Chap 18 Musculoskeletal System

7/30/2019 Chap 18 Musculoskeletal System

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Musculoskeletal System

Normal Changes of Aging

Significant alterations causing musculoskeletal changes in olderadults

o Human structure

o Function

o Biochemical

o Genetic patterns

Skeleton: Normal Changes of Aging

Two phases of bone loss in normal agingo Type I (menopausal bone loss)

Rapid

Affects women

Occurs first 5 to 10 years after menopauseo Type II (senescent bone loss)

Slower phase

Affects both sexes after midlife

Phases eventually overlap in women

Other conditions may alter signs of normal aging of skeleton

Bones becomeo Stiff

o Weakero Brittle

Changes in appearance are evident after the fifth decade.o Height most obvious

20 to 70 years of ageo Lose 1 to 2 cm in height every 2 decades

o Shortening of the vertebral column

Midlifeo Vertebral discs thin

Later yearso Decrease individual vertebrae height

Disproportionate size of long bones of the arm and legso Eighth and ninth decades

More rapid decrease in vertebral height

Osteoporotic collapse of the vertebrae

Shortening of the trunk with appearance of longextremities


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Additional postural changeso Kyphosis

o Backward tilt of the head for eye contact

Forward bent posture

Hips and knees in flex position

Muscles: Normal Changes of Aging

Muscle function varies with agingo Trainable into advanced age

o Muscle regeneration is normal as age progresses

Muscleo Mass

Sarcopenia by age 75o Strength

Slow decline Stamina decreased by age 50

Decreased 65 to 85% of midtwenties by age 80o Tone and tension

Decreases after age 30o Size

Decreases causing weakness

Type II muscle fiberso Faster contraction but more atrophy

Type Io Slower contraction and less atrophy

o Help maintain posture

o Help perform repetitive exercise s

o Shape

Distinct

More prominent

Routine daily activities keep the upper extremities functioningbetter than walking.

Joints, Ligaments, Tendons, and Cartilage: Normal Changes withAging

Cartilageo Hyaline cartilage (joint lining)

Normally lines joints

Erodes and tears with advancing age


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Causes bone to bone contacto Knee cartilage

Experiences normal wear and tear

Thins about .25 mm/yearo Discomfort and slow joint movement

o

Diminished joint lubricanto Nonarticular cartilage (ears and nose)

Grows throughout life

Ligaments, tendons, and joint capsuleso Lose elasticity

o Less flexible

o Joint ROM decreases

Risk factors for the older person

Metabolic Bone DiseasesOsteoporosis

o Most common metabolic disease

o Affects 50% of women during their lifetimes

o 20 million women and 8 million men diagnosed in the United

Stateso 3.8 million women receive adequate care

High risk factors for osteoporosis

o Increased age

o Female sex

o White or Asian race

o Positive family history

o Thin body habitus

Additional risk factors for osteoporosiso Low calcium intake

o Prolonged immobility

o

Excessive alcohol intakeo Cigarette smoking

o Long-term use of corticosteroids, anticonvulsants, or thyroid

hormones

Pathophysiology of Osteoporosis

Low bone mass


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Deterioration of bone tissue compromised bone strength riskfor fractures

Bone strength reflects integration of bone density and qualityo Bone density is grams of mineral per area or volume

o Bone quality is based on the

Architecture

Turnover

Damage accumulation

Mineralizationo Bone strength cannot be directly measured

o Bone mineral density (BMD)

o Replacement measure for bone strength

o Accounts for 70% of bone strength

Elder bone loss

o Normal BMD within 1 standard deviation of young adult meano Ostopenia BMD between 1 and 2.5 standard deviations below

the young adult meano Osteoporosis BMD 2.5 standard deviations below the young

adult mean

Decreased bone mass in older persono Failure to reach peak bone mass in early adulthood

o Increased bone resorption

o Decreased bone formation

Reduced BMDo Highly predictive of spinal and hip fractures

o Osteoporotic fractures affect 1.3 million per year in the United

Stateso Vertebrae fractures affect about 500,000 people per year

o Hip and wrist fractures affect about 260,000 per year

o One in five patients die within 1 year

o One third regain their prefracture mobility and independence

level

Classification of Osteoporosis

Primary osteoporosis

Type I (menopausal bone loss)

Type II (senescent bone loss)

Secondary osteoporosiso Hyperparathyroidism

o Malignancy


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o Immobilization

o Gastrointestinal disease

o Renal disease

o Drugs causing bone loss such as vitamin D deficiencies and

glucocorticoids

Menopausal Bone Loss

Before menopause, sex hormones protect from bone loss.

