Care of Clients with Problems In Inflammatory & Immunologic Response, Perception & Coordination (NCM104) Patients With Musculoskeletal

Alterations II

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Care of Clients with Degenerative Disorders

Osteoarthritis
o Definition: A joint disorder characterized by degenerative changes (aging process) of the articular cartilage (covering of the joint surface)

Topics Discussed Here Are: Based sa Course Outline ni MAM 1. Degenerative Disorder a. Osteoarthritis 2. Metabolic Disorders a. Osteoporosis b. Pagets Disease c. Osteomalacia d. Gouty Arthritis 3. Spinal Column Deformities a. Scoliosis b. Kyphosis c. Lordosis 4. Bone Infections BOOK a. Osteomyelitis BOOK 5. Muscular Disorders BOOK a. Muscle Dystrophy BOOK

Classifications of Osteoarthritis 1. Primary Type o 65 years old and above (Aging process) o Associated with NO HISTORY of TRAUMA, INFLAMMATORY PROCESS, and or JOINT DISORDER that affects the joints o Incidence: Women are more affected Associated with hormones Post menopause o Weight bearing joints are affected Hips and Ankles 2. Secondary Type o More associated with males o Brought about by certain JOINT DISORDER, TRAUMA and other INFLAMMATORY DISEASE

Risk Factors
1. Overweight (Obesity) o Due to burden on the weight bearing joints o Bone may produce friction due to the weight Trauma o Due to a bad fall/infectious process Genetic Factors o Studies show that Osteoarthritis can be given on a secondary generation from grandparents Note: Osteoarthritis can affect one joint, Pain (Stiffness) but it can also affect more than one o MOST COMMON!! o Characteristics of pain: Aggravated by any activity / walking BUT Relieved by rest Only allow the client to rest if ACUTELY in PAIN Because client is ENCOURAGED TO AMBULATE Crepitus, Mild Tenderness, Deficit ROM (Due to inflamed joint), and Joint Enlargement Formation of NEW GROWTHS o Bouchards Nodes LOCATED AT the Proximal Interphalangeal Joints o Heberdens Joints LOCATED AT the Distal Interphalangeal Joints

2. 3.

Clinical Manifestations
1.

2. 3.

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Diagnostic Test(s)
X-Ray Only on the affected joint!

Management
1. Medical a. Relieve Pain Rest If painful! Walking is encouraged if in the absence of severe pain Rationale: To improve the joint stability Alternate Hot (Heat) and Cold compress BOOK BASED Heat therapy only According to most clients Drugs: NSAIDs Mild GIT Irritation: Give on FULL STOMACH! Glucosamine MOA: Stimulates the cartilage cells to produce proteoglycans (Substance responsible for reducing the friction as the bones move) Chondroitin MOA: Prevents the breaking down of the enzyme proteoglycans b. Functional Independence As much as possible let the client or give the client a chance to do all the activities independently, if required, with the use of an assistive device c. Maintenance of Quality of Life Balance between rest and exercise DO NOT ALLOW the client to have a sedentary lifestyle It may exacerbate the disease Low impact exercise such as walking ***As long as the client can keep on going do so! Nursing Care Goal: To promote a healthy and positive adaptation a. Education Key to successful treatment Pain management (Drugs) Rest Activity balance Nutrition: As much as possible lessen the fats and red meat Give fruits and vegetables, milk and dairy products (Ca and Vitamins) REMINDER: Take everything, but in minimal! Weight loss Because putting on weight will put too much burden on the joints Self-Care Strategies Doing functional independence b. Maintaining Independence Wheelchairs Crutches Note: Osteotomy and Arthrodesis Surgical Management go HAND-in-HAND a. Osteotomy Resection of a bone Then removal of the damaged cartilage but the functioning of the bone can still be affected, so Arthrodesis is done b. Arthrodesis / Joint Fusion Disadvantage: Client has an impaired mobility Advantage: Pain will be relieved

2.

3.

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c.

