Musculoskeletal Disorders (Adult Care Nursing) Part 4

SYSTEMIC DISORDERS WITH MUSCULOSKELETAL MANIFESTATIONS

Gout

The body produces substances called purines during metabolism. If the body is unable to metabolize these substances, uric acid accumulates in the bloodstream and forms crystal deposits in the joints.

IN PRACTICE :IMPORTANT MEDICATIONS 77-1

FOR ARTHRITIS

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Ibuprofen (Motrin, Advil, Nuprin)

Indomethacin (Indocin)

Piroxicam (Feldene)

Sulindac (Clinoril)

Naproxen (Naprosyn, Aleve)

Ketoprofen (Orudis)

Ketorolac tromethamine (Toradol)

Nabumetone (Relafen)

Gold Salts

Auranofin (Ridaura)

Aurothioglucose (Solganal)

Gold sodium thiomalate (Myochrysine)

Antimalarials

Hydroxychloroquine sulfate (Plaquenil sulfate) Chloroquine (Aralen)

Corticosteroids

Cortisone (Cortone)

Hydrocortisone

Prednisone

Immunosuppressives

Methotrexate (Amethopterin)

Azathioprine (Imuran)

Cyclophosphamide (Cytoxan)

This arthritic condition, called gout or hyperuricemia, usually affects the big toe, instep, ankle, or knee, but it may appear in any joint. Gouty arthritis is more common in men. Alcohol, allergies, surgery, injury, infection, nitrogenous or fatty foods, a fasting diet, emotional stress, or a change in the person’s environment can trigger a gout attack.

IN PRACTICE: EDUCATING THE CLIENT 77-1

EXERCISING WITH ARTHRITIS

•    Keep your body in the best possible physical condition. Control weight, rest, and exercise.

•    Exercise daily even if you have pain. Do specific exercises and not just daily work.

•    Apply heat before exercise to lessen pain. Do not overdo exercise because of lessened pain.

•    Prepare for exercise with gentle stretching.

•    When possible, do active exercise. If not possible, do isometrics or have someone perform passive exercise. You may use a continuous passive motion machine. Stretching and exercise are better when they are done actively (self-movement) rather than passively (by a nurse or therapist).

•    Engage in low-impact exercises such as swimming, slow walking, or bicycling.

•    Stop exercising if pain becomes too severe.

•    Use an adaptive brace or corrective corset or brace as needed.

•    Prevent contractures: turn doorknobs to radial (thumb) side when possible. Flatten hand as much as possible.

Signs and Symptoms

Periodic gout attacks are characterized by joint swelling, redness, and severe pain. The slightest touch or weight on the affected area is unbearable during an attack. The person may have fever, tachycardia (rapid heartbeat), and anorexia. An attack lasts from 3 to 14 days, after which it disappears suddenly. It may return at any time. However, at other times, the joint is normal. Eventually, repeated attacks permanently damage the joint and limit its ROM. Renal damage and vascular damage (especially atherosclerosis) can follow.

Medical Treatment

Gout cannot be cured, but attacks can be prevented and controlled by adhering to prescribed routines and making regular visits to healthcare providers. Some physicians instruct clients to avoid high-purine foods (e.g., liver); other physicians prescribe no dietary changes. Gradual weight loss and avoidance of excessive alcohol intake are encouraged.

Colchicine (Colsalide) is usually effective in relieving gout symptoms. If this medication is given early enough, it works within 12 to 24 hours. Side effects include gastrointestinal disturbances (nausea, vomiting, abdominal pain, and diarrhea). The healthcare provider also may order corticosteroids or NSAIDs. Probenecid (Benemid) is used in longterm management because it prevents the kidney’s reabsorption of uric acid. Allopurinol (Zyloprim) inhibits uric acid formation. Instruct clients taking any of these medications to drink at least 3 L of a variety of fluids each day to promote excretion of a large urine volume. When taking these medications, clients should not take aspirin or any other salicylate because they counteract the effects of gout-relieving drugs.

Nursing Considerations

The affected joint needs protection. If the client is in bed, use a bed cradle to protect the joint. If necessary, hang a warning sign in a prominent place to prevent jarring or bumping of the bed. Gentle application of warm or cold compresses is sometimes ordered. Elevate the affected joint for comfort. To prevent the joint from stiffening, start ROM exercises as soon as the pain and the redness clear.

Lupus Erythematosus

The two types of lupus erythematosus are discoid and systemic. Discoid lupus erythematosus is a chronic disease with skin manifestations of disk-like patches with raised, reddish edges and depressed centers. Systemic lupus erythematosus (“lupus”) is an autoimmune systemic disorder that affects many body systems.

