgery, administer colchicine as ordered to help prevent gout attacks.
  • Evaluate the patient. When assessing response to treatment, note whether the patient’s pain is relieved or controlled. Also note whether he’s complying with drug therapy and dietary restrictions to maintain normal serum urate levels and avoid recurrence of acute episodes.

Osteoarthritis

Focus topic: Musculoskeletal disorders

Osteoarthritis is the most common form of arthritis. Symptoms usually begin in middle age and may progress with age. A thorough physical examination confirms typical symptoms, and lack of systemic symptoms rules out an inflammatory joint disorder such as rheumatoid arthritis.
Disability depends on the site and severity of involvement and can range from minor limitation of the fingers to severe disability in people with hip or knee involvement. The rate of progression varies, and joints may remain stable for years in an early stage of deterioration.

What causes it

The cause of osteoarthritis is unknown. Primary osteoarthritis, a normal part of aging, results from many things, including metabolic, genetic, chemical, and mechanical factors.

Fateful event

Focus topic: Musculoskeletal disorders

Secondary osteoarthritis usually follows an identifiable predisposing event, most commonly trauma, congenital deformity, or another disease such as Paget’s disease. It leads to degenerative changes.

Pathophysiology

This chronic condition causes deterioration of the joint cartilage and reactive new bone formation at the margins and subchondral areas. Degeneration results from a breakdown of chondrocytes, most commonly in the hips and knees. Cartilage flakes irritate the synovial lining, and the cartilage lining becomes fibrotic, causing limited joint movement. Synovial fluid leaks into bone defects, causing cysts.

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What to look for

The severity of these signs and symptoms increases with poor posture, obesity, and occupational stress:

  • joint pain (the most common symptom) that occurs particularly after exercise or weight bearing and is usually relieved by rest
  • stiffness in the morning and after exercise that’s usually relieved by rest
  • achiness during changes in weather
  • “grating” of the joint during motion
  • limited movement.

Irreparable damage

Focus topic: Musculoskeletal disorders

In addition, osteoarthritis of the interphalangeal joints causes irreversible changes in the distal joints (Heberden’s nodes) and proximal joints (Bouchard’s nodes). Nodes may be painless at first but eventually become red, swollen, and tender, causing numbness and loss of dexterity.

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What tests tell you

  • X-rays of the affected joint may show narrowing of the joint space or margins, cyst like bony deposits in the joint space and margins, joint deformity from degeneration or articular damage, and bony growths at weight-bearing areas (such as the hips and knees).
  • MRI shows the affected joint, adjacent bones, and disease progression.
  • Synovial fluid analysis rules out inflammatory arthritis.

How it’s treated
Most measures are palliative. Medications for relief of pain and joint inflammation include aspirin (or other nonopioid analgesics), indomethacin, ketorolac, ibuprofen and, in some cases, intraarticular injections of corticosteroids. Such injections may delay the development of nodes in the hands.

Stabilizing influences

Focus topic: Musculoskeletal disorders

Effective treatment also reduces joint stress by supporting or stabilizing the joint with crutches, braces, a cane, a walker, a cervical collar, or traction. Other supportive measures include massage, moist heat, paraffin dips for hands, protective techniques for preventing undue stress on the joints, adequate rest (particularly after activity), and, occasionally, exercise when the knees are affected.

Surgery for severe cases

Focus topic: Musculoskeletal disorders

Patients who have severe osteoarthritis with disability or uncontrollable pain may undergo one or more of these surgical procedures:

  • arthroplasty (partial or total): replacement of a deteriorated joint with a prosthetic appliance
  • arthrodesis: surgical fusion of bones, which is used primarily in the spine (laminectomy)
  • osteoplasty: scraping of deteriorated bone from a joint
  • osteotomy: excision of bone to change alignment and relieve stress.

