Nursing of Adult Patients with Medical

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Nursing of Adult PatientswithMedical Surgical
Conditions

• Musculoskeletal
• Disorders

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Assessment

• Scoliosis
• Lateral curvature of the spine

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Assessment

• Kyphosis
• A rounding of the thoracic spine
• Hump-backed appearance

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Assessment

• Loradosis
• An increase in the curve at the lumbar region

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Assessment

• Blanching Test
• Capillary nail refill
• Signals circulation status
• Compress each fingernail or toenail, release the
  pressure, and note how quickly the pink color
  returns to the nail bed.
• Should return to normal color within 2 seconds

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Diagnostic Tests

• Myelogram
• Injection of a radiopaque dye into the
  subarachnoid space at the lumbar spine to
  determine the presence of herniated disk or
  tumors.
• Assess for allergies to iodine and seafood
• Oil-based dye
• Removed to prevent meningeal irritation
• Flat for 12 hours (keeps air space in lower
  spine)
• Water-soluble dye
• Not removed absorbed by body
• Semi-fowlers position for 8 hours (keeps dye in
  lower spine)
• Encourage fluids to assist with absorption of dye

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Diagnostic Tests

• Nuclear Scanning
• Given a low dosage of radioactive isotopes
• Scanner or camera detector is used to record
  images
• Nursing Measures
• Written consent
• Informing the patient about radioacive isotopes
  will not affect others
• Follow instrucitions by nuclear medicine dept.

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Diagnostic Tests

• Magnetic Resonance Imaging
• Involves the use of magnetism and radio waves to
  make images of cross sections of the body
• Gives detailed picture of fluid filled soft
  tissue and blood vessels
• Patient must remove any metal objects
• patients with metal prosthesis (heart valves,
  othopedic screws) cannot undergo and MRI
• Sedatives may be given for anxiety due to
  claustrophobia

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Diagnostic Tests

• Computer Axial Tomography (CAT scan)
• 3-D picture of the structure (Soft tissue
  bones)
• More sensitive than standard x-rays
• Iodine contrast may be used
• Nursing Measures
• Written consent
• Ask about allergies to iodine and seafood
• NPO 3-4 hours before test
• Baseline vital signs
• Remove jewelry, etc.
• Teach pt. about procedure

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Computer Axial Tomography (CAT scan)
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Diagnostic Tests

• Bone Scan
• Detects metastatic and inflammatory bone disease
• Radioisotopes administered IV 2-3 hours before
  test
• Encourage fluids
• A scanning camera is used to reveal the degree of
  uptake
• Areas of uptake may indicate a tumor or other
  abnormality

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Diagnostic Tests

• Arthroscopy
• Direct visualization of a joint
• exploration of joint
• drainage of fluid from the joint
• removal of damaged tissue or foreign bodies
• Involves insertion of a large-bore needle into
  the suprapatellar pouch.
• Patient may be given a general or local
  anesthetic
• Activities may be limited for several days

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Diagnostic Tests

• Synovial Fluid Aspiration
• The puncture of a joint with a needle and the
  withdrawal of synovial fluid
• Used for diagnosis of trauma, systemic lupus,
  gout, osteoarthritis, and rheumatoid arthritis
• Normally straw colored, clear, or slightly cloudy
• After procedure
• support extremity
• joint rest for 12 hours
• ice to joint for 24 - 48 hours
• assess for s/s of infection

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Diagnostic Tests

• Electromyogram (EMG)
• Insertion of needle electrodes into the skeletal
  muscles to record the electrical activity
• Muscles do not produce electrical charge at rest
• Unusual patterns may be observed for neuropathy
  and myopathy

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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
• Agents that should protect the body attack joint
  tissues
• Can affect lungs, heart, blood vessels, muscles,
  eyes and skin
• Chronic inflammation of the synovial membrane of
  the diarthrodial joints (movable)

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Rheumatoid Arthritis

• Signs Symptoms
• Characterized by periods of remission and
  exacerbation
• Malaise
• Muscle weakness
• Loss of appetite
• Generalized aching
• Edema tenderness of joints
• Limited range of motion (morning stiffness)

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Rheumatoid Arthritis
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Rheumatoid Arthritis

• Diagnostic Tests
• Radiography studies show loss of articular
  cartilage and change in bone structure
• Laboratory Tests
• Erythrocyte Sedimentation Rate (ESR)
• increase indicates inflammation
• Rheumatoid Factor (RF)
• elevation indicates abnormal serum protein
  concentration
• Latex agglutination test
• detects presence of IgM version of rheumatoid
  factor (anti-IgG antibodies)
• Synovial fluid aspiration
• fluid is cloudy, yellow, less viscous and
  increased protein