Total Hip Replacement (Arthroplasty) Repair of the hips Restores joint motion by replacing arthritic bones with metal components The synthetic material can either be plastic / metal on the joint

Post Operative Care 1) Pain (Analgesics [Narcotics / Non-narcotics]) 2) Impaired mobility Immediate ambulation, but affected extremity is IMMOBILIZED! Immobilization: The affected extremity should have to be in an abducted position Makes use of an abduction wedge to prevent ADDUCTION and FLEXTION of the hip Rationale: If in the Event the prosthesis is adducted, it will not fit the site or dislodgement will occur! DO NOT PUT CLIENT ON COMPLETE BED REST Be aware of the weight bearing limit In-Bed Exercise Done during the 1st day If client goes out of the bed, do they need support? Assist the client with at least 2 personnel 3) Risk for peripheral neurovascular dysfunction Neurological Assessment: q4 hours Note: 4) Risk for Injury Related to Prosthesis Dislocation - Ask what type of vehicle No bending will bring the client home? Pedicure, tying of shoe laces - If the right hip is affected, Use of Elevated Toilet it should not be flexed Hips can only be up to 90 (only up to 90 only) Can use instead a bed site commode No Crossing of Legs Because one should maintain the 90 or it will promote twisting of the affected leg No Inward Rotation of the Affected Extremity

Osteoporosis
o Definition: Systemic skeletal disease characterized by bone mass and microarchitectural deterioration of bone tissue that leads to fragility and susceptibility to fracture Enumeration: Bone Mass (Quality of bone) Microarchitectural deterioration of bone tissue (Parts of the bone are damaged) Leads to fragility Leads to susceptibility to fracture Fragility Fracture Results from low trauma as bending Example: Accidentally put weight on the palm Osteopenia / Osteopenic Bone with Low MINERAL DENSITY

o o

Factors that Influence Development of Osteoporosis 1. Bone Mass o Quality of the bone o Measured by a Bone Densitometry

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Full Table DXA Report: Report: (Reported as t-Score) BMC Bone Mineral Content BMD Bone Mineral Density Normal: Bone reaches its highest length until 20 y/o Peak mass is up until 30 y/o then will plateau until menopausal period Note:
t-Score = Difference between the clients BMD/BMC and the BMD/BMC of a young normal adult having the same sex Standard Deviation =

o o 2. 3. 4. 5. 6. 7. 8. 9. 10.

Also present to males because it is influenced by hormones As one grows older, a person shortens due to bone mass

BB-CC-D-VHAMP

Bone Mass Heredity = 60 80% Body Weight Low Body Weight Less than 127 lbs, because it can activate the Osteoblasts Calcium Prolonged premenopauseal amenorrhea / Early menopause Cigar Inadequate physical activity Drugs Vit D Low intake of dietary calcium Hereditary Suboptimal level of Vitamin D Alcohol Cigarette smoking Menopause Alcohol intake Physical activity Drugs as Thyroid Hormone (Levothyroxine), Anti-convulsant (Phenobarbital), Furosemide (Lasix), Steroids (Prednisone, Decadron)

Remodeling
Bones are DYNAMIC o They undergo continuous remodeling o Remodeling Process of Changing old bones to have new bones o Phase I [Resorption] (7 10 Days) Activated: Osteoclasts will try to absorb portions of the bones considered old o Phase II [Bone Formation] After removing of old cells, Osteoblasts come in

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Bone Resorption
Old bone is replaced by new bone Functions: o So as biochemical properties are not compromised o For mineral homeostasis (Ca will be in-and-out) Process: o Bone Resorption: Activation of OSTEOCLASTS o Bone Formation OSTEOBLASTS form an organic matrix Controlled by 2 Important Factors 1) Systemic Factors Exemplified by the need of Ca 2) Local Cytokines Serves to coordinate the 1st and 2nd Phase

Clinical Manifestations
1. Severe Back Pain o May already be present, but client does not mind it o Only diagnosed after a history of fractures, compressed vertebra o Pain worsens on movement o Just like Osteoarthritis, relieved by rest o Present for 1 1 weeks Progressive Vertebral Deformities o Client stoops forward to relieve pain o Stooping progresses o As client becomes Kyphotic, rib cage compresses and client complains of abdominal discomfort (Bloated abdomen) o Restriction of lungs (DOB) Bone Loss o Mandibles are affected o Dentures loosen/tighten Changes in appearance

2.