People with systemic lupus erythematosus (SLE) produce autoantibodies that ultimately contribute to immune-complex formation and tissue damage. SLE primarily affects women. It can be acute or chronic, marked by remissions and exacerbations. It causes widespread damage to the collagen system, affecting any organ system, including the kidneys, heart, and lungs. The characteristic sign of SLE is a butterfly rash on the face. However, a rash may appear over other body parts as well. Arthritic symptoms include joint pain and muscle aches. Other symptoms include anorexia, nausea, vomiting, swollen glands, and general malaise. In severe cases, the inflammatory process may involve the lining of the lungs and heart, with damage to the kidneys, central nervous system, or brain.

Medical Treatment

Although SLE has no known cure, early intervention can often prevent serious joint damage. Treatment, which is focused on preventing complications, minimizing disability, and preventing organ dysfunction, is based on manifestations of symptoms.

Commonly used medications include NSAIDs, corticosteroids, and immunosuppressive drugs. Teach clients to avoid sunlight because it can intensify skin manifestations. If clients cannot avoid the sun, instruct them to apply sunscreen lotion with a sun protection factor (SPF) of at least 22. Adequate rest and prevention of exhaustion are essential. Treatment of the musculoskeletal symptoms of SLE is similar to the treatment of other types of arthritis: medication, exercise, and physical therapy.

Scleroderma

The term scleroderma means “hard skin.” Scleroderma is considered a collagen disorder that involves chronic hardening and shrinking of connective tissues. Most often, this condition affects women, usually beginning in middle age. Its most severe forms commonly affect men, African Americans, and older people. Scleroderma may have an autoimmune component. The disorder may be localized or generalized.

Localized scleroderma primarily involves the skin, muscles, and bones and is a less-severe form. Generalized scleroderma involves the skin, muscles, joints, and internal organs, such as the heart, digestive tract, lungs, and kidneys. Sclerodactyly is scleroderma of the fingers and toes; acrosclerosis is scleroderma of the distal extremities and face.

The disorder begins on the face and hands, where the skin becomes hard and unwrinkled and cannot be raised from the underlying structures. The condition slowly spreads. The person often has joint pain and difficulty moving. Raynaud’s phenomenon, evidenced by hands or fingers that are cold, numb, tingling, or blanched, is usually an early symptom. Over time, the face appears tight, shiny, and rigid. The fingers may become flexed and atrophied. Death may result from respiratory or renal failure or cardiac dysrhythmias.

Treatment is symptomatic. Joint manifestations are treated in the same manner as in other arthritic conditions. Drug therapy has been ineffective in treating scleroderma.

Nursing Considerations

Because of the client’s hardened skin, take measures to prevent skin breakdown. Also consider the condition of the client’s hardened skin when giving injections. Teach clients to avoid smoking and exposure to cold. Emotional support is vital.

Rickets and Osteomalacia

Rickets is a disease that results from a deficiency of vitamin D during childhood. The adult form of vitamin D deficiency, which results in softening of the bones, is called osteomalacia. The deficiency causes faulty absorption of calcium and phosphorus, both of which the body needs for normal bone hardening.

In rickets, bones remain soft and become distorted as the child grows. When the bones finally do harden, they remain in this deformed state. Severely bowed legs is an example of an effect of rickets. Children with rickets are slow to walk and cut teeth; they are pale, irritable, and inactive. Exposure to sunshine and vitamin D from an early age prevents rickets, making it rare in developed countries. Milk with vitamin D and exposure to sunshine are preventive measures.

TRAUMATIC INJURIES

Sprains

A sprain is a traumatic injury to the tissues around a joint. The tissues, such as tendons, muscles, and ligaments, can stretch and tear. Bone fractures may result, as the tearing forces of the tendons and ligaments pull against the bone.

Sprains cause swelling, pain, and interference with movement. At first, a sprain may seem mild with minimal swelling. Rupture of the nearby blood vessels often leaves bruises (ecchymosis). Tissue damage can be mild or quite severe. If the sprain is left untreated and the client continues to use the extremity, the tissue damage can become worse. X-ray examinations may be indicated to rule out fractures.

Treat a sprain by elevating the injured part and using an elastic bandage or splint to immobilize and support the affected area. Relieve pain and swelling by applying ice for 24 to 48 hours. After the first 24 to 48 hours, use warm, moist packs to provide pain relief and prevent muscle spasms. Occasionally, the healthcare provider will apply a cast to keep the area immobile and to facilitate healing. Ligament rupture may require surgical repair.

