PCC II Notes 030617 1 PDF

Preview

Summary

Lecture Notes ...

Description

PCC II Notes 030617 Muscoskeletal- Osteoarthritis, Fractures, Gout Osteoarthritis o Characterized by progressive deterioration of the articular cartilage.  Noninflammatory (unless localized)  Nonsystemic disease. o New tissue is produced as a result of cartilage destruction within the joint. The destruction outweighs the production. o Narrowed joint spaces result and this leads to  Pain  Immobility  Muscle spasms  Potential inflammation  Risk Factors o Primary vs. Secondary  Age (majority of adults over age _____ have joint changes on xray)  Women have higher incidence of OA than men  Obesity  Smoking  Possible genetic link  History of repetitive stress on joints (manual laborers, professional athletes, marathon runners)  Clinical Manifestations o Joint pain and stiffness that _____________ with rest or inactivity o Pain occurs mostly ___________ in the day on weight bearing / nonweight bearing joints. o Pain with joint palpation or range of motion o Limp when walking o Restricted activity due to pain (self-care, ADL’s deficits) o Crepitus o Heberden’s nodes enlarged at the distal interphalangeal (DIP) joints o Bouchard’s nodes located at the proximal interphalangeal (PIP) joints o Inflammation resulting from secondary synovitis o Joint effusion o Vertebral radiating pain  Radiating pain  Stiffness  Muscle spasms  Laboratory Tests & Diagnostic Procedures o Osteoarthritis without synovitis is not an inflammatory disorder o Erythrocyte sedimentation rate (ESR) and high-sensitivity C-reactive protein







o Radiographs, CT, and magnetic resonance imaging (MRI) can determine structural changes within the joint (decreased joint space, bone spurs). Patient-centered care o Assess & Monitor  Pain – location, characteristics, quality, severity  Degree of functional limitation  Levels of fatigue and pain after activity  Range of motion  Occupation  Ability to perform ADLs  History of obesity o ASK….  Stiff? How long? Where?  Which joints are swollen?  What is done to control the pain or stiffness? Medications o Acetaminophen (Tylenol)  Does not provide anti-inflammatory benefits, which may not be needed if synovitis is not present  Nursing Action  Limit administration of acetaminophen to a maximum of 4,000 mg/24 hr.  Monitor liver function tests.  Monitor for other preparations of acetaminophen o Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) o Analgesics and anti-inflammatories (celecoxib [Celebrex], naproxen [Naprosyn], ibuprofen [Motrin, Advil]) that are used to relieve pain and synovitis if present o May replace acetaminophen with an NSAID if adequate relief is not obtained o Nursing Actions  Monitor __________________________.  Educate the client that NSAIDs _________________________________________.  Teach the client to report __________________________________________ Medications o Topical  Lidoderm Patches  Up to three per 12 hr period  Apply to intact skin  Contraindicated for class I antiarrhythmics  Trolamine salicylate (Aspercreme)  may provide varying amounts of temporary pain relief, depending on client response.

Apply topically over the area of involvement. It contains salicylate.  Capsaicin (Axsain, Capsin)  may provide varying amounts of temporary pain relief .  Apply topically over an area of involvement. analgesics  Glucosamine and Chondoitin  Do not take if HTN  Read drug labels of all formulations to prevent overdose  Supplements show inconsistent results for effectiveness  Question clients about concurrent use of chondroitin, NSAIDs, heparin, and warfarin Intra-articular injections o Glucocorticoids are used to treat localized inflammation. o Hyaluronic acid (Hyalgan, Synvisc) is used to replace the body’s natural hyaluronic acid, which is destroyed by joint inflammation. o Client Education  Hyaluronic acid – Instruct the client to notify the provider if allergic to birds, feathers, or eggs because this medication is made from combs of chickens Nursing interventions o Balance rest with activity. o Instruct the client on proper body mechanics. o Encourage the use of thermal applications: ______ to alleviate pain and _____ for acute inflammation. o Complementary and alternative therapies, including acupuncture, tai chi, hypnosis, magnets, and music therapy. o Splinting for joint protection, and the use of larger joints. o Use of assistive devices to promote safety and independence, including ___________, __________________, __________________, & ________________________ o Daily schedule of activities that will promote independence (high-energy activities in the morning). o Well-balanced diet and ideal body weight. Consult a dietitian to provide meal planning for balanced nutrition. o Please visit Chart 18-6 Improving Mobility -Interdisciplinary Collaboration o Physical therapy services can provide  muscle strengthening exercises  application of heat  diathermy (treatment with electrical currents)  ultrasonography (treatment with sound waves)  stretching and strengthening exercises.  ambulation aids o A nutritionist  weight loss or control in relation to reduced activity level. 

















