Medical Surgical Nursing

Musculoskeletal Alterations:
Section 1 Infections
Osteomyelitis
• Infection of the bone
• May occur by:
– Extension of soft tissue infections
– Direct bone contamination
– Blood borne spread from other foci of infection
– Most common cause is trauma
• 70-80% caused by Staphylococcus aureus
Osteomyelitis (cont.)

• Who is at risk?
– Poorly nourished
– Elderly
– Obese
– Impaired immune system
– Chronic illness
– Long term corticosteroid therapy
Osteomyelitis (cont.)

• Bone infections are more difficult to

eradicate than soft tissue infections
because infected bone becomes walled of
– Natural immune responses are blocked;
antibiotics penetrate less
Osteomyelitis (cont.)
• Clinical Manifestations:
– Sudden onset with clinical symptoms of
septicemia
• Chills, high fever, rapid pulse, general malaise
– Extremity becomes painful, swollen, warm, and
tender
– Pulsating pain that intensifies with movement
– Abscess cavity contains dead bone tissue
(sequestrum) which does not drain
Osteomyelitis (cont.)

• Assessment/Diagnostic Methods
– X-rays show soft tissue swelling
– Bone scans or MRI can be done
– Blood studies and blood cultures taken
– Chronic osteomyelitis: x-ray shows large,
irregular cavities, and a raised periosteum or
dense bone formations
Osteomyelitis (cont.)

• Medical Management
Initial goal is to control and arrest the infective process
– Affected area is immobilized, warm soaks
– Blood cultures to identify organism
– IV antibiotic round the clock
– Once infection control—oral antibiotics for up to 3
months
– Surgical debridement with irrigation
Osteomyelitis (cont.)

• Assessment:
– Assess for risk factors
– Observe for guarded movements
– Observe for warmth and swelling, drainage,
elevated temperature
– Chronic cases may have minimal temperature
elevation
Osteomyelitis (cont.)

• Nursing Diagnosis:
– Pain related to inflammation and swelling
– Impaired physical mobility associated with
pain
– Risk for extension of infection: bone abscess
formation
– Deficient knowledge about treatment regimen
Osteomyelitis (cont.)

• Planning/Goals
Major goals include pain relief and improved
mobility, control and eliminate infection, and
patient education
Osteomyelitis (cont.)

• Nursing Interventions:
– Restrict activity and immobilize
– ROM to joints above and below affected
– Handle with care to avoid pain
– Elevate to decrease swelling
– Administer pain medications and use other
pain relief measures
– Monitor neurovascular status
– Encourage ADLs—some restrictions due to
weakness of bone
Osteomyelitis (cont.)
– Monitor response to antibiotics
– Watch for “super-infections”
– Diet high in protein and vitamin C to help
promote healing

• Patient Education: importance of adhering

to therapeutic regimen of antibiotics, and
prevention of falls
• IV equipment instruction
Medical Surgical Nursing

Musculoskeletal Alterations:
Section 2 Rheumatic
Musculoskeletal Alterations
Rheumatoid Arthritis
• Rheumatoid Arthritis (RA) is an
inflammatory disorder that primarily
involves the synovial membrane of the
joints
• Occurs between the ages of 30 and 50;
peak between 40-60 years of age
• Women affected 2-3x more than men
• Believed to be an autoimmune response to
unknown antigens
Rheumatoid Arthritis (cont)

• Clinical Manifestations:
Determined by the stage and severity of the
disease
– joint pain, swelling, warmth, erythema, and
lack of function
– Palpitation of joints reveals spongy or boggy
tissue
– Fluid can usually be aspirated from the
inflamed joint
Rheumatoid Arthritis (cont)

