What can go wrong with bones? They can become infected Osteomyelitis They can become soft with decrease in mineralization Osteomalacia They can

What can go wrong with What can go wrong with bones? bones?

They can become infected Osteomyelitis

They can become soft with decrease in mineralization Osteomalacia

They can become porosis Osteoporosis

They can develop abnormal remodeling andfunctioning of osteoblasts & osteoclasts Pagets

OsteomyelitisOsteomyelitis A severe infection of the:

bone bone marrow surrounding connective tissue

Most common causative organism is Staphylococcus aureus

OsteomyelitisOsteomyelitis

How does a person get an How does a person get an infection?infection?

Indirect Entry

Direct Route

Development of Development of OsteomyelitisOsteomyelitis Bacteria invade bone - inflammation

Edema develops and Pressure within bone increases

Bone abscess develops under the periosteum causing a decrease in blood supply with ischemia and bone necrosis. The dead bone tissue, called sequestrum

The abscess cavity does not liquify or drain easily.

The separated periosteum stimulates new bone growth = involcrum which surrounds the sequestrum.

Infection trapped inside sequestrum causing recurring abscesses.

Classification of Classification of OsteomyelitisOsteomyelitis

Acute Chronic

Clinical Manifestations of Clinical Manifestations of OsteomyelitisOsteomyelitis

Systemic

Local

Signs of Chronic Signs of Chronic OsteomyelitisOsteomyelitis

Chronic – an infection that persists for longer than 1 month

Signs and Symptoms

Constant bone pain Swelling Tenderness Warmth at site Continuous Drainage

Osteomyelitis Osteomyelitis DiagnosisDiagnosis

Biopsy of bone or soft tissue Cultures – blood and wound assessing for causative

organism Erythrocyte sedimentation rate (ESR) – elevated WBC - elevated X-ray, no initial bone changes Radionucleotidetide bone scan MRI

What test is the best way to determine the causative organism?

Goals of Care

Halt the InfectionRelieve Pain

Maintain Mobility

Halt the InfectionHalt the InfectionIntravenous AntibioticsIntravenous Antibiotics

Patient will need vigorous and prolonged treatment with antibiotics

Start out in hospital with aggressive antibiotic therapy usually via PICC.

Discharged to home with home health care follow up for up to 6 months

Patient taught care of PICC site and side effects of antibiotics.

OsteomyelitisOsteomyelitis

Assorted IV antibiotics Penicillin, nafcillin (Nafcil) neomycin, vancomycin cephalexin (Keflex), cefazolin (Ancef) cefoxitin (Mefoxin) gentamycin (Garamycin)

Oral Antibiotics ciprofloxacin (Cipro)

Nursing CareNursing Care Toxic effects:

Aminoglycosides - Nephrotoxic, ototoxic, optic neuritis, fluid retention • Renal function tests (creatinine and BUN) should be

done prior to administration and during therapy – therapy depends on test results.

• Vestibular and auditory function are assessed prior to therapy and again 3-4 weeks after drug discontinued.

Cephalosporins and Quinolones – jaundice, colitis,

photosensitivity, crystalluria• C&S prior to beginning treatment

Nursing Care / Patient Nursing Care / Patient TeachingTeaching

Measure peak and trough levels Dosages are adjusted to maintain peak levels

Preventive measures: Monitor I& O; Keep patient well hydrated to

prevent nephrotoxicity or crystalluria Avoid direct sunlight, wear sunscreen Monitor urinary function, hearing, vision Assess for signs of yeast infections in

genitourinary and mouth

Relieve the PainRelieve the Pain

Immobilization of the affected limb

Handle carefully , decreasing manipulation

Give meds NSAID’S Opioid analgesics Muscle relaxants

Maintain MobilityMaintain Mobility

After the initial treatment and decrease of pain, need to make sure that limb mobility is maintained ROM Assist to stand and ambulate Provide assistive devices to help with

ambulation

Surgical Treatment and Surgical Treatment and Nursing CareNursing Care

Debridement of the wound Insertion of antibiotic-impregnated

polymethylmethacrylate bead chains to combat the infection

Irrigation of wound with antibiotics

Wound vac used to draw wound together – assess wound and drainage

Treatment and Nursing Treatment and Nursing CareCare

OsteomyelitisOsteomyelitis Hyperbaric oxygen therapy – stimulates

circulation and healing of infected tissue Bone grafts If all else fails – amputation Nursing Care – good body alignment,

ROM, dressing changes, patient teaching about

antibiotics and use of assistive devices, monitor patients response to antibiotic therapy.