Strains

A strain generally involves damage to the muscle and sometimes to the attached tendon. A strain is a less severe injury than a sprain. Signs and symptoms include pain, swelling, ecchymosis, loss of function, and muscle spasm. Treatment includes application of ice packs for 24 to 48 hours, elevation of the affected part, and rest. Surgical repair may be needed.

Dislocations

When a ligament gives way so completely that a bone displaces from its socket, the resulting injury is called a dislocation. Dislocations cause severe pain, abnormal bone position, and inability to manipulate the joint. Following an x-ray examination, the healthcare provider is usually able to put the bone back into position by stretching the ligaments and manipulating the joint. The client may receive sedation or anesthesia for this procedure. Occasionally, the dislocation cannot be reduced. In this case, the area must be surgically opened and realigned. A splint, a brace, or an elastic bandage is applied to immobilize the parts until they heal.

Apply ice to reduce swelling. Perform neurovascular checks above and below the affected area. The joint capsule and surrounding ligaments may take several weeks to return to their normal position.

Fractures

Any break or crack in a bone is called a fracture (Fx). Fractures occur when stress placed on a bone is greater than the bone can withstand. Pathologic fractures are bones that break spontaneously or with nominal trauma, in diseases such as osteomalacia, osteoporosis, bone cancer, and osteomyelitis. An older adult client may experience a pathologic fracture to an ankle, hip, or wrist by the ordinary act of getting up out of a chair.

Key Concept Fractures involving any part of the vertebral column are very serious. Cervical fractures, especially C-1 to C-4, can be immediately life-threatening. Cervical fractures can result in long-term respiratory dependency All vertebral fractures can result in various levels of paralysis, with motor and nerve impairment. If you suspect any vertebral injury immobilize the client and call for help immediately

Most fractures, however, result from significant trauma. Usually surrounding structures, such as muscles, blood vessels, ligaments, and tendons, are injured as well. Traumatic events that cause fractures include striking a hard surface, a hard fall, or being subject to an indirect force that exerts a strong pulling force on the bone, such as getting a foot caught between rocks and the body falling away from the rocks.

Special Considerations: LIFESPAN

Child Abuse

Child abuse is a common cause of fractures in children. Suspect abuse in a child who presents with fractures if the child’s medical history is inconsistent, the child is younger than 1 year; the fracture is inappropriate for the child’s developmental level, fractures have occurred at different times, a sibling is blamed for the injury, other evidence of abuse exists, or family caregivers delay seeking treatment.

Until age 45, more men than women have fractures; however, after this time, more women are affected because menopausal changes may cause decalcification of bones (osteoporosis). Many women take oral calcium in an effort to prevent osteoporosis. Some physicians advise women to take the hormones estrogen and progesterone. A bisphosphonate, alendronate (Fosamax), increases bone density and reduces the risk of fractures and deformities.

Special Considerations: LIFESPAN

Slippery floors and bathtubs, loose rugs, and dark stairways or corners are hazardous, especially for older adults.

Types and Patterns

The following are basic categories of fractures:

•    Complete: An entire cross-section of the bone is involved; the bone is usually displaced, which means that the bone fragments are out of alignment.

•    Incomplete: A portion of the cross-section of the bone is involved.

•    Closed: The overlying skin is intact (this is sometimes called simple fracture).

•    Open: The overlying skin is broken (this is sometimes called compound fracture), with various grades of tissue involvement.

The pattern of the break defines some fractures. For instance, there are transverse, oblique, and spiral fractures, which are defined according to the direction of the fracture in the bone. A fracture may be depressed, in which bone splinters are driven into underlying tissue. In a compression fracture, the bone collapses in on itself. In a greenstick fracture, one side of the bone breaks, while the other side bends (Fig. 77-3).

Signs and Symptoms

The most pronounced symptom of a fracture is pain that becomes more severe with movement of the part or when pressure is placed over the affected area. Loss of function and deformity (an unnatural position of the part) may accompany pain. Other symptoms include swelling over the part and discoloration caused by bleeding within the tissues.

FIGURE 77-3 · Fracture types and patterns. Fractures are classified according to type (complete, incomplete, closed [simple], or open [compound]) and the direction of fracture line (transverse, oblique, spiral, depressed or compression, and greenstick).

Nursing Alert A complicated fracture may result in the loss of the pulse distal to the fracture. Perform frequent neurovascular checks of the affected extremity Compare skin color, pulse strength and symmetry and movement proximally and distally to the injured areas.