NURSE-UN 1243 Adult and Elder Nursing 3 Week 7 - Musculoskeletal Disorders,100% CORREECT

NURSE-UN 1243 Adult and Elder Nursing 3 Week 7 - Musculoskeletal Disorders • Learning Outcomes The student will be able to: – Implement health promotion practices related to musculoskeletal disorders identified by Healthy People 2030 for the adult & older adult population. • Reduce the proportion of older adults with osteoporosis • Increase the number of adults who get screened for osteoporosis • Reduce hip fractures among older adults • Reduce pain & disability from arthritis – Demonstrate clinical decision making based on the integration of information from multiple sources, including the patient, inter-professional team, & the best available evidence for patients with musculoskeletal disorders (Osteoporosis, Osteoarthritis, Hip Fracture). – Advocate for high quality, safe, & culturally competent patient centered care for hospitalized patients with musculoskeletal disorders. Osteoporosis (OP) ◼ Chronic metabolic disease in which bone loss causes decreased density and possible fracture; “silent disease/thief”--often discover at time of fracture ◼ Occurs when osteoclastic activity is greater than osteoblastic activity (breakdown faster than building) ◼ Bone Mineral Density (BMD) decreases rapidly post-menopause ◼ More common in women because less estrogen (protective against bone loss), after menopause , Calcium and vitamin d deficiency. Less exercise (decreased activity). ◼ vit d is needed for Ca absorption ◼ Bone resorption happens earlier than we thought---in our 30s! ◼ Testosterone in men builds bone ◼ Incidence/Prevalence ◼ 10 million Americans (1 in 10 Americans) have the disease and 54 million more have osteopenia and at risk for developing osteoporosis ◼ White thin women are likely to develop osteoporosis at an early age Classifications of Osteoporosis **Bucco says don’t have to know primary vs secondary ▪ Primary osteoporosis (post menopausal) occurs most commonly in postmenopausal women and men in their 60s and 70s. ▪ 1 in 4 men 50 are will have a osteoporosis related fracture. ▪ Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism (PTH usually makes sure blood calcium is not too low), long-term drug therapy, long-term immobility, and chronic drug use such as corticosteroids, heparin, anticonvulsants ▪ Regional osteoporosis occurs when a limb is immobilized. Risk Factors ◼ Older age - mainly women ◼ Female gender men are often underdiagnosed bc don’t go for bone density tests ◼ Familial history ◼ Low body weight, thin build -heavier people have more protection. Obese women store estrogen in tissues for longer period of time, hence, maintain serum Ca ◼ Chronic low calcium and/or Vitamin D intake ◼ Estrogen/Androgen deficiency ◼ Smoking ◼ High alcohol intake ◼ Lack of physical exercise or prolonged immobility ◼ White/ Asian ethnicity ◼ Long term use of steroids, thyroid replacement, heparin, long-acting sedatives & antiseizure drugs ◼ Studies have shown that some enzyme-inducing Anti Epileptic Drugs may increase the levels of chemicals in the liver that destroy vitamin D, reducing the amount of vitamin D in the body ◼ Men after age 50 have decreased testosterone and are at risk of osteoporosis ◼ underdiagnosed--less likely to go for bone density tests Health Promotion/Illness Prevention ▪ Teaching should begin with young women who begin to lose bone after 30 years of age. ▪ The focus of osteoporosis prevention is to decrease modifiable risk factors. ▪ Ensure adequate nutrition ▪ dark green veggies, dairy for calcium ▪ Avoid sedentary lifestyle ▪ Continue a program of weight-bearing exercises--prevention ▪ When any of the previous drugs are prescribed, teach the patient about the risk of osteoporosis. i.e. synthroid, steroids, heparin, long-acting sedatives, anti seizure meds ▪ sun exposure for vitamin D (600 IU activated vitamin