3.

4.

Categories of Osteoporosis
1. 2. 3. 4. Normal o BMD of client is not more than 1 SD below the young adult individual Low o If in the event it is 1 2.5 below the normal adult it is Low Bone Mass (Osteopenia) Osteoporosis o A value for BMD / BMC that is greater than 2.5 SD below the young adult measure value Severe Osteoarthritis o A value for BMD / BMC that is more than 2.5 SD below the young adult mean value and the presence of 1 or more fragility of fractures

BMD is Done on the Following

1. 2. 3. All Menopausal women under the age 65 y/o (With one or more additional risk factors) Women considering hormone replacement therapy (HRT) Individuals on prolonged steroid therapy

Management
1. Prevention a. Adequate intake of Ca and Vit D Women 25 50 y/o 1000 mg/day Post-menopausal Taking Estrogen 1000 mg/day Not Taking 1500 mg/day Women > 65 years 1000 mg/day

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Men < 65 years 1000 mg/day Men > 65 years 1500 mg/day Sources of Calcium o Broccoli, milk, dairy, green leafy veggies, fish Sources of Vitamin D o Sun (At least 50 minutes, do not use sunscreen), milk, fish

2.

b. Regular weight bearing exercise c. Avoidance of tobacco and alcohol Estrogen replacement

Pagets Disease (Osteitis Deformans)

o o Definition: Disorder of localized bone marrow turn over commonly affecting the Skull, Femur, Tibia, Pelvic Bone and Vertebra Enumeration Skull Femur Tibia Pelvic Bone Vertebra Incidence: 2% - 3% Occurs in adults 50 y/o and above More on males Cause - ?

Pathophysiology

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Clinical Manifestations
1. Skull o Thickens o Gives the face a SMALL and TRIANGULAR shape o May have impaired hearing Due to compression of Cochlear Nerve o Hat / Bonnet cant fit 1st MANIFESTATION! o Is insidious in nature! Long Bone o Femur and Tibia tend to bow, producing a waddling gait o Will form a bow-legged appearance o As the client walks, there is a change in gait Spine o Bent forward o Slightly rigid o Thorax is compressed Difficulty in breathing Trunk is focused** on legs o Worst scarring *** Pain, tenderness, warmth over the bones Mild to moderate aching pain that in pain, due to weight bearing

2.

3.

4. 5. 6.

Diagnostic Procedure
1. Blood Tests: Calcium = Normal o Serum Alkaline Phosphatase o Normal Serum Ca Urine Tests o Excretion of hydroxyproline X-Ray of the bones o Shows area of demyelination

2. 3.

Management
1. 2. 3. 4. 5. NSAIDs Walking Aids Done to move client around Reduce Weight Diet - in Ca and Vit D Anti-Osteoclastic Drugs o Calcitonin Hormone Preparation (Thyroglobulin) MOA: Reduces bone resorption by reducing the number and availability of osteoclasts o Bisphosphonates Two Important Functions 1. To reduce number of osteoclasts to lessen bone resorption 2. Relieves pain o Plicamycin Cytotoxic Antibiotic To control the progression of Pagets Disease

Osteomalacia (Rickets)
o o o o o Manage Problem: A deficiency with Vitamin D (Calcitriol) Also known as Adult Rickets Bones become abnormally soft because of disturbed Ca and Phosphate balance secondary to Vitamin D deficiency Inadequate mineralization (demineralization) of the bones Non absence and storage of Ca in bone