After menopauseo Overproduction of IL-6

Up to tenfold loss of bone mass

Resorption (loss of bone matrix) more than deposition(rapid bone growth)

Susceptible women close to age 70 can lose 50% of peripheral

cortical bone mass Cause of vertebral and Colles' fractures

Senescent Bone Loss

Decreased amount of bone during remodeling

Occurs in both sexes

Caused by aging

Decreased trabecular (cancellous) bone wall thicknesso Decreased osteoblast formation

o

Decreased bone mineral densityo Decreased rate of bone formation

o Cause of vertebral and hip fractures

Trajectory of Bone Loss for Women

Lower peak bone mass than men

Less in the "bone bank because of thinner bones

Lose bone mass with lactation

Rapid withdrawal from "bone bank" during perimenopause

Longer life span increases risk for osteoporosis Signs/symptoms usually absent

First sign is often a fracture

Osteomalacia

Metabolic disease

Inadequate mineralization of bone matrix

Usually a result of Vitamin D deficiency


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Pathophysiologic Mechanismso Three mechanisms cause

Vitamin D deficiency

Abnormal metabolism of vitamin D

Phosphate depletion

Pathophysiologic Process

o Volume of bone remains normal

o New bone replacement is soft osteoid versus rigid bone

o Deformities of long bones, spine, pelvis, and skull

Risk Factors for Osteomalaciao Primarily vitamin D deficiency

o Lack of exposure to ultraviolet radiation

o Poor dietary intake

o Older age

Inability to get outdoors Limited dietary intake of milk

Aging skin with less vitamin D production

Clinical Manifestationso Bone pain and tenderness varies

Generalized or localizedo Hips

o Pelvis

o Legs

o Ribso Vertebrae

o Fragile bones

Fractures occur with minor injuries

Difficult to differentiate from osteoporosis

Vertebral collapseo Changes in posture and height

Deformities (gibbus deformity, leg bowing)o Fatigue

Occurs easily

Causes unsteady gaito Muscle weakness with severe osteomalacia

Lack of vitamin D to muscle cell

Low calcium level

Low phosphorus level


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Vitamin D Metabolism

Step 1o Deficit occurs with inadequate intake or inadequate exposure

to suno Impaired absorption in small bowel

Postgastrectomy

Small bowel resection

Crohns disease

Step 2o Deficit occurs with

Severe liver disease

Certain drugso Phenytoin

o Barbiturates

o Carbamazine Step 3

o Deficit occurs with

Severe renal disease

Step 4o Deficit occurs with

Lack of calcitriol

Pagets Disease

Pagets disease (PD), or osteitis deformanso Chronic, localized bone disorder

o Unknown etiology in which

o Normal bone replaced with abnormal bone.o One or more skeletal lesions

Pelvis (68%) Vertebrae (49%)

Skull (44%) Femur (55%)o Occurs in men and women

o Affects those over 70 years of age

o Second most common bone remodeling diseaseo Affects 1 million to 3 million Americans

o Asymptomatic

o Serendipitous x-ray diagnosis for unrelated problem

Pagets Disease Pathophysiologyo Accelerated activity of abnormally large osteoclasts

o Resorbtion of bone at specific sites


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o Rapid bone formation inferior new bone structure

Less compact

Vascular

Prone to structural deformities, weakness, andpathological fractures

Etiology

o Unknown

o Viral particles, genetics, and hereditary factors implicated

Pagets Disease Clinical Manifestationso Determined by affected bone site(s)

o Bone pain most common symptom

Deep and aching with muscle spasms

Pagetic lesion site

Osteoarthritic joints (hips and knees)

Other sites with mechanical deformities bowing offemur or tibia

o Mobility impairments

Gait changes

Stress fractureso Bony growths

Spine kyphosis, cord compression, and paralysis

Skull enlargement, disfigurement of cranium CNScomplications

o Mental deteriorationo Dementia

o Headaches

o Tinnitus

o Vertigo

Skull interior growth cranial impingement hearingloss and visual changes

Jaw deformities dental problems (malocclusion)o Clinical manifestations can affect the quality of life of older

people.