D everyday, 800-1000 IU for people over 70) OP: Assessment and Diagnosis ▪ Physical assessment ▪ Assess for “dowager’s hump” ▪ reference photo, lose height and cause back pain (slumping at the thoracic - kyphosis) ▪ Once you have kyphosis, can’t return to original position (loss of bone and cartilage) ▪ Loss of height*** ▪ May complain of back pain ▪ Spontaneous fractures (vertebra-most common, foot bones while running) ▪ has to be a big fracture for it to be an osteoporosis fx, may need surgery ● Psychosocial assessment ▪ Assess of fallophobia (Colloquial term for fear of fall)--pt may be aware and avoid heels OP: Assessment and Diagnosis ◼ Laboratory assessment ◼ No definitive laboratory tests can confirm osteoporosis ◼ Serum calcium, Vitamin D, and phosphorus = to rule out secondary osteoporosis and other metabolic bone diseases ◼ DEXA scan is gold standard- looks at wrist, hip, and spine** ● Imaging assessment ○ Dual X-ray Absorptiometry (DEXA) ■ Diagnostic to measure bone mineral density (gold standard) ■ T-score (+1- -1) normal ● -1 to -2.5 is osteopenia, less than -2.5 is osteoporosis ● DEXA done at 65 y/o or greater, maybe done earlier for those with high risk (long term use of synthroid, steroids, long-acting sedatives, antiseizure drugs) ■ Quantitative ultrasound (QUS) ● use for people 65 yr old or older--medicare and most insurances pays for 1 every 2 years ● Risk factors: low estrogen, vertebral abnormality, long term steroid therapy, parathyroidism OP: Collaborative Management ◼ Goal: Prevent Fractures ◼ Nutrition therapy ◼ Calcium and Vitamin D – which foods are excellent source of Ca? dairy, dark green veggies ◼ Calcium 1000mg/day; 1200 mg/day 51 years old ◼ Vitamin D 800 IU ◼ Protein, Magnesium, Vitamin K and other minerals ◼ Lifestyle Changes ◼ Muscle strengthening and weight bearing exercises dance, walk (one of the best exercises), hike, stairs, weight training (not swimming so much) ◼ pectoral & abdominal stretching exercises expand lung capacity ◼ active range of motion exercises-lubricates the joints ◼ Walking for 30 minutes 3-5X a week*** (safe NCLEX answer for weight bearing exercise) ◼ Avoid smoking & drinking ◼ running, horse riding, and bowling can cause vertebral fractures and should be avoided - ELDERLY PEOPLE OP: Collaborative Management ▪ Bisphosphonates--inhibit osteoclasts and binds to crystal elements in spongy bone ▪ Bisphosphonates are a group of medicines that slow down or prevent bone loss, strengthening bones. Bisphosphonates inhibit osteoclasts which are responsible for breaking down and reabsorbing minerals such as calcium from bone (the process is known as bone resorption). ▪ Alendronate, Risedronate, Ibandronate - These are bisphosphonate derivatives ▪ S/E: Esophagitis – take on an empty stomach first thing in the AM with a full glass of water and remain upright/sitting for 30 minutes after taking or feel burning (irritates esophagus mucosa) ▪ Rare S/E: osteonecrosis of the jaw--jawbone exposed in mouth ▪ taken for 5 years--can take 1-2 years break--new blood test to check how long alendronate stays in bones and decide if want to continue taking bisphosphonate ▪ Calcium and Vitamin D ▪ 1-1.5 Grams in divided doses ▪ Estrogen Agonist/Antagonist ▪ ▪ Other Agents: ▪ Parathyroid Hormone (Forteo) increases osteoblasts but risk for bone cancer ▪ Calcitonin inhibits osteoclastic activity (slows bone loss) ▪ New monoclonal antibodies Denosumab (Prolia) injection--risk vs benefit--for people at high risk of fracture from ADL but severe bone pain and infections possible Case Study: Mrs. Davis ▪ Mrs. Davis presented to the clinic in December of 2014 with some concerns about osteoporosis. She was becoming more stooped and had already lost 1” in height over the last few years. She was 20 years postmenopausal and had never taken hormone replacement therapy. She subsequently received a DEXA scan