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Musculoskeletal Disorders 3/26/09Low Back Pain2nd leading cause for medical visits Possible causes:OsteoporosisBone MetastasisKidney DisordersPelvic ProblemsRetroperitoneal tumorsAbdominal AneurysmsPsychosomatic problemsIn your mind. Like if you get a headache every time your husband comes home. It really happens, i.e. you really get a headache, but there isn’t really a medical reason why.StressDepressionObesityAssessmentAcute vs ChronicAcute-less than 4 weeks. Chronic- continues after 4 weeks and can become debilitatingPain (PQRST)P-Provokes/Palliates- what makes it worse and what makes it betterQ- Quality- sharp, dull, achingR- Region/Radiating- where is it at and does it move else whereS- Severity/Setting- how bad is it (0-10 scale) and when does it happen?T- TimingGaitObserve from the front or backSpinal Mobility Watch them from the back to see how their spine movesMotor & SensoryStrength and FeelingParesthesia- is nerve damageNursing InterventionsPain ReliefTherapeutic and Non-therapeuticImproved physical mobilityBody mechanicsImproving self ConceptNutrition concernsProper nutrition to reduce weight, drink milk for strong bones, etc.Upper Extremity ProblemsBursitis and TendonitisTreat with NSAIDs and ice/heatLoose BodiesWhen articular cartilage wears and tears and you have bits of bone break offImpingement SyndromeOveruse or micro-trauma. Pinching together of the supraspinatus muscle and other soft tissue of the shoulder. Carpal Tunnel SyndromeOveruse of your wrist. The muscles get inflamed and have nowhere to go so they squish on the nerves. Usually medial. Common Foot ProblemsIngrown toenailsThe toenail growing into the surrounding tissue. The side of the nail basically starts growing sidewaysSpray stuff on your toe to numb it and give you shots or whatever. Then they all the way down the side of the nail so it doesn’t grow anymore. My brother has a toe that was cut down both sides so it looks really small and perfectly square. I make fun of him..Hammer ToeFlexion deformity, your toe points down. Women get it more often from wearing heels that squish their toesHallux ValgusBunion- get it from rubbing on the side of something. And you get it on a bony prominence. Morton’s NeuromaSwelling of the lateral branch of the median plantar nerve. Similar to carpel tunnels in the wrist. Extremity ProblemsPostoperative Nursing InterventionsNeurovascular assessment Check CMS (Circulation, mobility, sensation)Pain reliefIce/HeatDon’t leave ice on for more than 20 minsSelf care deficitsWill be limited in ADL’s because of dressings or whateverPrevention of InfectionMonitor WBC’s, S/S of infection, report odor, etc.Patient educationTeach them what the complications are of what they got, S/S of these things, what to do, etc.OsteoporosisWomen vs MenWomen start getting this at 35. 80+ years of age 84% incidence of osteoporosis.Men 80+ is 20% incidence of osteoporosis.Asymptomatic until fracture occursReduction in total bone mass and change in bone structureSusceptibility to fractures increasesVertebral CollapseRisk factorsSmall frame, thin white or Oriental femaleAge is the single biggest predictor for this. Also family history, early menaupause (before age 45), and removal of the ovaries or uterus. Ufrectomy or hysterectomy.Inadequate IntakeCalcium and Vit DSedentary lifestyleImmobilityAlcohol abuseCo-existing medical conditionsMedicationCorticosteroids, lasics, thyroid supplement. DiagnosisRoutine X-RayDEXA scanMost widely used for testing, measures bone densityLab studies and x-rays to rule out other medical dx.Medical ManagementNutrition- adequate intake of calcium9-19 y/o is 1300mg/day19-50 y/o is 1000mg/day51 and older 1200mg/dayPostmenopausal women 1200-1500 mg/dayActual Estimated Intake300-500 mg/day. This is what people really eat opposed to what they are supposed to.Exercise- weight bearingPharmacologic InterventionsHRT (Estrogen/Combo)Hormone Replacement Therapy. Biphosphorates (Fosamax, Acteonel)Great medication for osteoporosis, but can cause GI upset. Take it with food or sit them up to prevent GERDCalcitonin (Miacalcin)Direct action on osteoclasts (they break down bone). Slows their action.Selective estrogen receptor modulators (Evista)Just another type of estrogenEstrogen is best. Osteoarthritis (Degenerative Joint Disease)Most Common and Disabling Joint disorder Primary vs SecondaryPrimaryYou got it from genetics. SecondaryYou got it from something else, injury, disease, etc. Primary risk factor: AgeOther Risk FactorsGender, body mass, menopause, nutrition, etc. Pathophysiology of OsteoporosisJoint injury firstRelease of enzymesUnderlying bone, cartilage, and synovium degenerateCartilage thins (bone on bone), synovium becomes inflamedPain, stiffness, loss of function in that joint. Management of OAMedicalExerciseWeight reductionPharmacologicalNSAIDSTopical AnalgesicsSurgical (only if everything else doesn’t work)ArthrosopyTotal Joint ReplacementNursing InterventionsEducationPain managementMedicationAssistive DevicesLifestyle changesImprove Functional AbilityOsteomyletisBone InfectionThree modes of infectionExtension of soft tissue infectionDirect Bone contaminationThru surgery or a fractureHematogenesisInfection of the blood in the boneClassificationsIncisionalFrom the incision, on the surface of the boneDeepInfection goes deep into the bone (worse)AcuteShort period of timeChronicLonger (worse)Staph Aureus causes 70-80% infectionsSymptoms- hematogenesisInflammatory processSepticemiaPain, edema and extreme tendernessSymptoms – non-hematogenicLocalized inflammatory responseDiagnosticsX-rays (do x-ray first because bone scans and MRI’s because they are expensive)Bone ScansMRILab StudiesElevated Leukocytes and elevated SED (sedimentation) RateTreatment and GoalsPrevention is the goal (it’s so hard to get rid of them!)Early TreatmentPostpone elective orthopedic surgery when current infection present or recent hxSurgical asepsisProphylactic antibodiesAseptic wound care post opDon’t change the wound, but just reinforce it and call the drManagement of OsteomyelitisPharmacologicCulture siteAntibiotic therapyThey get up to 3-6 wks of IV treatment in the hospital and can last up to 3 months orally Antibiotic associated colitisSurgical (Only if there is no response to antibiotics)Irrigation and debridement (called and IND)Very rare, they don’t want to cut into the bone because it is so infected. The cavity is cleaned and post op continuous irrigation of the wound can take place up to 7-10 daysPost op continuous wound irrigationBone TumorsBenignMore common than malignant primary bone tumorsOsteochondroma is the most common type of benign bone tumorBone Cysts- expanding lesionsGiant cell tumors (osteoclastoma) may invade local tissues and may become malignant (cancerous)Malignant Relatively rareSarcomasArise from connective and supportive tissue cells. Most common and most fatal. It’s usually a secondary tumor. You got lung cancer and it spread to your bones. Manifested by pain, swelling, limited ROM, and weight loss.May have palpable, tender, fixed bone mass (you can’t move it)MyelomasArise from the bone marrowMetastatic Disease to BoneSecondary bone tumor (sarcoma)- more common than primary bone tumorMost Common primary tumor sitesKidney, prostate, lung, breast, etc. Don’t need to knowMost Common sites to get bone cancerSkull, femur, spine, etc. We don’t need to know these.Medical ManagementPrimary Bone tumorsDestroy or remove the tumor thru amputation.Radiation or chemotherapySecondary TumorsPalliative treatmentThey’re basically fucked and you just want to make them as comfortable as possible. They don’t even try to fix it. ................
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