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Rheumatoid Arthritis

• Treatment
• Medications
• Salicylates (Aspirin)
• Nonsteroidal Anitinflammatory Drugs (NSAIDs)
• indomethacin (Indocin)
• ibuprofen (Motrin)
• naproxen (Naprosyn)
• piroxicam (Feldene)
• nabumetone (Relafen)
• Potent Antiinflammatory Agents
• adrenocorticosteroids (prdnisone)
• phenylbutazone (Butazolidin)
• Slow-Acting Antiinflammatory Agents (6-12 mo.)
• hydroxychloroquine (Plaquenil)

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Rheumatoid Arthritis

• Rest
• 8-10 hours of sleep a night 2 hour nap during
  day
• Exercise
• Range of motion 2-3 times per day
• prevents joints from freezing and muscles from
  weakening
• Heat
• Hot packs, heat lamp, and/or hot paraffin
• Relaxes and soothes muscles
• Rehabilitation
• Help pt. to adapt to physical limitaions and
  promoting normal daily activities

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Rheumatoid Arthritis

• Prognosis
• Remissions and exacerbations are common
• Disease normally progresses to include joint
  deformity, extensive muscle atrophy, soft tissue
  lesions, bone and cartilage destruction, and
  fibrous or bony ankylosis (fixed joints)

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Ankylosing Spondylitis

• 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

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Ankylosing Spondylitis

• Signs Symptoms
• Low back pain and stiffness
• sciatica pain lasts for a few days then
  subsides
• worse when standing
• May also affect joints in the neck, jaw,
  shoulders, knees, and hips
• Decreased ROM
• Elevated temperature
• Tachycardia
• Hyperpnea

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Ankylosing Spondylitis
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Ankylosing Spondylitis

• Diagnostic Tests
• Hemoglobin and Hematocrit
• Low due to anemia
• ESR
• elevated due to inflammation
• Serum alkaline phosphatase
• elevated due to immobilization
• Radiographic
• reveals sacroiliac joint and intervertebral disk
  inflammation with bony erosion and joint space
  fusion

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Ankylosing Spondylitis

• Treatment
• Analgesics
• NSAIDs
• Exercise program
• swimming and walking
• Surgery
• replace fused joints
• Maintain spine alignment
• firm mattress
• bed board
• back brace
• Breathing exercises
• Turn and position every 2 hours

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Ankylosing Spondylitis

• Prognosis
• Chronic disease
• Lasts about 20 years leaving permanent damage

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Degenerative Joint Disease (Osteoarthritis)

• Etiology/Pathophysiology
• Nonsystemic, noninflammatory disorder that
  progressively causes bones and joints to
  degenerate
• Primary
• Cause is unknown
• Secondary
• Caused by trauma, infections, previous fractures,
  rheumatoid arthritis, stress on weight-bearing
  joints.

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Degenerative Joint Disease (Osteoarthritis)
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Degenerative Joint Disease (Osteoarthritis)

• Signs Symptoms
• Joint edema, tenderness, instability, and
  deformity
• Heberdens Nodes
• nodules on the sides of the distal joints of
  fingers
• Bouchards Nodes
• nodules on the proximal joints of fingers

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Degenerative Joint Disease (Osteoarthritis)
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Degenerative Joint Disease (Osteoarthritis)

• Diagnostic Tests
• Radiographic studies
• Arthroscopy
• Synovial fluid examination
• Bone scans

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Degenerative Joint Disease (Osteoarthritis)

• Treatment
• Exercise balanced with rest
• Heat applications
• Gait enhancers (canes, walkers, etc.)
• Medications
• Salicylates (aspirin)
• NSAIDs (Motrin)
• Steriods (cortisone)
• Surgery
• Osteotomy
• Joint replacement

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Degenerative Joint Disease (Osteoarthritis)

• Prognosis
• Chronic disease that ultimately causes permanent
  destruction of affected cartilage and underlying
  bone.