Try ThisTry This

Which of these manifestations should cause the nurse the MOST concern after treating a patient with osteomyelitis for two days with IV antibiotics? A. Sudden increase in temperature B. Complaints of pain at site of infection C. Drainage from wound D. Guarding of involved extremity

Metabolic Bone Disease

OsteomalaciaOsteomalacia Decalcification and softening of the bone

Caused mainly by: vitamin D deficiency **Vitamin D is required for the

absorption of calcium from the intestine and calcium

is responsible for mineralization of bone

Vitamin DCalcium

OsteomalaciaOsteomalacia

Who is at risk for developing osteomalacia?

Someone with: lack of exposure to ultraviolet rays (sun) GI malabsorption, extensive burns,

chronic diarrhea, pregnancy, drugs such as Dilantin.

OsteomalaciaOsteomalaciaSigns and SymptomsSigns and Symptoms

Most Common Bone pain Difficulty rising from a chair Difficulty walking

Additional Signs and Symptoms Low back pain, muscle weakness Weight loss, progressive deformities

DiagnosisDiagnosis Blood work – how do each of these

tests assist in diagnosing Osteomalacia? serum calcium or phosphorus alkaline phosphatase

X-Rays Show looser's transformation zone – (ribbons of decalcification in bone)


OsteomalaciaOsteomalacia Medication Therapy Vitamin D supplements Calcium salts or phosphorus supplements

What would the nurse teach the patient to eat to increase vitamin D and calcium?

What is the purpose of weight bearing exercises? What are examples of weight bearing

exercises?

OsteoporosisOsteoporosis

Characterized by low bone mass and structural deterioration

Normal homeostatic bone remodeling is altered – the rate of bone resorption is greater than the rate of bone formation.

OsteoporosisOsteoporosis

Osteoporosis is more common in women than

men because?

DiagnosisDiagnosisBone Mineral Density Test Bone Mineral Density Test

(BMD)(BMD) Dual-energy x-ray absorptiometry

(DEXA)


Diet Therapy Encourage a diet high in calcium – see chart

p.1636.

Weight bearing Exercises ** Impact aerobics is NOT encouraged

Decrease Risk Factors Quit smoking and decrease consumption of

alcohol

Medications used in Medications used in Treatment of OsteoporosisTreatment of Osteoporosis

Estrogen Replacement Therapy Calcium & Vitamin D supplements Calcitonin Bisphosphonates (Fosamax, Didronel,

Actonel, Boniva, Aredia, Bonefos, Skelid) Selective Estrogen receptor modulator –

Evista

Medications used in Medications used in treatment of Osteoporosistreatment of Osteoporosis

Hormone Replacement Therapy – Estrogen Controversy over use. Should discuss with health

care provider Calcium

There is a variety of calcium supplements available (See Table 64-15, p. 1636). • They should be taken with Vitamin D to aid in

absorption. • Also if taking large doses i.e. 1000 mg. / day –

take in divided doses of 500mg BID for better absorption


Calcitonin A hormone made by the thyroid gland

that helps keep calcium levels in the body from getting too high. It does this mainly by blocking the breakdown (absorption) of bone, which slows the release of more calcium into the blood

What is needed to counter that effect?


Bisphosphonates – (Fosamax, Boniva) Inhibit osteoclast-mediated bone resorption thereby

increasing BMD and total bone mass.

Side effects – anorexia, weight loss, gastritis

Patient Teaching• Take on an empty stomach, in the morning, at least 30

minutes before any food, beverages or medications. • Do not take within 2 hours of any calcium- containing food• To decrease esophageal irritation - take with a full glass of

water, and the patient must remain upright for at least 30 minutes after taking the medication.


Selective Estrogen Receptor Modulators Mimic effect of estrogen on bone by

reducing bone resorption without stimulating the breasts or uterus.

Side effects•Leg cramps•Hot flashes

Paget’s DiseasePaget’s Disease

Excessive bone resorption followed by replacement of normal marrow by vascular, fibrous connective tissue.

The new bone is larger, disorganized, and weaker Most often affect the pelvis, long bones, spine, ribs, sternum, and cranium

Paget’s DiseasePaget’s Disease Clinical Manifestations

Bone pain Fatigue CV disease (vasodilation of vessels in skin/tissues

overlying affected bones) Waddling gait; bowing of legs; Hip or knee

involvement can lead to limping, as well as pain and stiffness of the hip or knee.

Headaches, visual deficits, loss of hearing occur as skull becomes enlarged and thickened

Enlarged vertebrae cause spinal cord compression/ pinch of adjacent nerves causing tingling and numbness.

Pagets DiseasePagets Disease

bowing of legs

skull becomes enlarged and thickened

Waddling gait

Hip or knee involvement

can lead to limping

Loss of hearing

Spinal cord compressed

Paget’s DiseasePaget’s Disease Diagnosis

Elevated serum alkaline phosphatase

X-ray will show increase in bone size

Will the bone return to normal size and shape following treatment?