Joint Disorders: Noninflammatory and Inflammatory Categories

Noninflammatory joint disease (osteoarthritis)o lack of synovial inflammation

o absence of systemic manifestations

o normal synovial fluid


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Inflammatory joint disease (rheumatoid arthritis, gout, andpseudogout)

o Synovial inflammation

o Systemic manifestations

o Abnormal or lack of synovial fluid

Noninflammatory Joint Disease: Osteoarthritis

Osteoarthritis Statisticso Most common form of arthritis in the United States

o Affects more than 50% of people > 65

o Leading cause of disability for > 65

o Chronic disease

o Women are affected more than men

o Severity varies from insignificance to major life disruption

o Nodal disease at middle age associated with knee OA in 60s

and 70so Predicts self-care abilities as older adult

o Aging alone does not cause this disease

o Other associated factors for OA include

Obesity

Overuse of a joint

Trauma

Cold climate

Primary or Idiopathic Osteoarthritiso No single, clear cause

o Group of similar disorders

o Involve complex biomedical, biochemical, and cellular

processeso Changes in several joints as a result of various causes

Secondary Arthritiso Secondary arthritis involves

An underlying condition

Trauma Bone disease

Inflammatory joint diseaseo Pathophysiology

Progressive erosion of joint articular cartilageo Formation of new bone in joint space

o Involved joints

Hands


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Weight bearing joints of the knees and hips

Central joints of the cervical and lumbar spine

How does this happen?

o Cartilage thins underlying bone (subchrondal

bone) is no longer protectedo

Cartilage not available to buffer Subchrondral bone becomes irritated degeneration of

the joint bone hypertrophy bony spurs (osteophytes)

growth and enlargement contours of the joint

Small pieces may break off (joint mice) irritate the

synovial membrane joint effusion limited movement

Clinical Manifestationso 90% of all people have x-ray evidence of primary osteoarthritis

in their weight-bearing joints by age 40.

o OA symptoms 40% of people with severe OA have pain

Most common symptoms

Early morning stiffness resolving in 30 minutes

Joint paino Occurs during activity

o Relieved by rest

With progressive diseaseo Pain may be present at rest

o Interrupt ion of sleep patternso Source of pain may be unknown, but it needs to be identified in

order to provide treatmento Joint involvement

Asymmetrical at first

Bony appearance of joints

Crepitus (a grating sound on movement)

Range of motion deficit

Muscle weaknesso Hands

New bone growtho Heberdens nodes (DIPdistal interphalangeal joint)

o Bouchards nodes (PIPproximal interphalangeal

joint)o Pain with active and passive motion


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o Joint damage + chronic pain + muscle weakness impaired

balance + decreased activity

Inflammatory Joint Disease

Rheumatoid arthritis (RA)o Most prevalent inflammatory arthritis of any age group

o Common in the elderly

o Incidence increases to age 80

o three-to-one ratio for women to men

o Course of the disease varies greatly

o Mild remitting disease

o Severe disability, joint deformity, and even premature death

Pathophysiologyo Rheumatoid arthritis

Chronic syndrome

Symmetric inflammation of the peripheral joints pain +swelling

Significant morning stiffness

General symptoms of fatigue and malaise

Unknown cause

o Unknown environmental factors trigger

autoimmune responseo Genetic predisposition

Susceptibility Severity of symptoms

o Long-term exposure to offending antigen converts

antibodies (IgG & IgM) synovial fluid + serum autoantibodies

(rheumatoid factors [RFS]) mild cell proliferation

neoplasmlike mass in synovium (pannus) bone spurts +

osteophytes scar tissue formation shortened tendons +

joints subluxation + contractures + joint damage

Clinical Manifestationso Course of RA

Slow and insidious

Acute process affecting several joints (polyarticular)

De novo development = first symptoms appear afterage 65

o Primary RA clinical manifestations

o Disabling morning stiffness


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Lasts more than an hour

Occurs after period of resto Marked joint pain especially in upper extremities

Severe redness

Swelling

Warmth of the soft tissue

o Subcutaneous nodules with advanced disease

Pressure areas on elbows or sacrum

Not attached to bone or underlying skino Nonspecific systemic symptoms

Fatigue

Malaise

Weight loss

Fever

Occur several weeks or months before typical jointsymptoms

o Symptoms cause

Severe pain on movement

Limitation of movement

Disrupted sleep patterno Systemic and nonarticular manifestations

Cutaneous manifestations: rheumatoid nodules, Sjgrenssyndrome

Ocular manifestations: episcleritis and scleritis Pulmonary involvement: pleurisy with effusion