at that time and was placed on Fosamax 10 mg daily. Over the next year, this seemed to be working well for her and she did not experience any side effects from the medication. In the fall of 2015, she sustained a fracture to her 4th metacarpal on her left hand (not significant for a bone fracture. true fracture = breaking big bone) that she suffered during a fall. She received another DEXA scan in late 2015 with no change. She seemed fairly stable and was only seen yearly after that time. During a repeat exam in 2016, DEXA scores continued to show progression and she was subsequently referred to an endocrinologist to eliminate secondary causes. After a thorough work-up, no cause was found for her worsening osteoporosis. Thyroid studies were normal as well as serum phosphorus, PTH and urine calcium. Case Study: Mrs. Davis ▪ Family and Social History: Mother died at age 40 (CA-cancer); Father died at age 57 (CAD); Brother w/ CAD, age 79; Twin sister with osteoporosis and depression. Patient is very active; she walks 1-2 miles/day. She stopped smoking 30 years ago, has an occasional drink. She also drinks a cup of coffee a day. She reports diarrhea and gas with dairy products so avoids them. ▪ health promotion ▪ stopped smoking ▪ walks 1-2 miles a day ▪ risk factors ▪ Family history- twin sister with osteoporosis ▪ Caffeine ▪ Lack of calcium, nutrient malabsorption from being lactose intolerant Case Study: Mrs. Davis -- History/Medications 1. Osteoporosis 2. Mild hyperlipidemia 3. Mild hypertension 4. Coronary artery disease 5. Tendonitis of Rt shoulder 6. Meds: ▪ Simvastatin 20 mg daily ▪ ASA 81 mg daily ▪ Furosemide 10 mg daily ▪ Alendronate 10 mg daily bisphosphonate for treatment ▪ Calcium + Vit. D 600 mg daily supplements ▪ Vit. E, Vit. C, Mg Risk factors here: meds are ok, not contributing to osteoporosis no steroids, sedatives, thyroid replacement therapy, heparin, anti seizure meds → remember steroids and antiseizure meds lead to that bone loss Case Study: Mrs. David -- Plan of Care • What concerns you re: Mrs. Davis? • fall risk • lasix--electrolyte imbalance, dizzy, hypotension, go to bathroom at night • can’t do ADL from finger fracture • stooped posture • lung can’t fully expand with kyphosis, weakened breathing • balance is off • hard to socialize • poor vision • How can we plan care to address risks associated with worsening osteoporosis? • activity--weight bearing exercise • diet • decrease caffeine • safety precautions • move things to remove clutter • put the call bell/items closeby • What do we need to teach her? • esophagitis side effect of Alendronate--take it in the morning with glass of water, upright 30 min Osteoarthritis (OA) - about 60 years old ▪ Joint pain and loss of function characterized by progressive deterioration and loss of cartilage in the joints ▪ cartilage is made of water, glycoproteins, chondroitin, keratin, collagen ▪ wear and tear of cartilage, decrease of synovial fluid and glycoprotein with age ▪ crepitus (grinding sensation) when bone and cartilage particles enter joint ▪ Development of osteophytes=bone spurs=bone hypertrophy ▪ A bone spur (osteophyte) is a tiny pointed outgrowth of bone. Bone spurs are usually caused by local inflammation, such as from degenerative arthritis (osteoarthritis) or tendonitis. Bone spurs develop in areas of inflammation or injury of nearby cartilage or tendons. Bone spurs may or may not cause symptoms. ▪ Affects women more (hands & knees) than men ▪ Hip OA in men (usual age 70-80) Osteoarthritis (OA) - Review the list ◼ progressive--risk factor: obesity, older age, female, smoking, repetitive stress on the joints ◼ non-inflammatory in the process; mechanical destruction ◼ Development of OA is complex ◼ Articular surfaces become cracked & worn (similar to osteoporosis) ◼ end up getting Secondary synovitis which is an inflammatory process OA: Assessment and