What to do

  • Promote adequate rest, particularly after activity. Plan rest periods during the day, and provide for adequate sleep at night. Moderation is the key; so teach the patient to pace daily activities.
  • Assist with physical therapy and encourage the patient to perform gentle ROM exercises. Provide emotional support and reassurance to help the patient cope with limited mobility. Explain that osteoarthritis isn’t a systemic disease.
  • Other specific nursing measures depend on the affected joint:
    – For the hand, apply hot soaks and paraffin dips as ordered to relieve pain.
    – For the lumbar or sacral spine, recommend a firm mattress or bed board to decrease morning pain.
    – For the cervical spine, check the cervical collar for constriction; watch for redness with prolonged use.
    – For the hip, use moist heat pads to relieve pain, and administer antispasmodic drugs, as ordered. Assist with ROM and strengthening exercises, making sure that the patient gets the proper rest afterward.
    – For the knee, twice daily, assist with prescribed ROM exercises, exercises to maintain muscle tone, and progressive resistance exercises to increase muscle strength. Provide elastic supports or braces if needed.
  • Check crutches, braces, cane, or walker for proper fit, and teach the patient how to use them correctly. For example, the patient with unilateral joint involvement should use an orthopedic appliance (such as a cane or walker) on the unaffected side. Advise the use of cushions when sitting and suggest an elevated toilet seat.
  • Evaluate the patient. Assess whether compliance with the exercise regimen slows down the debilitating effects of osteoarthritis. The patient should maintain or improve his ability to perform ADLs. He should also be able to obtain and use appropriate assistive devices. Note whether he understands and makes use of pain control interventions for involved joints.

Osteomyelitis

Focus topic: Musculoskeletal disorders

A pyogenic bone infection, osteomyelitis may be chronic or acute. The infection causes tissue necrosis, breakdown of bone structure, and decalcification. Although it commonly remains localized, osteomyelitis can spread through the bone to the marrow, cortex, and periosteum.
In acute osteomyelitis, bacteria or fungi are either carried through the blood from another infectious site or enter the bone through the skin after surgery or trauma. With prompt treatment, the prognosis is good.
Chronic osteomyelitis, which is rare, is characterized by multiple draining sinus tracts and metastatic lesions. More prevalent in adults, it carries a poor prognosis.

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What causes it

Causes of osteomyelitis include:

  • traumatic injury
  • acute infection originating elsewhere in the body
  • organisms, such as Staphylococcus aureus (most common), Streptococcus pyogenes, Pneumococcus, Pseudomonas aeruginosa, Escherichia coli, and Proteus vulgaris
  • fungi or viruses.

The rest of the risks

Focus topic: Musculoskeletal disorders

Other risk factors include:

  • diabetes
  • hemodialysis
  • I.V. drug use
  • any condition that decreases blood supply to the bone.

Pathophysiology

Organisms settle in a hematoma or weakened area and spread directly to the bone. Pus is produced and pressure builds within the rigid medullary cavity. Then pus is forced through the haversian canals. A subperiosteal abscess forms, depriving the bone of its blood supply. Necrosis results and new bone formation is stimulated. Dead bone detaches and exits through an abscess or the sinuses.

What to look for

Usually, the clinical signs for chronic and acute osteomyelitis are similar. However, chronic infection can persist intermittently for years, flaring up spontaneously after minor trauma. Sometimes the only sign of chronic infection is persistent drainage of pus from an old pocket in a sinus tract. Acute osteomyelitis usually has a rapid onset.

Three sure signals

Focus topic: Musculoskeletal disorders

Local signs and symptoms include:

  • sudden pain in the affected bone
  • tenderness, heat, and swelling over the affected area
  • restricted movement.

What tests tell you

  • WBC shows leukocytosis, and the patient has an elevated erythrocyte sedimentation rate (ESR).
  • Blood culture results enable the practitioner to identify the causative organisms.
  • X-rays may not show bone involvement until the disease has
    been active for some time, usually 2 to 3 weeks. Bone scans may
    enable the practitioner to detect infection early.

