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MedSurg I Musculoskeletal 2

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olanjones's version from 2016-11-01 01:32

Osteomyelitis

Question Answer
Bugs that are often responsibleStaphylococcus aureus, Staphylococcus epidermis, Escherichia coli, Mycobacterium tuberculosis, Neisseria gonorrheae, Pseudomonas, Salmonella, Fungi, mycobacteria
Invasion by indirect entry (from somewhere else in the body)Blunt trauma to growing bones (often of < 12 y.o. boys) – Commonly from long bones to pelvis and vertebrae
Direct Entry Cycle Steps1. Microorganisms enter area of bone with ↓ circulation
2. Microorganisms grow
3. ↑ pressure
4. Ischemia
5. Infection goes thru bone cortex and marrow cavity
6. Cortical revascularization
7. Necrosis
Sequestruminfected area of bone (surrounded by pus) which may enlarge and harbor organisms
Involucrumperiosteum that continues to have blood supply and forms new bone
Why is a sequestrum so dangerous?It is hard to reach (abx, WBC) making it hard to treat, It can move into the soft tissue (including brain & lungs)
I&D treatment of sequestrumdebridement may allow revascularization, allowing bone to heal (if not removed can become necrotic and may develop a sinus tract, resulting in chronic, purulent cutaneous drainage)
Acute vs ChronicAcute = infection of < 1 month duration, Chronic = infection that persists > 1 month or that has failed to respond to initial course of tx (can be continuous or intermittent)
Manis of Acute osteoHigh fever (or spiking fever), Nausea
Chills, Night sweats, Restlessness
Bone pain that is unrelieved by rest and worsens with activity
Restricted movement of affected part
Drainage from sinus tracts (late sign)
Manis of Chronic osteoConstant bone pain, swelling, tenderness, and warmth at site (systemic signs may be diminished)
Diagnostic studiesBone/soft tissue bx, Blood/wound cultures, Elevated WBC & ESR, Bone scan (gallium & indium), MRI, CT
Tx of choice for acute osteo without ischemiaIV abx via PICC or CVAD (4-6 wks to 3-6 mths) – cultures or bx should be performed prior to tx (delayed abx tx may require surgical debridement & decompression)
Abx often usedpenicillin, nafcillin (Nafcil), neomycin, cephalexin (Keflex), cefoxitin (Mefoxin), gentamycin (Garamycin), tobramycin (Nebcin), cefazolin (Ancef)
Alternative abx tx for chronicoral therapy with a floroquinolone (e.g. ciprofloxacin) for 6-8 wks may be prescribed instead of IV tx
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Osteomyelitis Surgical & Nursing

Question Answer
Augmentation to Surgical Debridement-Implantation of abx-impregnated bead chains, -Protection of limb/surgical site with cast or brace
-Suction irrigation system insertion into wound, -Intermittent or constant irrigation with abx
-Removal of orthopedic device (prosthesis), -Myocutaneous flap/skin/bone grafts
-Amputation of extremity, -Hyperbaric oxygen therapy (value of tx is controversial)
Long-term complications of osteoSepticemia, Septic arthritis, Pathologic fx, SSC, Amyloidosis (disease resulting from abnormal protein deposits)
Subjective Assessment DataMedications/IV drug use, Malaise/Weakness/Paralysis, Anorexia/Weight loss, Chills/Local tenderness, Pain with movement/Muscle spasms, Irritability/Withdrawal/Dependency/Anger
Objective Assessment DataHigh/Spiking Temp/Erythema, Diaphoresis/Restlessness, Restricted movement/Spontaneous Fx, Leukocytosis/↑ ESR, +blood or wound culture, Presence of sequestrum & involucrum
ND for osteoAcute pain, Impaired physical mobility, Ineffective therapeutic regimen/management
NI for Health Promtion/early detection*Control existing infections to prevent osteo
*Educate pts on local/systemic manis of osteo (S/S that should be immediately reported: bone pain, fever, swelling, restricted limb movement)
*Inform families in their role of monitoring pt’s health
NI for acute osteo-Pain assessment/intervention,
-Dressing management (dry sterile, wet-to-dry, NS or abx saturated)
-Immobilization/avoid excessive manipulation of affected area
-Bed rest (in early stages)/Avoid activites such as exercise or heat application
-Alignment and frequent position changes
-Exercise or uninvolved joints/muscles
Education points for Home CareProper management of VAD & Abx admin, Importance of abx completion (even if feeling better), Dressing changes, Infection is not contagious, Periodic home nursing visits to support/reduce anxiety
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Bone Tumor/Muscular Dystrophy

Question Answer
Bone tumor causesBone neoplasm, Metastasis from a primary site
Associated risks of bone tumorPathologic fx, Immobility hazards (falls, skin breakdown, atrophy), If metastatic tx is palliative (poor prognosis)
Characteristics of MSgenetic, progressive, involves symmetrical wasting of skeletal muscle (w/o neurological involvement)
Types of MS*Duchenne (onset <5 yrs, progressive weakness of shoulder/pelvis, unable to walk after 12 yr, resp failure in 20s, mental impairment)
*Becker (onset btwn 5-15 yrs, slower course of weakness than Duchenne, resp failure, may survive into 30s-40s
*Landouzy-Dejerine (onset <20 yrs, slowly progressive weakness of face, shoulder, foot dorsiflexion, deafness
*Erb (onset ranges early childhood to early adulthood, slow progressive weakness of shoulder and hip)
Tx for MSCorticosteroids can temporality halt progression but cannot stop it
Goals for MSPreserve mobility as long as possible, Maintain independence through exercise, PT, orthopedic appliances
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Osteoporosis