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Incidence o Affects the pelvises, spine, and lower extremities o More on women with multiple pregnancies and had breast fed o Common among Muslims (Clothing)

Causes:
1. 2. 3. 4. 5. 6. 7. 8. 9. Strict Vegetarianism (Not ENOUGH with VEGGIES ) Very low fat diet Malabsorption syndrome Excessive loss of Calcium GIT Disturbances as biliary tract obstruction Liver and Kidney Disease (Site of Vit D conversion to active form) Renal insufficiency Hyperparathyroidism Decreased intake of food HIGH in Ca and Vit D

Pathophysiology

Assessment 1. Easy fatigability, body malaise and bone pain o Cant PINPOINT where the pain is 2. Physical Assessment a. Skeletal Deformities Bow-leggedness b. Waddling/Limping Gait c. Muscle Weakness 3. Laboratory Test a. Serum Ca b. Moderate increased alkaline Phosphatase c. Urine excretion of Ca and Creatinine 4. Biopsy o amount of Osteoid (Pre-bone) o A picture of deminerlizing of bone

Management
1. Gentle handling of clients o Assist when changing position o Use of pillows to relieve pressure / pain Ca and Vit D Supplement Protein Expose to sunlight (50 minutes) Use of braces (Assistive Devices)

2. 3. 4. 5.

Gouty Arthritis
o o Brought about by deposition of URIC ACID A metabolic disorder in which Purine (CHONE) metabolism is altered, there is accumulation of uric acid usually on the BIG TOE

Classifications of Gouty Arthritis 1. Primary o Inherited defect of Purine metabolism o About 85%; 95% are males o Occurs on 3rd or 4th Decade of life 2. Secondary o Acquired condition as in: a) Hematopoietic Disorders Any disorders of the blood (Bleeding Loss of Globulin/Albumin) b) Rapid Induction of Chemotherapy Radiation

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Destruction of surrounding tissue Cells has protein inside, if destroyed, then no more protein c) Renal disorders Can no longer have conversion of AMMONIA to UREA d) Drugs as aspirin, thiazide and anti-TB Drugs e) Alcoholism f) Starvation

Tophi -

Deposition of uric acid at the big toe Appears at the LAST STAGE

Pain is known as the Thief of the Night Because pain appears during the night

Clinical Manifestations
1. Asymptomatic Hyperuricemia o Elevated URIC ACID (> 7.0 mg/dL) o No signs o Requires no treatment o Fluid Intake To pass out URIC ACID easily Acute Gout o Has deposited uric acid in the joint spaces leading to: Sudden onset of pain

2.

3.

4.

Interval / Intercritical o Period between acute attacks o No signs o Normal joint function Chronic Tophaceous Gout / Advanced Gout o Most disabling; develops over a long period o Has caused permanent damage to joints and times to the kidneys o With proper treatment, wont progress to this stage

Diagnosis
1. 2. Persistent *** - >7.0 mg/dL Presence of uric acid in aspirated synovial fluid o To determine level of uric acid at synovial space

Management

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2.

Management of Acute Attack Reduce pain a. Cold compress b. Rest until pain subsides Splint to immobilized foot c. Use of Drugs Colchicine 1st Antigout Drug NSAIDs / Steroids To the inflammatory process and Pain Allopurinol Blocks formation of Uric Acid Probenecid Promotes resorption and excretion of uric acid by the kidney Long Term Management a. Diet AVOID RED MEAT SEA FOODS As long as kidney is normal, OKAY! Organ Meat b. Fluid intake c. Weight

Management of Clients with Spinal Column Disorders

Scoliosis
o Definition: The lateral curvature of the spine May occur at the cervical, thoracic, thoracolumbar / lumbar area Incidence: Curve less than 10 = 1.5% - 3% Less than 20 - Affects both Male and Female Most common Over 10 years; more on female