Diagnosis -- OA does not have a gold standard for diagnosis but X-RAYS do an amazing job ▪ Chronic joint pain and stiffness* ▪ Pain gets worse with use ▪ Stiffness after periods of rest ▪ One side of the body ▪ With progressive disease ▪ Pain may be present at rest ▪ Interruption of sleep patterns ▪ Tenderness on palpation/range of motion ▪ Enlarged joint b/c of bone hypertrophy ▪ Heberden’s and Bouchard’s nodes ▪ Reference photo ▪ Joint effusion--common in the knee ▪ Atrophy ▪ Loss of function - disability b/c cannot do ADL with pain ▪ more pain with use RA vs OA - NOT RESPONSIBLE FOR RA OA risk factor--being overweight OA Morning stiffness lasts for 20 minutes usually Left: OA Right: RA OA: Assessment and Diagnosis ◼ Laboratory assessment: (ESR) normal ◼ Not a definitive confirmation for OA bc this level goes up when joint has inflammation ◼ Radiographic assessment ◼ X-rays--narrow joint space due to lost of cartilage ◼ X-Ray more diagnostic certainty for OA ◼ Other diagnostic assessments: ◼ Bone scan ◼ MRI imaging ◼ CT studies ◼ Synovial fluid analysis ◼ No gold standard for OA OA: Collaborative Management ◼ Current therapy directed at relief of pain and minimizing functional disability ◼ Analgesics ◼ Drug of choice: always acetaminophen for pain ◼ Lidoderm 5% patch- 12 hours on, 12 hours off-document start-end date. Need to report on and off patch times at the change of shift ◼ NSAIDs for inflammation (ibuprofen) ◼ No therapy will slow or halt progression ◼ Other: ◼ Cortisone injections ◼ Hyaluronate injections ◼ Muscle relaxants ◼ good supportive & good-fitted shoes ◼ good postures ◼ Hot application: ◼ Heat may decrease muscle tension ◼ Hot showers/baths ◼ Rest and positioning elevate legs (8-12 inches) to reduce stress on back ◼ Ice for inflammation but mostly commonly with OA patients have stiffness & would benefit with heat ◼ Weight control- biggest thing; they will NOT do surgery until they lose 25-30 pounds ◼ Complementary and alternative therapies ◼ do not smoke ◼ avoid recreational sports ie football, running , repetitive stress activity (knitting, typing for long time) - In context of elderly patients Arthroplasty--goal is to reduce inflammation and restore function. ▪ 1 million Americans ▪ Reconstruction or replacement of a joint knees hips (replacements last 10-15 years) ▪ Done for OA, RA, avascular necrosis, congenital deformities, dislocations & other systemic diseases weigh pros and cons of replacing in elderly with comorbidities, some wait to get replacement so they just need one for rest of life ▪ Available for elbows, shoulders, fingers, hips, wrists ankles, and feet ▪ Includes: ▪ Surgical reshaping of the bones of the joint ▪ Replacement of part of a joint ▪ Total joint replacement OA: Collaborative Management ▪ Total Hip Arthroplasty (THA) elective surgery, so want people to be as healthy as possible beforehand ▪ Preoperative care ▪ if overweight, at greater risk of dislocation and infection post surgery, complicated rehab therapy ▪ think ahead to postop and educate: pain, infection, ADL, care for themselves ▪ Operative procedures ▪ Postoperative care: ▪ Prevention of dislocation, infection ▪ ***thromboembolic complications*** --give prophylaxis heparin ▪ Assessment of bleeding ▪ Management of anemia ▪ ADL will be difficult - will need help ▪ PAIN: Promote the use of analgesics - also we want to to get off asap, if no longer needed ▪ incentive spirometer Total Knee Arthroplasty- CPM machine ▪ Compression dressing ▪ Knee Immobilizer ▪ CPM machine ▪ A continuous passive motion (CPM) machine is a motorized device that passively moves a joint through a pre-set range of motion. These devices may be used after surgery to reduce joint stiffness and improve range of motion ▪ Helps with passive range of motion but will not increase strength nor prevent blood clot ONLY range of motion for a few weeks after surgery