o Occupational therapy services  ADL’s o Conservative Measures: includes balancing rest with activity, using bracing or splints, cane, medication, and applying thermal therapies (heat or cold) Arthroplasty o When all other conservative measures fail, a total joint arthroplasty can relieve the pain and improve mobility and quality of life. Total Hip Arthroplasty and Total Knee Arthroplasty o Total hip arthroplasty  Involves the replacement of the acetabular cup, the femoral head, and the femoral stem o Hemiarthroplasty  Refers to half of a joint replacement. o Total knee arthroplasty  Replacement of the distal femoral component, the tibia plate, and the patellar button. o Unicondylar knee replacements  Done when a client’s joint may be diseased in one compartment of the joint. Client Presentation o Pain when bearing weight on the joint (walking, running) o Joint crepitus and stiffness o Joint swelling (primarily occurs in the knees) o Goal: The goal of both hip and knee arthroplasty is to ___________ pain, ____________ joint motions, and ___________ a client’s functional status and quality of life. Contraindications o Recent or active infection (urinary tract infection) can cause microorganisms to migrate to the surgical area and cause the prosthesis to fail o Arterial impairment to the affected extremity o The client’s inability to follow the postsurgery regimen o A comorbid condition  Uncontrolled diabetes mellitus or hypertension  Osteoporosis  Progressive inflammatory condition  Unstable cardiac or respiratory conditions Diagnostics o CBC, urinalysis, electrolytes, BUN, creatinine – Assess a client’s surgical readiness, and rule out anemia, infection, or organ failure. o Epoetin alfa may be prescribed preoperatively to increase Hgb. o Chest x-ray – Rule out pulmonary surgical contraindications (infection, tumor). o ECG – Gather a baseline rhythm to identify cardiovascular surgical contraindications (dysrhythmia).









o XRAY, MRI and CT of the affected joint Client Education o Postoperative care  incentive spirometry  transfusion  surgical drains  dressing  pain control  transfer  exercises  activity limits o Autologous blood donation o Scrubbing of the surgical site with a prescribed antiseptic soap the night before and on the morning of surgery o Wearing clean clothes and sleeping on clean linens the night before surgery o May take antihypertensive medication, as well as other medications that the surgeon allows with a sip of water the morning of surgery Arthroplasty Procedure o May use general or neuroaxial anesthesia o Removal and replacement of joint components with artificial components o Components may or may not be cemented in place. Components that do not use cement allow the bone to grow into the prosthesis to stabilize it.  Non-cemented prosthetics-Weight bearing is delayed several weeks until the femoral shaft has grown into the prosthesis Hip Arthroplasty-Complications o Provide postoperative care, and prevent postoperative complications.  Deep vein thrombosis may develop and result in a _____________________________________________________ _____________ o Monitor a client for symptoms of pulmonary embolism including _____________, ________________________, and __________________________ o Pharmacological management, antiembolic stockings, and sequential compression devices while in bed. o Plantar flexion, dorsiflexion, and circumduction exercises to prevent clot formation. o EARLY ambulation with physical and occupational therapy. o Other complications include hip dislocation, infection, anemia, and neurovascular compromise. o Clients who are obese, and those with a history of deep vein thrombosis, are also at a ________ risk for developing deep vein thrombosis or pulmonary emboli. Hip Arthroplasty-Complications o Monitor a client for bleeding.