Cardiac: pericarditis and myocarditis

Renal involvement

Feltys syndrome (neutropenia and splenomegaly)

Vasculitis

Gout

Statisticso Most common inflammatory joint disease in men > 25 years

o Peak onset

Males between 40 and 50 years of age

Women usually after menopauseo Prevalence in adults 2.6 to 8.4 per 1,000

o Older persons between 65 and 74 years of age

6 per 1,000 for the older female


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24 per 1,000 for the older maleo Gout is both misdiagnosed and underdiagnosed.

Pathophysiologyo Cause

Linked to purine metabolism and kidney function

Genetic abnormality of purine metabolism

Underexcretion of uric acido Serum urate levels > 7 mg/Dl leads to increased risk

of gouto Predisposing factors

Family history

High purine diet

Obesity

Drugs low urate renal clearance

o Alcoholo ASA

Decreased renal function

o Urate crystals deposit in peripheral joint pain + inflammation

+ destruction

Clinical Manifestationso First signs

Acute paino So severe older person cannot tolerate sheet or

blanket weighto Warmth + swelling metatarsophalangeal joint of big

toe

Mild attack = few hours

Severe attack = several weeks

Over time attacks continue affects other Jointso Other signs

General malaise

Fever

Chills accompany these painful joint symptoms

WBC and ESR elevation

Definitive diagnosis is urate crystals in synovial fluid

Chronic Gout (Tophaceous Gout)

Occurs 3 years to 40 years after initial attack


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o Persistent aching joints, soreness, and morning stiffness,

especially in hands and feet

Urate crystal deposits (tophi)o Cartilage

o Synovial membranes

o Tendons

o Soft tissue

Changeso Duration and severity of hyperuricemia

o Size varies

Irregular lumps

Swellings of the joints

o Size increases severe movement limitation + hands and

feet deformities

Pseudogout

Pseudogout or calcium pyrophosphate deposition disease (CPPD)o Familial

o Occurs in persons > 60 years

o Occurs in women > men

o Associated with history of hypothyroidism,

hyperparathyroidism, or acromegaly

Pathophysiology

o CPPD calcification of hyaline and fibrous cartilage(chondrocalcinosis) painful asymmetric inflammatorypolyarthritis

Clinical Manifestationso CPPD crystals form in large joint

o Similar goutlike nature with acute attacks of joint

o Knee joint commonly affected

o Other joints include the shoulder, hip, and elbow

Tendonitis and Bursitis Tendonitis and bursitis (rheumatism)

o Most common and least understood causes of musculoskeletal

paino Acute pain in joint area with soft tissue injury

o Caused by

Repetitive injury as a result of age, sports

Occupational injuries


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Bursitiso Irritation of subcutaneous tissue

o Inflammation of underlying bursae

o Acute bursitis

o Deep aching pain on movement of structure adjacent to bursae

Tendonitis

o Inflammation of tendon sheath (tenosynovitis)

Falls and the Older Person

Major health problem for older persons

Implications for medical AND financial outcomeso Most falls occur in home during normal routines

o Serious implications for older person

o Leading cause of accidental death in the United States

o

Seventh leading cause of death persons > 65 years in theUnited Stateso Deaths as a result of falls increases with age

o Serious problem need for ongoing prevention as part of

overall care of older person

The majority of fractures in older adults caused by falls

Most common fall-related injurieso Osteoporotic fractures of hip, spine, and forearm

Likelihood of sustaining a hip fracture increases with age Hip fractures cause the greatest number of deaths

After hip fractureo One quarter of older people remain in institution for at least a

yearo Many never return home

Falls and the Older Person

Prevention of falls is a key goal of gerontological nursing practices

o Recognize older persons who are at risk for fallingo Identify and correct fall risk factors

Improve balance, gait, and mobility

Improve functional independenceo Reduce or eliminate environmental factors that contribute to

fall risko Evaluate outcomes

o Revise plan as needed


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Hip Fracture

Occur in 1 in 3 women and 1 in 6 men who reach age 90

Causeso Low-energy trauma

o Occur in the home

o History of falls

o Unable to bear weight

Hip fractures include upper third of the femuro Intracapsular

Located within the joint capsule and are furthercategorized as femoral neck and subcapital fractures