How it’s treated

To prevent further bone damage, interventions against acute osteomyelitis may begin before definitive diagnosis. Measures include:

  • administration of large doses of I.V. antibiotics after blood cultures are taken (usually a penicillinase-resistant penicillin, such as nafcillin or oxacillin)
  • early surgical drainage to relieve pressure buildup and formation of sequestrum (dead bone fragments that separate from sound bone during necrosis)
  • immobilization of the affected bone by plaster cast, traction, or bed rest
  • supportive treatment, such as analgesics and I.V. fluids.

Attacking an abscess

Focus topic: Musculoskeletal disorders

If an abscess forms, treatment includes incision and drainage, followed by a culture of the drainage matter. Antibiotic therapy to control infection includes administration of systemic antibiotics, intracavitary instillation of antibiotics through closed-system continuous irrigation with low intermittent suction, limited irrigation with a closed drainage system with suction, and local application of packed, wet, antibiotic-soaked dressings.
If an infected artificial joint is the cause, it’s usually removed. Antibiotic therapy is given for 2 to 3 weeks before surgery.

Bad to the bone

Focus topic: Musculoskeletal disorders

Besides antibiotic and immobilization therapy, patients with chronic osteomyelitis usually need surgery to remove dead bone and promote drainage. Even after surgery, the prognosis remains poor. The patient usually feels great pain and requires prolonged hospitalization. Therapy-resistant chronic osteomyelitis in an arm or leg may necessitate amputation.

What to do

Your major concerns are to control infection, protect the bone from injury, and offer meticulous supportive care. To help meet these needs, follow these guidelines:

  • Use strict sterile technique when changing dressings and irrigating wounds. If the patient is in skeletal traction for compound fractures, cover insertion points of pin tracks with small, dry dressings, and tell him not to touch the skin around the pins and wires.
  • Administer I.V. fluids to maintain adequate hydration as needed. Provide a diet high in protein and vitamin C.
  • Assess vital signs every 4 hours. Assess wound appearance and new pain sites, which may indicate secondary infection, daily.
  • Carefully monitor suctioning equipment. Don’t let containers of instilled solution become empty — this allows air into the system. Monitor the amount of solution instilled and suctioned.
  • Support the affected limb with firm pillows. Keep the limb level with the body, and don’t let it sag. Provide good skin care. Turn the patient gently every 2 hours, and watch for signs of developing pressure ulcers.
  • Provide good cast care. Support the cast with firm pillows, and “petal” the edges with pieces of adhesive tape or moleskin to smooth roughness. Check circulation and drainage every 4 hours for the first 24 hours postoperatively. Promptly report excessive drainage or signs of neurovascular deficits.
  • Protect the patient from mishaps, such as jerky movements and falls that may threaten bone integrity. Report sudden pain, crepitus, or deformity immediately. Watch for sudden malposition of the limb, which may indicate fracture.
  • Evaluate the patient. Note whether he sustained any neurovascular deficit secondary to treatment. He should achieve pain relief or pain control. New areas of pain, possibly indicating secondary infection, shouldn’t appear.
  • Also assess whether the patient pursues meaningful, satisfying activities that avoid the risk of fracture. Is he following therapeutic interventions? If so, look for normal body temperature, absence of pain and edema, and full ROM.

Osteoporosis

In osteoporosis, bones lose calcium and phosphate salts and become abnormally vulnerable to fracture. Osteoporosis may be primary or secondary to an underlying disease.

Primarily postmenopausal

Focus topic: Musculoskeletal disorders

Primary osteoporosis most commonly develops in postmenopausal women, although men may also develop osteoporosis. It’s called postmenopausal osteoporosis if it occurs in women ages 50 to 75 and senile osteoporosis if it occurs between ages 70 and 85. Risk factors include inadequate intake or absorption of calcium, estrogen deficiency, and sedentary lifestyle. Osteoporosis primarily affects the weight-bearing vertebrae, ribs, femurs, and wrist bones. Vertebral and wrist fractures are common.