Goal of Treatment

Relieve the Pain

Drug Therapy for Paget’sDrug Therapy for Paget’s

Human calcitonin (Cibacalcin) or Calcitonin-salmon (Miacalcin)

NSAIDS

Bisphosphonates

Paget’s DiseasePaget’s Disease

Other treatments and Nursing Care Back support by firm mattress Teaching about use of Splints or braces

to support bones and joints and help prevent weakened bones - skin care, circulation, etc.

Teach how to correctly use canes or walkers

Physical Therapy

Etiology and Etiology and Pathophysiology of Pathophysiology of

Rheumatoid ArthritisRheumatoid Arthritis Rheumatoid arthritis is an autoimmune disease. This means that the body's immune system mistakenly attacks the tissues it is supposed to protect.

RF antibodies are formed in synovium against body’s IgG antigens.

This leads to formation of immune complexes which cause inflammation of synovium –synovitis.

1. Synovitis causes release of WBC and enzymes which damage the bone and breakdown cartilage of the joint and the surrounding tissues.

2. Vascular granulation tissue grows across the surface of the cartilage (pannas) with loss of cartilage beneath the expanding pannas

12

Etiology and Etiology and Pathophysiology of Pathophysiology of

Rheumatoid ArthritisRheumatoid Arthritis3. Inflammatory pannus causes cartilage

destruction and bone erosion.

4. This leads to joint deformities.

Loss of Bone Density

Destruction of bone cartilage

Joint Deformity

Erosion o f edges o f

bone

Increased soft tissue swelling due to

Inflammation and thickening of synovium

3

Rheumatoid ArthritisRheumatoid ArthritisSigns and SymptomsSigns and Symptoms

Fatigue Anorexia Weight loss Generalized stiffness Joints are tender, painful,

and warm to touch Rheumatic nodules Multi-system involvement

Rheumatoid ArthritisRheumatoid ArthritisDeformitiesDeformities

BoutonniereBoutonniere

Swan neckSwan neck

SynotenovitisSynotenovitis

Ulnar Drift

Rheumatoid ArthritisDeformities

Mutlans deformity (rapidly progressing RA)

Hitch-hiker thumbGenu valgus (knee away from midline)

Hallux valgus (bunion)

Hammer Toe

Extraarticular Extraarticular ManifestationsManifestations

See page 1652 in Lewis

Nodules

Diagnostic TestingDiagnostic Testing Blood Studies

↑ Rheumatoid factor (RF) – 80% ↑ Erythrocyte sedimentation rate (ESR) ↑ C-reactive protein (CRP)

Synovial fluid analysis

X-rays Will not diagnosis – only show bone changes

Goals of CareGoals of Care

Control disease activity

Relieve pain

Maintain functionality and activities of daily living (ADLs)

Maximize quality of life

Treatment and Nursing Treatment and Nursing Care for Rheumatoid Care for Rheumatoid

ArthritisArthritis See Table 65-3 for meds used for arthritis p.

1646-1647. Salicylates NSAIDs Antibiotics Topical analgesics Corticosteroids DMARDs Gold compounds Antimalarials Immunosupressants Biologic/Targeted therapy

Drug TherapyDrug TherapyDisease-Modifying Antirheumatic Disease-Modifying Antirheumatic

DrugsDrugs

Methotrexate (Rheumatrex)is know as the cornerstone medication in treating RA –

explain.

What are the side effects?

What are important nursing implications?

Drug TherapyDrug Therapy Antimalarials – Plaquenil and Azulfidine Second choice of drug treatment

May suppress formation of antigens

Side effects: • Ocular toxicity - changes in vision, • Ototoxicity - changes in hearing or tinnitus, • Peripheral neuritis - muscular weakness

Nursing Care• Monitor CBC and hepatic function• Tell patient to report any above changes immediately

Drug TherapyDrug Therapy Gold Compounds

Parenteral – Myochrysine, Solganal Oral - Ridaural

Side effects:• Common - Stomatitis, dermatitis, photosensitivity,

proteinuria• Serious - Leukopenia, thrombocytopenia, anemia

Nursing Care:• Observe for pruritis, rash, sore mouth, metallic taste• Monitor CBC, UA

Drug TherapyDrug Therapy Immunosuppressant's – Imuran, Cytoxan

Used to decrease DNA. RNA, protein synthesis Assess for GI irritation Advise patient to report unusual bleeding or bruising Avoid during pregnancy

Biologic/ targeted therapy Used to decrease inflammatory process and slow disease

process Report persistent fever; it may be the only sign of an

infection. Assess for signs of CHF. The response to a PPD may be suppressed and a false

negative may result Giving a live vaccine could result in contracting disease

Relieve PainRelieve Pain NSAID’s

DMARD’s

Non-Pharmacological Heat or Cold applications Rest Relaxation techniques


Diet Therapy Rest Heat and cold applications Exercise Patient and Family Teaching Protection of joints – page 1658.

