Inflammatory Disorders

Inflammatory Disorders of the Musculoskeletal System Bursitis Inflammation of Bursa (fluid filled sac allowing joint movement) Usually from trauma or repetitious movement Appears calcified on X-ray Treatment – Rest-Immobilization with heat or cold pack – Anti-inflammatory (NSAIDS) and analgesics – Sometimes injectable steroids and anesthetics into joint

Inflammatory Disorders of the Musculoskeletal System Polymyositis Inflammation of striated/skeletal muscle Etiology unknown (possibly autoimmune) Can affect heart, GI tract, and lungs

Inflammatory Disorders of the Musculoskeletal System Arthritis – Most common type of joint disorder – Defined as “inflammation of the joints” – 4 types of arthritis Rheumatoid, osteoarthritis, gout and septic (infectious) arthritis

Rheumatoid Arthritis Etiology/pathophysiology Most serious form of arthritis Chronic, systemic disease Most common in women of childbearing age Autoimmune disorder, but may also be genetic May affect lungs, heart, blood vessels, muscles, eyes, and skin Chronic inflammation of the synovial membrane of the diarthrodial joints (movable)

Rheumatoid Arthritis Characteristics – Symmetrical joint swelling – Joint swelling rather than bony enlargement (osteoarthritis) – Permanent deformity as result of inflammatory process

Rheumatoid Arthritis Clinical manifestations/assessment Characterized by periods of remission and exacerbation – Exacerbations increased by physical, emotional stress Muscle weakness Malaise Loss of appetite Generalized aching Edema and tenderness of joints Limited range of motion (morning stiffness)

Figure 44-7 (From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2 nd ed.]. St. Louis: Mosby.) Rheumatoid arthritis of hands.

Rheumatoid Arthritis Clinical manifestations/assessment – Inflammation, tenderness, swelling of joints – Moderate to severe pain; morning stiffness lasting longer than 30 min – Joint deformities – Spongy, soft feeling to joints – Low grade temperature, fatigue, weakness – Anorexia, weight loss, anemia

Rheumatoid Arthritis Diagnostic tests Radiography studies show loss of articular cartilage and change in bone structure Laboratory tests – Erythrocyte sedimentation rate (ESR) – Rheumatoid factor (RF) – Latex agglutination test – Synovial fluid aspiration

Rheumatoid Arthritis Medical management/Nursing Interventions Medications Rest: 8-10 hours of sleep a night Exercise: Range of motion 2-3 times per day; balance rest/activity Heat: Hot packs, heat lamp, and/or hot paraffin Rehabilitation: splints to prevent deformity Surgical intervention-joint replacement

Rheumatoid Arthritis Goals for Treatment – Control of Disease (Medications) – Pain Relief (Medications, nrsg interventions) – Prolong Joint Function (Physical Therapy) – Slow Progression of Damage (Healthy Lifestyle, Exercise, Weight Loss)

Ankylosing Spondilitis – Etiology/pathophysiology Chronic, progressive disorder of the sacroiliac and hip joints, the synovial joints of the spine, and the adjacent soft tissues Most common in young men Strong hereditary tendency – Clinical manifestations/assessment Pain and stiffness in back; decreased ROM Elevated temperature; tachycardia; hyperpnea

Ankylosing Spondylitis – Diagnostic tests Hemoglobin, hematocrit, ESR, alkaline phosphatase Radiographic – Medical management/nursing interventions Analgesics, NSAIDs Exercise program: swimming and walking Surgery: replace fused joints Maintain spine alignment Turn, position, and breathing exercises every 2 hours

Degenerative Joint Disease Osteoarthritis

Osteoarthritis or DJD Degenerative Joint Disease- progressive degeneration of joints Non-systemic, non-inflammatory Primary osteoarthritis-cause unknown Secondary osteoarthritis-caused by trauma, infection, RA. stress on weight-bearing joints

Osteoarthritis Clinical manifestations/assessments – Joint edema, tenderness, instability and deformity – Heberden’s Nodes and Bouchard’s Nodes Diagnostic tests – Radiographic studies – Arthroscopy – Arhtrocentesis – Bone Scan

Figure 44-8 Heberden’s Nodes Heberden’s nodes. (From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2 nd ed.]. St. Louis: Mosby.)

Bouchard’s Nodes

Osteoarthritis Medical management/nursing interventions – Exercise balanced with rest – Heat applications – Gait enhancers (walkers, canes, etc.) – Medications-ASA, NSAIDS, steroids – Surgery-osteotomy (bone cut to correct joint deformity), joint replacement

Nursing Considerations Goals: – Encourage patient to maintain ADLs – Adapt to limitations of the disease Reminders to older people with cognitive impairment to move, turn, etc. Weight reduction if obesity a problem Splint support – check for fit and potential pressure areas

Nursing Considerations If long-term anti-inflammatory med use: stool guiac and/or emesis guiac Gait enhancers – for safety – Rubber tips on ends of mobility devices – walkers, canes – Proper size – Pt. knowledge re: use