Question Answer
Stats28 million in US have some degree of osteoporosis
Osteoporosis is 8 times more common in women than men (↓ca++ intake, ↓bone mass, earlier bone reabsorption, pregnancy/breastfeeding depletes ca++, women live longer)
1 in 2 women & 1 in 8 men over 50 will sustain an osteoporosis related fx
Characteristicsporous bone, low bone mass, structural deterioration of bone tissue (chronic, progressive metabolic bone disease)
RFFemale/White or Asian/Small stature
FH/Early menopause/Oophorectomy
ETOH/Smoking/Sedentary lifestyle
Liver disease/Insufficient ca++ intake/Long-term corticosteroid use
Common sitesSpine, hips, wrist
ManisSudden strain, Fx, Back pain, Loss of height, Spinal deformation (“silent disease” no definitive early symptoms)
Diagnostic studiesHistory & PE, Bone mineral density (BMD), Quantitative US, DEXA (a type of BMD study)
Good Ca++ sourcesMilk and milk products, Green leafy vegetables, Seafood, Almonds, Hazelnuts
Poor Ca++ sourcesEggs, Beef, Poultry, Pork, Apple, Banana, Potato
Preventative measuresProper nutrition, ca++ & vit D supplements (high fluid intake to prevent kidney stones)
Weight bearing exercise (need PT & MD ok), Bed exercises
Quit smoking, ↓ETOH intake
Drug therapyERT (after menopause)
Calcitonin
Bisphosphonates (inhibit osteoclasts)
Selective estrogen receptor modulators (prevent bone loss)
Parathyroid hormone (prevents bone loss & promotes bone growth)
Calcitonincalcitonin salmon (Miacalcin), calcitonin salmon rDNA (Fortical)
Selective estrogen receptor modulatorraloxifene (Evista)
Bisphosphonatesetidronate (Didronel), alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva)
Parathyroid hormoneteriparatide (Forteo)
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Osteoarthritis & Rheumatoid Arthritis

Question Answer
Osteoarthritis Slowly progressive, Non-inflammatory disorder of the diarthrodial (synovial) joints - >90% of adults are affected by age 40 (<50 more men than women, >50 women twice as often as men)
RF OAEstrogen reduction at menopause, Genetic factors, Obesity, Joint over/under-use, Joint abnormalities (scoliosis or “double-jointed”)
Patho OArepair < destruction of joint, fissuring & eroding of collagen, thinning central cartilage, increased cartilage & osteophytes at joint margins -> uneven distribution of stress, ↓motion, secondary synovitis -> inflammatory changes (pain/stiffness)
Common Joints OAHip, Knee, PIP, DIP, Carpometacarpal, Metatarsophalangeal, Lower lumbar & cervical vertebrae
Manis OAAsymmetrical joint pain (relieved by rest in early stages, generally worsens with joint use), Morning stiffness that improves, Can tell the weather by pain, Crepitation, Joint nodes that may be red, swollen, & tender
Heberden’s nodesOsteoarthritis - Affect DIP joints (indicate osteophyte formation)
Bouchard’s nodesOsteoarthritis - Affect PIP joints
OA Diagnostic studiesBone scan, CT/MRI/X-ray, ESR, CBC
OA Primary Tx’sPain/inflammation management (often with ice, anti-inflammatories, opioids); Maintain & improve joint function (heat, movement may help reduce pain/stiffness; rest during acute inflammation – not to exceed 1 week)
Rheumatoid arthritisChronic & systemic, Autoimmune, Exposure to virus/bacteria which may lead the immune system to attack joint tissue; Inflammation of connective tissue and synovial joints; Periods of remission and exacerbation
Manis RASwollen/tender joints (both sides of body), Nodules develop at pressure points, Morning stiffness lasts > 1 hour or does not improve, Includes other systems: Integument (subcutaneous nodules), CV (Raynaud’s, anemia, dysrhythmias), GI (splenomegaly), General (lymphadenopathy, fever)
RA Primary TxMeds (cornerstone of tx): Anti rheumatics, Systemic corticosteroids, Biologic targeted therapy (infliximab), methotrexate (also a drug for chemo)
RA Diagnostic StudiesLabs - Rheumatoid factors, CBC, ESR, CRP, ANA; X-ray – evidence of joint space narrowing, bony erosion & deformity
Assessments for arthritisType, location, severity, frequency, and duration of joint pain/stiffness; Pain-relieving practices
ND for arthritisAcute & Chronic pain, Disturbed sleep pattern, Impaired physical mobility, Self-care deficit, Imbalanced nutrition: less than body requirements, Chronic low self-esteem
NI for arthritisHealth promotion (eliminate modifiable risk factors), Pain management, Patient and family teaching, Ambulatory & Home care interventions (environment modification/safety, sexual counseling)
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