• Begins with small joints in hands, wrists and feet

• Progressively involves knees, shoulders, hops,
elbows, ankles, cervical spine, and TMJ
• Symptoms are acute in onset, bilateral and
symmetric
• Morning stiffness lasts for more than 30 minutes
• Deformities of the hands and feet result from
misalignment and immobilization
Rheumatoid Arthritis (cont)
• Extra-articular features:
– Fever, weight loss, fatigue, anemia, sensory
changes
– Raynaud’s phenomenon
– Rheumatoid nodules, non-tender and movable;
found in subcutaneous tissue over bony
prominences
Rheumatoid Arthritis (cont)
• Assessment and Diagnostic Findings
– Several factors lead to diagnosis of RA
• Rheumatoid nodules, joint inflammation, extra-
articular changes
– Laboratory findings:
• Rheumatoid Factor (RF) found in 80% of patients
• ESR elevated
• RBC and C4 decreased
• C-reactive Protein (CRP) and antinuclear antibody
(ANA) may be +
– Arthrocentesis and x-rays can be performed
Rheumatoid Arthritis (cont)

• Medical Management
Includes education, a balance of rest and
exercise, and referral to community agencies
for support
– Early RA:
• Medical management includes therapeutic doses
of salicylates or NSAIDs; includes new COX-2
inhibitors, gold, penicillamine
• Occupational and physical therapy
• Reconstructive surgery and corticosteroids
Rheumatoid Arthritis (cont)

• Advanced RA:
– Immunosuppressive agents such as
methotrexate and cyclophosphamide
• RA patients frequently experience
anorexia, weight loss, and anemia.
Corticosteroids may stimulate appetite and
cause weight gain
• Low dose antidepressant medications to
promote adequate sleep and manage pain
Rheumatoid Arthritis (cont)

• Assessment:
– Assess patient’s self-image
– Assess joints by inspecting palpating, and
inquiring about tenderness, swelling, and
redness
– Assess joint mobility, ROM, and muscle
strength
Rheumatoid Arthritis (cont)

• Planning and Goals

– Goals include pain relief
– Relief of fatigue
– Optimal functional mobility
– Independence in ADLs
– Improved sleep
– Absence of complications
Rheumatoid Arthritis (cont)

• Nursing Interventions:
– Pain relief measures
– Relief of fatigue
– Increasing mobility
– Improving sleep
– Monitoring for potential complications
– Increase knowledge of disease
– Promoting self-care
Systemic Lupus Erythematosus (SLE)

• Chronic inflammatory autoimmune

collagen disease resulting from disturbed
immune regulation that causes an
exaggerated production of autoantibodies
SLE (cont)

• Pathophysiology
– Brought on by some combination of genetic,
hormonal and environmental factors
– Certain medications have been implicated in
chemical- or drug-induced SLE
– Some foods (alfalfa sprouts) have been
implicated
– Usual onset during childbearing years
Pathophysiology cont
• In autoimmunity, the body produces antibodies
against its own cells
• Formed antigen-antibody complexes can
suppress the body’s normal immunity and
damage tissues
• Pt’s with SLE can produce antibodies against
many tissue components: red blood cells,
neutrophils, platelets, lymphocytes or any organ
or tissue in the body
SLE Susceptibility
• Genetic predisposition
• Stress
• Streptococcal or viral infections
• Exposure to sunlight or UV light
• Immunization
• Pregnancy
• Abnormal estrogen metabolism
Drugs that spark SLE
• Procainamide
• Hydralazine
• Isoniazid
• Methyldopa
• Anticonvulsants
• Penicillins, sulfa drugs, and oral
contraceptives (less common)
SLE (cont)
• Clinical Manifestations
– Onset is insidious or acute
– SLE can go undiagnosed for many years
– Clinical course is one of exacerbations and
remissions
– Multisystem features
• Nephritis, cardiopulmonary disease, rashes,
evidence of systemic inflammation
SLE (cont)
• Musculoskeletal System:
– Arthralgias and arthritis, joint swelling, morning
stiffness
• Integumentary system:
– Butterfly rash across bridge of nose and cheeks
– Lesions can be provoked by sunlight or artificial UV
light
• Cardiovascular
– Pericarditis
• Other:
– Pleuritis or pleural effusions
– Renal involvement, HTN, depression
SLE (cont)
• Diagnostic Studies
– Complete history
– Analysis of blood work
– No specific lab work confirms SLE
– Other diagnostic immunologic tests support but do not
confirm the diagnosis.
• Anemia, leukopenia, lymphopenia, thrombocytopenia, and an
elevated ESR
– Women may report irregular menstruation
– 90% have joint involvement that resembles RA
– 40% have Raynaud’s phenomenon
SLE (cont)
• Pharmacologic Therapy
– NSAIDs and corticosteroids
– Topical corticosteroids for cutaneous
manifestations
– Immunosuppressive agents for most serious
forms of SLE
SLE (cont)
• Nursing Interventions
– Generally the same as those for patients with
rheumatic disease and address:
• Fatigue
• Impaired skin integrity
• Disturbed body image
• Knowledge deficit
Osteoarthritis (Degenerative Joint
Disease)
Osteoarthritis (OA) is the most common joint disorder.
Characterized by a progressive loss of joint cartilage.
Risk Factors:
• female
• genetic pre-disposition
• Obesity
• Mechanical joint stress
• Trauma
• Congenital and developmental disorders
• Inflammatory joint diseases
• Endocrine and metabolic diseases
OA (cont)