and is delivered to the patient's house. ▪ DVT prevention is doing weight bearing exercise and flexion of muscle to get blood flow going CPM: Continuous Passive Movement- you put your leg in the machine and it bends and straightens the leg to the amount of degrees you set. Passive ROM for the patient Prevention of Complications pulses (if can’t find pulse use doppler before calling surgeon), poikilothermic(cold feet), paresthesia, paralysis (MUST KNOW THEM) ▪ Management of pain aggressively at the beginning and sent home with OTC pain meds ▪ Progression of activity ▪ ROM activity ▪ Promotion of self-care ▪ VTE (Venous Thromboembolism) prophylaxis 10-14 days ▪ wanna look for clot, blockage, bleeding, compression of vein and artery (compartment syndrome) if you can't feel the pulse 3 big things: PAIN, INFECTION, DVT management: 1. pain--give pain meds 2. infection--through wound check, frequent monitor, vital+temp, hand hygiene- 3. DVT--heparin prophylaxis. Hip Fracture ● Most common injury in older adults ● 95% result from a fall ● High mortality rate ○ 25%-40% of patients die within 1 year after surgery ○ Women men ● Area of concern: femoral neck fracture ○ Could lead to avascular necrosis of the femoral head Case Study: Mrs. Davis 6 months later ▪ Six months later, Mrs. Davis slipped on ice while out walking and fell, fracturing her left hip. She is admitted to the hospital through the emergency room and is taken to surgery for repair after a medical evaluation found her a good candidate for surgery. Open Reduction Internal Fixation with hemiarthroplasty (Femur and head of femur replacement) of the L proximal femur is successfully completed. ▪ During an open reduction, orthopedic surgeons reposition the pieces of your fractured bone surgically so that your bones are back in their proper alignment. In a closed reduction, a doctor physically moves the bones back into place without surgically exposing the bone. **Nerve block better choice for pain management vs opiods What are you concerned about: worried about pain, infection, ROM, ADLs can use PCA, Thromboembolism heat, ice after surgery to help manage pain, PT/OT for ROM & ADL, heparin, compression stocking Hip Fracture: Assessment and Diagnosis ◼ Assessment ◼ Extreme pain prevents movement ◼ Muscle spasm ◼ Severe pain & tenderness ◼ Interprofessional Care ◼ Surgery-standard of care ◼ Femoral Nerve Blocks ◼ Bucks Traction 24-48 hours Traction- monitor skin integrity pulling it in a direction ▪ Skin or skeletal ▪ The pic is an example of skin traction. Skeletal transaction is when a rod is placed into the bone. ▪ weight needs to dangle freely ▪ Buck’s traction maybe used before surgery (picture) Uses of traction: ▪ Reduce pain ▪ Improve alignment (based on angulation) ▪ Reduce the fracture - meaning remove the angle and make it straight → the two segments at the point of break are facing each other at an angel, so when you “reduce”, you’re reducing that angle (i.e. making it straight) ▪ Promote active & passive exercise ▪ Expand a joint space ▪ Complications? Soft tissue damage from ends of bone Traction Principle of traction ▪ Balanced suspension skeletal traction. ▪ Most commonly used for fractures of the femur, hip, and lower leg. ▪ Maintained continuously ▪ Weights hanging freely ▪ Have countertraction ▪ Weights moving freely- this helps them do their job ▪ Keep the weights off the floor Hip Fractures: Collaborative Management ▪ Surgery is the treatment of choice: ▪ Open Reduction Internal Fixation (ORIF) ▪ “Open reduction” means a surgeon makes an incision to re-align the bone. “Internal fixation” means the bones are held together with hardware like metal pins, plates, rods, or screws. After the bone heals, this hardware isn’t removed. ▪ Hospital 3-4 days → rehab ▪ Type of surgical procedure depends on ▪ Type of injury ▪ Condition of the person ▪ Preexisting orthopedic