Impair blood to femoral head avascular necrosis +nonunion fracture

o

Extracapsular Intertrochanteric (in the trochanter) and subtrochanteric

(below the trochanter)

Acute blood loss from the vascular cancellous bone

Assessmento Injured leg shortened

o Externally rotated

o Extreme pain prevents movement

Common nursing diagnoses of older persons Impaired physical mobility related to stiffness, pain, joint

contractures, and decreased muscle strengtho Defined as the state in which an individual experiences a

limitation of ability for independent physical movemento Major defining characteristics

Inability to purposefully move within the physicalenvironment

Limited range of motiono

Minor defining characteristics Decreased muscle strength

Less control

Inability to sit unsupported

Impaired coordinationo Related factors for impaired mobility include

Decreased strength and endurance

External devices, such as casts


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Acute or chronic pain

Acute pain related to progression of inflammationo Lasts less than 6 months

Chronic pain related to joint abnormalitieso Persistent for more than a 6-month period

Fatigue related to pain and systemic inflammation

Body image disturbance related to chronic illness, joint deformities,impaired mobility

Ineffective coping related to personal vulnerability in a situationalcrisis

Pharmacology and Nursing Responsibilities

Older person with musculoskeletal dysfunctiono Monitor physiological changes of aging

o

Monitor altered drug metabolism for Serious side effects

Drug toxicitieso Identify medications and doses

o Careful monitoring

Pharmacology and Nursing Responsibilities for Osteoporosis

Antiresorptive therapyo Preserves or increases bone density

o Decreases rate of bone resorption Classifications and special considerations

o Bisphosphonates (alendronate [Fosamax] and risedronate

[Actonel])

Inhibit osteoclastic activity

Decrease postmenopausal vertebral and nonvertebralfractures by 40 to 50%

Adverse gastrointestinal symptomso Esophageal irritation, heartburn

o Difficulty swallowing Do not take calcium with bisphosphonates interferes

with absorption

Selective estrogen receptor modulators (SERMs)o Provide benefits of estrogens without the disadvantages

o Raloxifene approved for postmenopausal prevention and

treatment of osteoporosis in womeno SERMS less effective than bisphosphonates


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Calcitonino Safe but less effective treatment for osteoporosis

o Decreases spinal fractures by up to 35%

Hormone replacement therapy (HRT)

Pharmacology and Nursing Responsibilities for Osteomalacia

FDA approved treatment for Pagets diseaseo Bisphosphates and calcitonin

Goal is to relieve bone pain and prevent progression of deformitieso Alendronate (Fosamax) given 40 mg daily for 6 months may

produce a prolonged remissiono Calcitonin (Miacalcin) by injection 50 to 100 units daily or 3

times a week for 6 months; repeat course can be given after ashort rest period

Treatment goal to remineralize the bone Vitamin D replacemento 50,000 to 100,000 U/day for 1 to 2 weeks

o Followed with daily dose of 400 to 800 U/day

older persons monitored for serum and urine calcium

Calcidiol and calcitriol for specific vitamin D deficiency

Older persons with osteomalacia need calcium intake (1,000 to1,500 mg/day)

Pharmacology and Nursing Responsibilities for Osteoarthritis No therapy will slow or halt progression

Current therapy directed at relief of pain and minimizing functionaldisability

Agents for pain relief for OA

Topical agentso Capsaicin nonprescription drug

o Prevent the reaccumulation of substance P (a

neurotransmitter) in peripheral sensory neurons

o Applied 2 to 4 times daily to affected area May cause heat or burning

Relief may require up to 4 to 6 weeks of applications

Systemic oral agentso Acetaminophen (Tylenol)

First line pharmacological therapy

Give up to 4 gm/day with minimal toxicity

Higher doses may cause liver damage


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Ceiling effect = increasing the dose does not increase theanalgesic benefit Use alone or as an adjunct to NSAIDs

o Nonsteroidal anti-inflammatory drugs (NSAIDs)

Most common treatment for pain and inflammation of OA

COX-2 inhibitors, a new category of anti-inflammatory

drugso Considered safe for the GI tract

o Side effects include renal impairment (see RA

section)