• Classified as:
– Primary (idiopathic)
– Secondary (related to risk factors): most
commonly -- trauma, congenital deformity, or
obesity
Obesity increases the pain and discomfort of the
disease
OA peaks between the fifth and sixth decades of
life
OA (cont)
• Clinical Manifestations:
– Pain, stiffness, and functional impairment
– Stiffness is most common in the morning—lasts less
than 30 minutes
– Functional impairment is related to pain
– Aching during weather changes
– “grating” of joint during motion
– Most often occurs in weight bearing joints (hips,
knees, cervical and lumbar spine)
– Bony nodes may be present (painless)
• Heberden’s nodes: distal joints
• Bouchard’s nodes: proximal joints
OA (cont)
• Assessment and diagnosis:
– X-ray shows narrowing of joint space and
osteophytes (spurs) at the joint margins
– Serum studies are not useful
– No laboratory test is specific for osteoarthritis
• Medical Management:
– Focuses on slowing and treating symptoms—
no treatment available that stops the
degenerative joint process
OA (cont)
• Prevention:
– Weight reduction
– Prevention of injuries
– Perinatal screening for congenital hip disease

• Pharmacologic Therapy
– Acetaminophen; NSAIDs
– COX-2 inhibitors
– Topical analgesics
– New therapeutic approaches
OA (cont)
• Conservative Measures
– Heat, weight reduction, joint rest
– Orthotic devices
– Isometric and postural exercises
– OT and PT
• Surgical Management
– Joint replacement
OA (cont)
• Nursing Management
– Manage pain
– Optimize functional ability
– Assist with weight loss strategies
– Encourage use of assistive devices for
ambulation
– Patient safety
Gout
A heterogeneous group of conditions related
to a defect of purine metabolism and
resulting hyperuricemia
• Pathophysiology
– Over secretion of uric acid or renal deficit in
excreting or combination of both
– May be due to starvation, excessive intake of
purine rich foods, or heredity
Gout
• Primary gout usually occurs in men over
age 30 and post-menopausal women who
take diuretics
• Intermittent
• Between attacks patient may be symptom
free for years
Gout (cont)
• Clinical Manifestations
– Four stages
• Asymptomatic hyperuricemia– urate levels rise but
don’t produce symptoms
• Acute gouty arthritis
– Most common early sign
– Metatarsophalangel joint of the big toe
– Acute attack triggered by trauma, alcohol, diet,
medication
– Abrupt onset occurs at night
– Early attacks go away spontaneously
– May be months or years before the next attack
Gout (cont)
• Hyperuricemia
– Few people develop clinically apparent urate crystal
deposits
– Development of gout is directly related to duration an
magnitude of hyperuricemia
• Tophi
– Chalky deposits of sodium urate
– Associated with frequent and severe inflammatory
episodes
– High uric acid concentrations associated with tophi
– Found in various places
• Risk for urolithiasis
Gout (cont)
• Medical Management
– Hyperuricemia, tophi, joint destruction treated
after the acute inflammatory process
– Uricosuric agents to correct hyperuricemia
– Colchicine or NSAIDs
– Allopurinol—limited due to risk of toxicity
Gout (cont)
• Nursing Management
– Restrict consumption of foods high in purines
• (organ meats, anchovies, sardines, sweetbreads)
– Avoid alcohol
– Maintain normal body weight
– Pain management
– Instruction to continue medications to
maintain effectiveness