Check the dressing site frequently, noting any evidence of bleeding. Monitor and record drainage from surgical drains. Monitor daily laboratory values, including Hgb and Hct levels. The client’s Hgb and  Hct may continue to drop 24 to 48 hr after surgery.  Autologous blood from presurgery donation or blood salvaged intraoperatively or postoperatively using special collection devices may be used for postoperative blood replacement. o Monitor the neurovascular status of the surgical extremity every 2 to 4 hr (movement, sensation, color, pulse, capillary refill, and compare with contralateral extremity) Hip Arthroplasty Medications o Provide medications as prescribed.  Analgesics  opioids (epidural, PCA, IV, oral), NSAIDs  Antibiotics  prophylaxis and postoperatively  Anticoagulant  low-molecular weight heparin, such as enoxaparin (Lovenox); warfarin (Coumadin), dalteparin (Fragmin), fondaparinux (Arixtra)  A continuous peripheral nerve block provides localized pain relief.  Monitor the client for systemic effects of local anesthetic, such as hypotension, bradycardia, restlessness, or seizure. Hip Arthroplasty Post Op Care o Transfer the client out of bed from his unaffected side into a chair or wheelchair. o The client’s weight-bearing status is determined by the orthopedic surgeon and by choice of cemented (usually partial/full weight-bearing as tolerated) versus non-cemented prostheses (usually only partial weightbearing until after a few weeks of bone growth). o Use assistive devices (walker) and adaptive devices (raised toilet seat) when caring for the client. o Apply ice to the surgical site following ambulation as a nonpharmacological measure to decrease pain and discomfort. o Use total hip precautions to prevent dislocation of the new joint. o Client position  Place the client supine with the head slightly elevated and the affected leg in a neutral position.  Place a pillow or abduction device between the legs when turning to the unaffected side.  The client should not be turned to the operative side, which could cause hip dislocation. o Monitor the client for new joint dislocation: acute onset of pain, reports hearing “a pop,” internal rotation of the affected extremity, and shortened affected extremity.   





 







Hip Precautions Knee Arthroplasty o A continuous passive motion (CPM) machine may be prescribed to promote motion in the o Knee and prevent scar tissue formation. o CPM is usually placed and initiated immediately after surgery. CPM provides passive range of motion from full extension to the prescribed amount of flexion. The prescribed duration of its use should be followed, but it should be turned off during meals. o Positions of flexion of the knee are limited to avoid flexion contractures. o Avoid knee gatch and pillows placed behind the knee. o To prevent pressure ulcers from developing on the heels, place a small blanket or pillow slightly above the ankle area to keep heels off the bed. Total knee Arthroplasty Medications o Provide medications as prescribed. o Focus needs to be about pain medications. This promotes client participation in early ambulation. o Analgesics  Opioids (epidural, PCA, IV, oral), NSAIDs o A continuous peripheral nerve block  Continuous infusion of local anesthetic directly into sciatic or femoral nerve o Antibiotics  Prophylaxis and postoperatively o Anticoagulant  Low-molecular weight heparin, such as enoxaparin (Lovenox); warfarin (Coumadin) Total knee Arthroplasty o Ice or cold therapy may be applied to reduce postoperative swelling. o Monitor a client’s neurovascular status of surgical extremity every 2 to 4hr (movement, sensation, color, pulse, capillary refill, and compare with contralateral extremity). o Assess a client frequently for overt bleeding and signs of hypovolemia, such as hypotension and tachycardia. o Monitor compression bandage and wound suction drain for excessive drainage. o Monitor the auto transfusion drainage system, if used, and reinfuse blood as prescribed by the provider. Client Education o The client requires extensive physical therapy to regain mobility. The client may be discharged home or to an acute rehabilitation facility. If discharged home, outpatient or home therapy must be provided. o Home care should be available for 4 to 6 weeks.

o Monitor for evidence of incisional infection (fever, increased redness, swelling, purulent drainage), and care for the incision (clean daily with soap and water). o Monitor for deep vein thrombosis (swelling, redness, pain in calf), pulmonary embolism (shortness of breath, chest pain), and bleeding if the client is taking an anticoagulant. o Hip arthroplasty  Follow position restrictions to avoid dislocation. Arrange for and instruct the client about the use of raised toilet seats, and care items (long-handled shoehorn, dressing sticks). o Knee arthroplasty  Dislocation is not common following total knee arthroplasty. Kneeling and deep-knee bends are, however, limited indefinitely Bone Fractures  Fractures  Break in a bone secondary to trauma or a pathological condition.  Trauma is the most common type of bone fracture.  Pathological fractures  metastatic cancer, osteoporosis, or Paget’s disease.  Bone is continually going through a process of remodeling as osteoclasts release calcium from the bone and osteoblasts build up the bone.  Remodeling of bone occurs at equal rates until an individual reaches their thirties.  In women, this process significantly increases following menopause.  Fractures  A closed, or simple, fracture  An open, or compound, fracture  Open fractures are graded based upon the extent of tissue injury.  Grade I – minimal skin damage  Grade II – damage includes skin and muscle contusions but without extensive soft tissue injury  Grade III – damage is excessive to skin, muscles, nerves, and blood vessels  Common Types of Fractures  Comminuted: Bone is fragmented.  Oblique: Fracture occurs at oblique angle and across bone.  Spiral: Fracture occurs from twisting motion  Impacted: Fractured bone is wedged inside opposite fractured fragment.  Greenstick: Fracture occurs on one side (cortex) but does not extend completely through the bone (most often in children).  Fracture Descriptions  Complete fracture  goes through the entire bone, dividing it into two distinct parts.  Incomplete  goes through part of the bone.  Simple fracture  has one fracture line