conditions ▪ With acute or chronic disease risk of surgery may be too great ▪ Medical management may be the preferred course Care of the Patient after Hip Fracture Repair ◼ Assessment ◼ A, B, C (Airway, Breathing, Circulation) ◼ incentive spirometry ◼ General nursing care of post-op patient ◼ Neurological assessment -5Ps ◼ Pain / Pallor / Pulses / poikilothermic / Paralysis / Paresthesia ◼ Pain Assessment ◼ Skin Assessment ◼ Body Alignment ◼ Ambulation ◼ DVT prophylaxis- SCD (sequential compression devices) and ambulation ◼ Provide analgesic before the first time out of bed. ◼ Education for return to home ◼ Limited weight bearing ◼ PT/OT referrals Case Study: Mrs. Davis -- Post-op Post-op orders include: ▪ Lactated Ringers at 100 ml/hr ▪ Morphine 4 mg IV every 4 hours as needed for pain ▪ IV famotidine 20 mg every 12 hours due to GI distress post op (FOR GERD) ▪ Cefazolin 1 g. IV q. 8 h. X 3 doses. (Antibiotic) She has quite a bit of hip and back pain in the immediate post-op period, leading to maximum doses of morphine, becomes restless and confused with hallucinations, particularly in the evening. Evaluation by her medical MD leads to discontinuing IM morphine, replaced with hydrocodone/acetaminophen 5 mg./325 mg. ) 1 or 2 tabs every 4 to 6 hours as needed for pain. Her IV famotidine is converted to the oral route and she is started on risperidone (t/x mood disorders) 3 mg. daily for confusion and hallucinations. Her aspirin and furosemide are restarted on the second day. -Pt appears to have delirium; related to the opioids given. Case Study: Mrs. Davis -- Post-op Mrs. D finally starts on PT on day 3 of the admission but complains of dizziness and lightheadedness, almost resulting in a fall. She is found to be hypotensive so her diuretic therapy for hypertension is discontinued. On day 4 of her admission, she is making progress in PT but is complaining of constipation. Review of her intake/output shows that she has not had a bowel movement since surgery; evaluation of her medications shows that she has an order for docusate 100 mg. daily, which started on day 3 when she began taking oral medications. **PT should begin day 1; ask for different stool softener since the docusate isn't working Case Study: Mrs. Davis -- Post-op How can the following issues be best managed? ▪ Pain ▪ Constipation ▪ Hypotension - sit on the side of the bed before getting up ▪ Reduced functional mobility ▪ Assistance required for self-care ▪ Nutrition - good nutrition leads to good healing ▪ Plan for discharge Total Hip Replacement: Hip Precautions ▪ Do not stand or sit for long periods ▪ Do not flex hips more than 90 degrees at hips ▪ Abduction pillow – for posterior approach in hip replacement - keeping the knees apart bc one of the ways you can dislocate the hip is by bringing the knees together or bending too much ▪ Avoid internal rotation ▪ patient should have a raised toilet seat - reduces the risk of the dislocating the hip after surgery - after every dislocation, the pt is more likely to have another dislocation ▪ watch out for chairs, cars, couches that are low that can displace the hip post-op Monitor for Complications S/P Hip Fracture Surgery ▪ Assessment and prevention for common complications ▪ Post-op delirium ▪ Dislocation of the device - dislocation can occur from hyperflexion, internal rotation, or addaction ▪ Avascular necrosis - due to fracture; head of the femur can loose circulatory function and die off ▪ Infection ▪ Delayed healing – smoking cessation (nicotine delays bone union) ▪ Pulmonary Emboli and DVT – Heparin or low molecular weight heparin - prevents clots not cure ▪ Compartment syndrome – reduced circulation in an area due to edema ▪ pain, pressure, paralysis, paresthesia, pallor, pulselessness (check using doppler) ▪ Poor Alignment – dislocation of the prosthesis ▪ Infection ▪ Skin Alterations ▪ Hazards of immobility