ETIOLOGY 1. Congenital o Results from (Intrauterine) malformation of body segments of the spine due to failure of: Formation Absence of portion of vertebra Segmentation Absence of normal separations between vertebra 2. Neuromuscular o Associated with spinal deformities as Poliomyelitis (1 leg is shorter), Cerebral Palsy o Born with a NORMAL spine TYPES 1. Congenital Associated with a GENE called CHD7 2. Idiopathic According to onset a. Infantile <3 years b. Juvenile 3-10 years c. Adolescent Over 10 years MOST COMMON d. Adult Older (21 years and above) 3. Functional o Spine is NORMAL, but an ABNORMAL curve develops because of a problem as: One leg is shorter (Shifting of weight on the side without pain) Muscle spasm at the back 4. Neuromuscular o There is a problem where the spines are formed as: Failure of spines to form completely Failure to separate completely Associated with birth defect (Meningomyelocele)

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6. 7.

8.

Degenerative o Occurs in aged o Caused by changes in spine as arthritis Structural Does not correct itself on forced bending Non-structural Easily corrected No vertebral rotation (DO EXERCISE if diagnosed early) Types According to Vertebra Affected (Scoliosis) Thoracic Lumbar

ASSESSMENT
Assess for the symmetry of the shoulder Assess also for appearance of hips The Gluteal folds must be equal Paraspinal muscles Adams Forward Test (Bend FORWARD)

Diagnosis
1. Adams Forward Test o Ask client to bend o Used as a screening test o WOF: Deformation of the Paraspinal muscles X-Ray Cobb Angle o To assess the curvature quantitatively o Upper end plate, uppermost vertebra involved and lower end plate of the lowest vertebra Spinal Fusion - Spinal Fusion Less then 20 - Exercise - Steel rods help support the o Turning of body Towards the opposite fusion of the vertebra o Stretching of the body Towards the opposite - Bone grafts are placed to o SWIMMING! grow into the bone and o MONKEY BARS! fuse the vertebra Between 20-40 - Milwaukee Brace Surgery - >45 o Spinal Fusion WITH Instrumentation Insertion of a Harrington Rod o Lessen discomfort, movement, by use of HIPS, the spine should not be moved!

2. 3.

Management
1.

2. 3.

Kyphosis
o o Abnormal convex angulation in the curvature of the THORACIC spine Posterior rounding of the thoracic spine

Causes
1. 2. 3. 4. 5. Poor posture Most common among females, early breast tissue formation Secondary to Disease Ex. TB Of Spine (Infection of Spine) Degenerative Process Developmental Problems Trauma

Types of Kyphosis
1. Congenital

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3. 4. 5.

o Spinal column not fully developed in the womb o Vertebra may be malformed / fused together Postural o Most common o Attributed to SLOUCHING o Among Younger Slouching Kyphosis o Adult Dowagers Hump / Hyperkyphosis Nutritional Occurs in childhood with Vitamin D Deficiency Associated with children with Rickets Scheuermanns Kyphosis o Among females o Worst COSMETICALLY o Causes pain at apex aggravated by physical activity and prolonged standing or sitting o Apex at curve Thoracic vertebra rigid (Compression of lungs) Poor expansion (DOB)

Managment
1. 2. Orthosis Use of Milwaukee Brace Surgery or Kyphoplasty Repair of Kyphotic Vertebra

Lordosis
o o o Excessive inward curvature of lumbar spine / vertebra Cervical and Lumbar Vertebra Lordotic; convex anteriorly, concave posteriorly Excessive Saddle back, Sway Back / Hollow Back

Causes
1. 2. 3. 4. 5. Tight low back muscles (Muscles at Lumbar area) Excessive visceral fats Pregnancy Secondary to disease as Flexion Contracture of hip Associated with congenital hip dislocation

Manifestations
1. 2. 3. 4. May lead to Sway Back Lumbosacral spinal curves sharply and Thoracolumbar Spine exhibits Kyphosis Sagging shoulder Exaggerated pelvic angle Medial rotation of legs

Management
1. 2. 3. Loss of weight Use of brace Surgery Spinal Fusion!

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