                                       

Comminuted fracture has multiple fracture lines splitting the bone into multiple pieces. Displaced fracture has bone fragments that are not in alignment Non-displaced fracture has bone fragments that remain in alignment. Fatigue (stress) fracture results when excess strain occurs from recreational and athletic activities. Compression fracture occurs from a loading force pressing on callus bone. Risk factors for fractures Osteoporosis Excessive exercising and weight loss from dieting and malnutrition can lead to osteoporosis. Women who do not use estrogen replacement therapy after menopause lose estrogen and are unable to form strong new bone Clients on long-term corticosteroid therapy lose calcium from their bones due to ______________________________ ______________________________ Falls Motor vehicle crashes Substance use disorder Diseases (bone cancer, Paget’s disease) Contact sports and hazardous recreational activities (football, skiing) Physical abuse Lactose intolerance Age Clinical Manifestations Physical Assessment Findings Crepitus: __________________ __________________________ Deformity: _________________ __________________________ __________________________ Muscle spasms:_____________ __________________________ Edema: ___________________ Ecchymosis: _______________ History Trauma metabolic bone disorders chronic conditions with possible use of corticosteroid therapy Subective Pain and/or reduced movement manifests at the area of fracture or the area distal to the fracture. Diagnostic Procedures Standard radiographs, computed tomography (CT) imaging scan used to detect fractures of the hip and pelvis, and/or magnetic resonance imagery (MRI) Identify the type of fracture and location.

     

                            

Indicate pathological fracture resulting from tumor or mass. A bone scan Emergent Patient Centered Care Provide emergency care at time of injury. Maintain ABCs. Monitor the client’s vital signs and neurological status because _________________________ ________________________________________________________________ _____________ ________________________________________________________________ _____________ Stabilize the injured area, including the joints above and below the fracture, by using a splint and avoiding unnecessary movement. 1. 2. 3. 4. Maintain proper alignment of the affected extremity. Elevate the limb above the heart and apply ice. Assess for bleeding and apply pressure, if needed. Cover open wounds with a sterile dressing. Remove clothing and jewelry near the injury or on the affected extremity. Keep the client warm. Emergent Patient Centered Care Assess pain frequently and follow pain management protocols, both pharmacologic and nonpharmacologic. Initiate and continue neurovascular checks at least every hour. Immediately report any change in status to the provider. Prepare the client for any immobilization procedure appropriate for the fracture. Fracture Immobilization Types of Immobilization Devices Casts Splints/immobilizers Traction External fixation Internal fixation Reduction Closed reduction when a pulling force (traction) is applied manually to realign the displaced fractured bone fragments. Once the fracture is reduced, immobilization is used to allow the bone to heal. Open reduction when a surgical incision is made and the bone is manually aligned and kept in place with plates and screws. This is known as an open reduction and internal fixation (ORIF) procedure Splints and immobilizers

        

                

 

Splints and immobilizers provide support, control movement, and prevent additional injury. Removable and allow for monitoring of skin swelling or integrity. Used to support fractured/injured areas until casting occurs and swelling is decreased. Immobilizers are prefabricated and typically fasten with Velcro straps. Client Education Application protocol regarding full-time or part-time use. Observe for skin breakdown at pressure points. Neurovascular assessment Pain – Assess the client’s pain level, location, and frequency. Assess pain using a 0 to 10 pain rating scale and have the client describe the pain. Immobilization, ice, and elevation of the extremity with the use of analgesics should relieve most of the pain. Sensation – Assess the client for numbness or tingling sensation of extremity. Loss of sensation may indicate nerve damage. ...