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What causes it

The cause of primary osteoporosis remains unknown. Secondary osteoporosis may result from:

  • prolonged therapy with steroids, aluminum-containing antacids, heparin, anticonvulsants, or thyroid preparations
  • total immobility or disuse of a bone (as with hemiplegia). Osteoporosis is also linked to alcohol abuse, malnutrition, malabsorption, scurvy, lactose intolerance, hyperthyroidism, osteogenesis imperfecta, and Sudeck’s atrophy (localized to hands and feet, with recurring attacks).

Pathophysiology

In osteoporosis, the rate of bone resorption accelerates as the rate of bone formation decelerates. Decreased bone mass results, and bones become porous and brittle.

What to look for

Although osteoporosis develops insidiously, the disease is usually discovered suddenly. An elderly person typically becomes aware of the disorder when he bends to lift something, hears a snapping sound, and then feels a sudden pain in the lower back. Any movement or jarring aggravates the backache.

Other ominous signs

Focus topic: Musculoskeletal disorders

Other signs and symptoms include:

  • pain in the lower back that radiates around the trunk
  • deformity
  • kyphosis (humpback)
  • loss of height
  • a markedly aged appearance.

What tests tell you

  • X-rays show typical degeneration in the lower thoracic and lumbar vertebrae. The vertebral bodies may appear flattened, with varying degrees of collapse and wedging, and may look denser than normal. Loss of bone mineral becomes evident in later stages.
  • CT scan accurately assesses spinal bone loss.
  • Bone scans show injured or diseased areas.
  • Serum calcium, phosphorus, and alkaline phosphatase levels are within normal limits, but parathyroid hormone levels may be elevated.

How it’s treated

The patient receives symptomatic treatment aimed at preventing additional fractures and controlling pain. Measures may include:

  • a physical therapy program emphasizing gentle exercise and activity
  • estrogen to decrease the rate of bone resorption and calcium and vitamin D to support normal bone metabolism (However, drug therapy merely arrests osteoporosis; it doesn’t cure it.)
  • a bisphosphonate, such as alendronate (Fosamax) or ibandronate (Boniva), which slows bone resorption but does not decrease bone formation
  • a back brace to support weakened vertebrae
  • surgery to correct pathologic fractures of the femur by open reduction and internal fixation. Colles’ fracture, a fracture of the radius where it joins the wrist, requires reduction followed by plaster-cast immobilization for 4 to 10 weeks.

An ounce of prevention

Focus topic: Musculoskeletal disorders

Adequate intake of dietary calcium and regular weight-bearing exercise may reduce a person’s chances of developing senile osteoporosis. Although hormone therapy may offer some preventive benefit, it also has risks and adverse effects.
Secondary osteoporosis can be prevented through effective treatment of the underlying disease and by judicious use of steroid therapy, early mobilization after surgery or trauma, decreased alcohol consumption, careful observation for signs of malabsorption, and prompt treatment of hyperthyroidism.

What to do

Your care plan should focus on the patient’s fragility, stressing careful positioning, ambulation, prescribed exercises, and injury prevention strategies. Take these steps:

  • Check the patient’s skin daily for redness, warmth, and new sites of pain, which may indicate new fractures.
  • Encourage activity by helping the patient walk several times daily. As appropriate, perform passive ROM exercises, or encourage the patient to perform active exercises. Make sure the patient regularly attends scheduled physical therapy sessions.
  • Provide a balanced diet high in nutrients that support skeletal metabolism, such as vitamin D, calcium, and protein.
  • Administer analgesics as needed. Apply heat to relieve pain.
  • If the patient is prescribed a bisphosphonate to increase bone density, stress the importance of remaining upright for at least 30 minutes after taking the medication to prevent damage to the esophagus.
  • Evaluate the patient. Assess whether adherence to the prescribed regimen of medication, exercise, and dietary intake of calcium, vitamin D, and protein is preventing progression of the disease. Note whether the patient demonstrates good body mechanics and if she can identify and subsequently avoid activities that increase the risk of fracture.
MUSCULOSKELETAL DISORDERS

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