Adjuvant agentso Intra-articular agents

Corticosteroids valuable for synovial inflammationo Synovial effusion removed prior to injections

o Limited to 4/year in any one joint

Hyaluronic acid

o Normal component of the joint for lubrication and

nutritiono Decreased pain for longer periods than other intra-

articular therapieso Administered in series of 3 to 5 injections

Pharmacology and Nursing Responsibilities for RheumatoidArthritis

Prednisoneo Decrease inflammation rapidly

o Improve fatigue, pain, and joint swelling

o Usual dose is low (2.5 to 7.5 mg per day)

Minimal toxicity

Low doses take up to 10 years to produce osteoporosiso Good alternative if cannot tolerate other drugs

o Discuss long-term risk vs. benefit of steroids

NSAIDs

o Common drug category for RAo High doses required to relieve the inflammation in the elderly

toxic side effects

GI bleeding

GI perforation

Renal failure

COX-2 inhibitorso Safer for the GI track


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o Damaging side effects include renal impairment

o Vioxx withdrawn in 2004

Studies found increased myocardial infarction in olderpeople

o Celebrex to be used with caution

Lowest dose possible Short periods of time

Disease-modifying antirheumatic drugs(DMARDs)o Use after corticosteroid steroid failure

o Slow the rate of joint erosion and dysfunction

o Benefit if offered early in disease process

o Suppress lymphocyte destruction of the synovial membrane

Pharmacology and Nursing Responsibilities for Gout

Gout

o NSAIDs

o Oral colchicine loading

o Intra-articular steroid injections

o Systemic steroids

Pseudogouto NSAIDs

o Short course of oral corticosteroids

o Intra-articular corticosteroids for large joint involvement

Chronic gouto Colchicines (0.5 mg)

Decrease inflammation

May be given long term to reduce repeated attacks ofgout

Maximum dose lowered for elderly

Liver, renal, and bone marrow toxicity

If serum urate levels remain high, try other agentso Allopurinol, Probenemid, and Sulfinpyrazone

Prevent long-term complications by lowering serum uricacid blood level

Probenemid and sulfinpyrazone are uricosuric agents excretion of uric acid

Allopurinol is a uric acid synthesis inhibitor lowersformation of uric acid

o More versatile than uricosurics and safe at all levels

of renal function


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Goal of therapy is to decrease serum urate levels to 6.5mg/d

Pharmacological Treatment of Bursitis

Treatment depends on cause

o Infection (gram-positive staph or strep, group A) oral

antibiotics

o Absence of microcrystalline disease and infection aspiration

of fluid injection of the bursal sac with corticosteroido Milder cases

Rest joint during acute phases of pain

Physical therapy

Braces or splints

NSAIDs

Nonpharmacological management

Selected Diagnostic Tests and Values for MusculoskeletalProblems

Bone mineral density test (BMD)o Dual energy x-ray absorptiometry (DEXA)

Proximal femur predicts hip fracture risk best

Gold standard for fracture prediction

Other sites tested include spine, wrist, or total bodyo Results

Compared with young adult mean

Or compared norm group of same age

BMD 1 SD below mean (-1 S) = osteopenia

BMD 2.5 SD below mean (-2.5 SD) = severe osteoporosis

Bone mineral density test (BMD)o Pitfalls

Bone changes also the result of arthritis or disk disease in

lumbar spine Arbitrary SD cutoffs to determine diagnosis

Results vary with technique and patient position

Current criteria based on postmenopausal white women

Bone and Joint Radiography

X-ray useo Diagnose and stage rheumatic diseases


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o Diagnose fractures

o Detect musculoskeletal structure, integrity, texture, or density

problemso Evaluate disease progression and treatment efficacy

Computed tomography (CT)/magnetic resonance imaging (MRI)o Visualize

o Inflammation

o Musculoskeletal changes

Synovitis

Edema

Bone bruiseso Occult fractures and articular damage

Computed tomography (CT)/magnetic resonance imaging (MRI)o Advantages

Uses a large magnet and radio waves to produce energyfield

Detailed image

Does not use radiation or a contrast mediumo Disadvantages

More expensive

Requires special facilities

Cannot show calcification or bone mineralization

Client hears soft to thunderous noises and may use

earplugs

Bone Scan

Detects skeletal trauma and disease

Determines degree bone matrix takes up radioactive isotope

Determines reason for an elevated ALP

Blood Serum Tests

Electrolytes: calcium level

Bone and muscle enzymes: alkaline phosphatase (ALP) Joint tests

o Rheumatoid factor (RF)

o Acute phase reactants

C-reactive protein (CRP)