Gout Metabolic disease resulting from excessive uric acid in blood; urate crystals deposit in joints Caused by ineffective metabolism of purines Primary cause: heredity; disorder of purine metabolism Secondary cause: certain drugs, complication of other disease, idiopathic More men than women, not before puberty in men, not before menopause in women

Gout Clinical manifestations – Excruciating pain – Edema of joints; low grade temp; pruritis – Inflammation (most often in great toe) – Tophi (hard, fairly large irregular shaped deposits in skin) Diagnostic Tests – CBC, ESR, Serum uric acid – X ray, arthrocentesis

Gout Medical management/nursing interventions – Medications: Colchicine, phenylbutazone (Butazolidin), indomethacin (Indocin), corticosteroids, allopurinol (Zyloprim), sulfinpyrazone (Anturane) – Encourage fluid intake: greater than 2000cc/day! – Monitor I&O – Bedrest and joint immobilization during acute attacks – Diet-avoid foods high in purines (wine, cheese, organ meats)

Osteomyelitis Local or generalized infection of the bone and bone marrow Staphylococci are the most common cause Introduced through trauma (injury or surgery) or via the bloodstream from another site in body to bone Bacteria invade the bone and degeneration occurs

Osteomeylitis Most common cause – Bacterial infection from open fracture Also from infected teeth, tonsils, or URI Common organisms – Staphylococus aureaus – Pseudomonas – E. Coli

Osteomyelitis

Clinical manifestations – Persistent, severe and increasing bone pain – Wound draining purulent fluid – S/S of infection-fever, tachycardia, tachypnea – Edema of affected area Diagnostic tests – Radiographic studies; bone scan – CBC, ESR, cultures of blood and drainage

Osteomyelitis Medical management/nursing interventions – Broad spectrum antibiotic therapy – Surgical removal of necrotic bone – Absolute rest of affected area – Wound care: irrigation of area with H2O2 or antibiotic solution and cover with sterile dressing – Drainage and secretion precautions – Diet: high in calories protein and vitamins

Fibromyalgia Etiology/pathophysiology Musculoskeletal chronic pain syndrome Fatigue and sleep disturbances Multiple tender points-back of head, upper back of head and neck, upper chest, elbows, hips and knees Unknown etiology, more common in women than in men

Fibromyalgia Clinical manifestations/assessment – Generalized aching – Irritable bowel syndrome – Tension headache – Paresthesia of upper extremities – Sensation of edematous hands

Fibromyalgia Diagnostic tests – No specific diagnostic tests can diagnose FMS Medical management/nursing interventions – Patient education and reassurance – Tricyclic antidepressants – Exercise – Relaxation techniques

Lyme Disease – Caused by bacterium Borrelia burgdoferi; transmitted to humans by bite of blacklegged tick – – Symptoms include: fever, HA, characteristic rash called erythema migrans – If not treated, can spread to joints, heart and nervous system

Lyme Disease Diagnosis based on symptoms, physical findings (e.g. rash) and possibility of exposure to infected ticks Treatment involves several weeks of antibiotics Prevention: insect repellant, remove ticks promptly, pest management

Other Musculoskeletal Disorders

OSTEOPOROSIS Reduction of bone mass Most common: women ages Contributing Factors: – Immobilization – Steroids – High intake caffeine – Diet low in calcium, high in protein – Smoking – Sedentary lifestyle

OSTEOPOROSIS Hormonal influence – Postmenopausal osteoporosis Poss. related to estrogen deficiency – Influences bone resorption and sensitivity to parathyroid hormone - i.e. parathyroid hormone weakens the bone by increasing calcium movement from bone into extracellular fluid.

OSTEOPOROSIS Clinical Manifestations – Backache – Porous and brittle bones – Dowager’s hump Subjective Data: lifestyle pracitices; pain c/o Objective Data: observable deformities; gait impairment; inability to maintain erect posture

OSTEOPOROSIS Medical Management – Lab work: serum calcium, phosphorus, alkaline phosphatase; CBC; BUN, Cr., UA; liver and thyroid function – Bone Mineral Density (BMD) Test – Medication/supplements: (See p. 129 Table 4-6) Calcium Supplements, Vitamin D Weight bearing exercises Estrogen, Biphosphanates (Fosamax, Boniva) Parathyroid hormone – Diet: milk, dairy; limit caffeine, low animal protein (red meat) and low sodium

OSTEOPOROSIS Medications: – Biphosphonates: (Fosamax, Actonel, Boniva) Taken after arising in A.M. with full glass of water No eating or drinking for 30 min. after taking med Remain upright for 30 min. after taking med – Estrogen Receptor Modulator (Evista) Mimic effect of estrogen on bone by reducing bone resorption – Teriparatide (Forteo) Stimulates new bone formation Used to treat osteoporosis in men and post menopausal women at high risk for fx.

OSTEOPOROSIS Treatment Dowager’s Hump: – Surgical Interventions Kyphoplasty: a balloon is used to separate the vertebrae then bone cement is injected to fill the space Vertebroplast: bone cement is injected between the vertebrae without separating the vertebrae