Causes of GoutCauses of Gout

Inflammatory response related to: increase in the production uric acid underexcretion of uric acid increase consumption of foods that

contain purines

Thereby causing high levels uric acid in blood (hyperuricemia)

Causes of GoutCauses of Gout Urate salts deposited in articular, periarticular and

subcutaneous tissue

Primary gout – related to heredity error of purine metabolism in 90% of cases

Secondary gout - to increased cell turnover and related to medications, diseases, leukemia, etc.

Clinical Manifestations of Clinical Manifestations of GoutGout

Stage 1: asymptomatic; hyperuricemic

Stage 2: acute gouty arthritis; affect single joint due to trauma, stress; high level uric acid; joint hot, red swollen; generally metatarsophalangeal joint great toe.

Gout Gout

Stage 3: Chronic Tophi occur if gout untreated >urate pool increases > develop in multiple areas (esp. ear, bursae, toes) > compress nerves and erode through tissues.

Diagnostic TestsDiagnostic Tests Serum Uric acid – elevated; usually above 6

mg/dl; not specifically diagnostic of gout

WBC- elevated as high as 20,000/mm3 during acute attack

ESR: elevated

24 hour urine collection-determine uric acid production and excretion (evaluate if from decreased renal excretion or overproduction of uric acid)

Most commonly diagnosed via clinical symptoms such as Tophi seen – indicator of chronic disease

Drug Therapy for GoutDrug Therapy for Gout

Colchicine

NSAIDs

Corticosteroids

Uricosuric Agents Probenecid (Benemid) Sulfinprazone (anturan)

Drug TherapyDrug Therapy Xanthine-oxidase inhibitors

Decrease uric acid productionDecrease uric acid production

Allopurinal (zyloprim) – can lead to agranulocytosisAllopurinal (zyloprim) – can lead to agranulocytosis

ULORIC (febuxostat)

Force Fluids while on these medications!!Force Fluids while on these medications!! to keep urine alkalineto keep urine alkaline


Diet Therapy Avoid foods high in Purine such as?


Bedrest and position for comfort

Joint immobilization and protect joint from pressure

Local application of heat or cold

Assess for complications Formation of kidney stones Hypertriglyceridemia Hypertension

Chronic multisystem disease involving vascular and connective tissue

Pathophysiology of SLEPathophysiology of SLE

Lupus is an autoimmune disease characterized by acute and chronic inflammation of various tissues of the body.

Patients with lupus produce abnormal antibodies in their blood that target tissues within their own body rather than foreign infectious agents.

Because the antibodies and accompanying cells of inflammation can affect tissues anywhere in the body, lupus has the potential to affect a variety of areas

Causes of SLECauses of SLE The precise reason for the abnormal

autoimmunity that causes lupus is unknown.

Inherited genes, viruses, ultraviolet light,

Dozens of medications have been reported to trigger SLE.

Clinical Manifestations of Clinical Manifestations of SLESLE Fatigue; Low-grade fever

Loss of appetite Muscle aches; arthritis; polyarthralgia Ulcers of the mouth and nose Facial rash ("butterfly rash") Photosensitivity Pleuritis and pericarditis, tachypnea, Poor circulation to the fingers and toes with cold

exposure (Raynaud’s syndrome) Proteinuria and development of glomerulonephritis Focal seizures, peripheral neuropathy, organic brain

syndrome

DiagnosisDiagnosis

Autoantibody Testing: Anti-DNA- specific Anti- smith antibody (Anti-Sm) Anti nuclear antibody (ANA)

ESR – elevated C-reactive protein – elevated These are not diagnostic for SLE, but help in

the diagnosis


What is the single most important medication used in the treatment of SLE?

Other Medications : Anitmalarial Immunosuppressive agents


Relieve pain and discomfort and Fatigue Application of heat and cold Encourage to alternate Rest and activity Support devices – braces, splints, firm mattress Analgesics and anti-inflammatory medications

Nursing CareNursing Care

Maintain Skin Integrity Apply topical anti-inflammatory Avoid direct sunlight. Use sunscreens and

protective clothing, sun hats

Increase Mobility ROM Assistive devices – walkers, canes, crutches


Facilitate self care Provide adaptive equipment for eating, bathing,

toileting, dressing Allow patient extra time to complete care

Improve body image Encourage patient to verbalize feelings,

perceptions, and fears Monitor for complications

Assess for serious adverse effects of medications used in treatment

Avoid immunizations with live viruses

Documents

What can go wrong with bones? They can become infected Osteomyelitis They can become soft with decrease in mineralization Osteomalacia They can