Erythrocyte sedimentation rate (ESR)o Serum uric acid (SUA)


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Special considerationso Electrolytes: serum calcium and phosphorus decreased in the

older persono Calcium

Increased in Pagets disease, with bone fractures, andwith immobility

Decreased in osteoporosis and osteomalacia

Serum calcium (normal range older adult 8.8 to 10.2mg/dl)

o Phosphorus

Phosphorus (normal range for older person > 60 = 2.3 to3.7 mg/dl)

Increased in bone fractures and healing state

Decreased in osteomalaciao

Serum Uric Acid (SUA) Diagnosis of gout is not established unless SUA is found in

tissue or synovial fluid

Rheumatoid factoro Antibody (IgM, IgG) binds to Fc fragment of immunoglobin G

o RF negative early stages of the disease

o 70 to 80% of patients with RA will become RF positive

o High RF (positive RF high titers 1:320) predictive

Disability

Extra-articular diseaseo RF elevated in other diseases such as liver, lung, and other

conditionso RF not diagnostic but with clinical assessment confirms

diagnosiso RF does not change rapidly, need not repeat test if titer is high

Acute phase reactants C-reactive protein (CRP) and erythrocytesedimentation rate (ESR)

o Erythrocyte sedimentation rate

Most common measurement of acute phase proteins inrheumatic disease

Direct relationship to acute phase proteins

Results in 1 houro C-reactive protein

Acute phase reactant determines presence ofinflammatory process

o Bacterial infection or rheumatic disease


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Increases and returns to normal quicker than ESR

Alkaline phosphatase (ALP)o Enzyme associated with bone activity

o Normal values: men = 45 to115 U/L, women = 30 to 100 U/L

o Values increase after age 50

o

Identify increases in osteoblastic activity and inflammatoryconditionso Elevated with Pagets disease (> 5x normal)

o Isoenzymes ALP1 (liver origin) and ALP2 (bone origin)

determine if elevation is bone disease

Synovial Fluid Analysis

Based on visual inspection of the synovial fluido Appearance

o Volume

o Cellular contents

4 classificationso I = clear

Noninflammatory

Low WBC (< 1,000/ul)

Associated with osteoarthritiso II = transluscent

Inflammatory

Moderate WBC (2,000 to 20,000 /ul) Associated with diseases such as rheumatoid arthritis

4 Classificationso III = opaque

Purulent

WBC (more than 100,000/ul)

Infectiouso IV = bloody

Bloody fluid from a traumatic event

Other factorso Groups II to IV should be cultured for infection

o Examine for monosodium urate crystals (MSU, gout) and CPPD

crystals (MSU crystals mandatory )

Establishing gout diagnosis

Diagnosis of acute arthritis


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Lifestyle Changes

Increase in exercise

Weight loss

Eating healthy diets

Healthy People 2010 (www.health.gov/healthypeople)o

Nations goals and objectives for improved healtho Includes an objective for arthritis patient

Nonpharmacological treatment of osteoporosiso Assessment of risk factors

o Education about prevention

Older persons with risk factors

Diagnosis of osteoporosis = bone density of -2 SDo Education about positive lifestyle changes

Diet, exercise, and other risk modifications Assessment/Prevention of Risk Factors for Osteoporosis

o National Osteoporosis Foundation recommendations

Educate all women about osteoporosis risk factors

Women with fracture history BMD test to determineosteoporosis diagnosis

BMDo Any woman under 65 with risk factors for

osteoporosis

o all women over 65 Preventive activities for older men

o Many risk factors same for men

o Most men have bigger bones than women so they

have increased protection

Lifestyle Modification Activities to Prevent or Treat Osteoporosiso Promote diet with adequate calcium and vitamin D

o Encourage weight-bearing exercise

o Reduce or eliminate smoking

o Reduce or eliminate consumption of beverages containingalcohol, caffeine, and phosphorus

Nonpharmacological treatment of osteomalaciao Space activities to conserve energy

o Monitor safety measures for the home

o Evaluate home hazards


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Nonpharmacological treatment of osteoarthritiso Nonpharmacological strategies are applicable to most types of

arthritiso Individualize to older persons needs

o Educate the older person about the disease

o Weight reduction to decrease stress on joints

o Exercise to relieve pain and stiffness (and many other benefits)

o General and specific rest as needed to control symptoms

o Use canes, crutches, and walkers to protect joints

o Use assistive technology to help with functional ability

o Surgical intervention may include joint replacement (hips and

knees)

Prevention and Treatment of Osteoarthritis

Factors to prevent progression of diseaseo Weight loss as indicated

o Regular exercise may enhance joint health

o Rest may ease pain and relieve fatigue for painful joints

Weight losso Single most important risk factor for OA that can be modified is

obesity

Exerciseo Joints depend on surrounding muscles for

Strength

Joint protection

Weight bearing

o Muscle disuse atrophy weakness, falls, and mobility

limitations

Resto General rest

o Adequate seep at night

o Rest periods to prevent excessive fatigue common with

inflammatory conditions Short periods to prevent stiffness

Specific times

Proper positioning

Limit to prevent disuse of prolonged immobility

Additional Nonpharmacological Strategies


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Additional nonpharmacological strategies to enhance comfort withOA or RA

o Apply heat to painful joints

o Use cold applications to reduce pain and swelling

o Use canes, crutches, and walkers to protect joints

o Use assistive technology

Maintain, increase, or improve function

Commercial purchase or custom made

Available for general daily living, home management,school, and work activities

Nonpharmacological Treatment for Rheumatoid Arthritis

Nonpharmacological treatment for RA is focused ono Reducing joint stress

o

Maintaining joint functiono Promoting independence

o Managing fatigue

Long rest periods morning and afternoon

o Strength training reverse muscle wasting

Teaching Guidelines for Patient and Family for RAo Education to prevent cure myths or other inappropriate

treatment include

Contacting Arthritis Foundation

Visiting government websites for information Talking with nurse regarding efficacy of advertisements

for RAo Exercise and positioning to prevent contractures, muscle

weakness, and atrophy include

Doing full ROM daily

Participating in an exercise program

Encouraging patient activity

Avoiding positions of deformity

o Rest to reduce joint stress during times of inflammation include Resting the painful joint

Weight reduction

Splint specific joints (fingers, hands, wrist, etc.)

Use larger stronger joints when possibleo Encourage rest periods to prevent fatigue

Plan rest periods in morning and afternoon


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Whole body rest is needed to reduce inflammatoryresponse

o Minimize functional limitations with assistive devices

Use equipment that will enhance self-care abilities

Modify environment to ensure social activities

Find tools that allow leisure activities

Nonpharmacological Treatment to Prevent Falls and Fall-Related Injuries

Assess for risk factorso Changes in vision, balance, judgment

o Cardiovascular problems

o Medications

o Urinary incontinence

o Other physical conditions

Assessment of functional mobility offers valuable clues to fall risk

o Gait

o Balance

o Position changes

Educate to get up from a fallo Turn over on the stomach and crawl on all fours

o Scoot on the bottom or side to reach a phone

o Crawl to a stairway and climb up until able to stand

o If injury does not allow movement, cover self to stay warm

Nursing management principles related to the nursing care of olderpatients with arthritis.

Treatment of Hip Fractures

Immobilize immediately to prevent further damage

Surgery is the treatment of choice

Type of surgical procedure depends ono Type of injury

o Condition of the persono Preexisting orthopedic conditions

With acute or chronic disease risk of surgery may be too great medical management may be the preferred course

Treatment of Hip Fractures

Fracture Type Surgical Procedure


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Nondisplaced subcapitaland femoral neckfractures

Internal fixation with multiplepins

Displaced fractures ofsubcapital and femoral

neck

Open reduction internalfixation (ORIF)

ORIF for active and weight-bearing elders

Moores prosthesis for lessactive person

Total hip replacement withpresence of severe arthritis

Intertrochanteric andsubtrochanteric femoralfractures

Sliding compression screw andside plate

Nursing care of the older person with THR or internal fixation of thehip

o Assessment and prevention for common complications

Dislocation of the device

Avascular necrosis Infection

Delayed healingo General nursing care of postop patient depends on specific

surgical procedure

Documents

Chap 18 Musculoskeletal System