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Gout (Gouty Arthritis)

• Etiology/Pathophysiology
• Metabolic disease resulting from an accumulation
  of uric acid in the blood
• Caused by an ineffective metabolism of purines
• Primary
• hereditary factors
• Secondary
• use of certain drugs, complication of other
  diseases, or idiopathic
• Affects men more frequently than women
• Does not occur before puberty in the male or
  before menopause in the female

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Gout (Gouty Arthritis)

• Signs Symptoms
• Excruciating pain
• Edema
• Inflammation
• Most common in the great toe
• Tophi
• calculi deposits

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Gout (Gouty Arthritis)
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Gout (Gouty Arthritis)

• Diagnostic Tests
• Serum and uric acid levels
• Complete blood count
• ESR
• Radiography studies
• reveal cysts
• Synovial fluid aspiration
• contain urate crystals

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Gout (Gouty Arthritis)

• Treatment
• Medications
• colchicine
• decreases uric acid
• phenylbutazone (Butazolidin)
• indomethacin (Indocin)
• antiinflammatory
• corticosteroids
• allopurinol (Zyloprim)
• decreased the production of uric acid
• sulfinpyrazone (Anturane)
• increases secretion of uric acid by the kidneys

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Gout (Gouty Arthritis)

• Encourage fluid intake
• at least 2000 cc/day
• Monitor intake and output
• Bed rest and joint immobilization
• Diet
• Avoid high purine foods
• organ meats
• anchovies
• yeast
• herring
• mackerel
• scallops

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Gout (Gouty Arthritis)

• Prognosis
• Signs and symptoms are usually recurrent
• Can progress to destructive joint changes

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Osteoporosis

• Etiology/Pathophysiology
• Reduction of bone mass
• Most common in women ages 55-65
• possibly related to lack of estrogen
• Contributing Factors
• Immobilization
• Use of steroids
• High intake of caffeine
• Diet low in calcium
• Smoking
• Excessive protein in diet
• Sedentary lifestyle

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Osteoporosis

Magnification of Healthy Bone
Bone with Osteoporosis
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Osteoporosis

• Signs Symptoms
• Backache
• especially in the thoracic and lumbar regions
• worse with sitting, standing, coughing, sneezing,
  and straining
• Bones porous and brittle
• pathological or spontaneous fractures
• Dowagers hump
• spinal deformity and height loss that develop
  from repeated spinal vertebral fractures

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Osteoporosis

• Diagnostic Tests
• CBC
• Serum calcium
• Phosphorus
• Alkaline phosphatase
• Blood urea nitrogen
• Creatinine level
• Urinalysis
• Liver and thyroid function tests
• Radiography studies

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Osteoporosis

• Treatment
• Calcium supplements
• 1000 mg for men
• 1500 mg for women
• Vitamin D
• Weight-bearing exercises
• Estrogen
• alendronate (Fosamax)
• absorbs calcium phosphate crystal in bone
• Diet
• Milk and dairy products provide the most calcium
• Limit caffeine

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Osteoporosis

• Prognosis
• Chronic disorder
• Prevention should begin before bone loss occurs

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Osteomyelitis

• Etiology/Pathophysiology
• Local or generalized infection of the bone and
  bone marrow
• Staphylococci most common cause
• Introduced through trauma (injury or surgery) or
  by the bloodstream from another site in the body
  to the bone
• Bacteria invade the bone and degeneration of bone
  occurs

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Osteomyelitis

• Signs Symptoms
• Persistent, severe, and increasing bone pain
• Wound draining purulent fluid
• S/S of infection
• temperature, tachycardia, and tachypnea
• Edema of affected area

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Osteomyelitis

• Diagnostic Tests
• Radiography studies
• Bone scan
• CBC (esp WBC)
• ESR
• Cultures of blood and drainage

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Osteomyelitis

• Treatment
• Antibiotic therapy
• broad-spectrum antibiotic
• Keflin (cephalothin)
• IV for several weeks
• Surgery
• removal of necrotic bone
• Absolute rest of affected extremity
• Wound Care
• irrigate with hydrogen peroxide or antibiotic
  solution
• cover with sterile dressing
• Drainage and secretion precautions
• Diet
• high in calories, protein, and vitamins

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Osteomyelitis

• Prognosis
• Acute
• usually responds to treatment after several weeks
• Chronic
• may persist for years with exacerbations and
  remissions

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Herniation of Intervertebral Disk(Herniated
Nucleus Pulposus)

• Etiology/Pathophysiology
• Rupture of the fibrocatrilage surrounding an
  intervertebral disk, releasing the nucleus
  pulposus that cushions the vertebrae above and
  below
• Lumbar and cervical herniations are most common
• May occur from lifting, twisting, trauma, or
  degenerative changes.

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Herniation of Intervertebral Disk(Herniated
Nucleus Pulposus)
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Herniation of Intervertebral Disk(Herniated
Nucleus Pulposus)

• Signs Symptoms
• Lumbar
• low back pain that radiates over the buttock and
  down the leg
• numbness and tingling in affected leg
• Cervical
• neck pain, headache, and neck rigidity

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Herniation of Intervertebral Disk(Herniated
Nucleus Pulposus)

• Diagnostic Tests
• Radiography studies
• CT
• Myelogram
• Electromyelography (EMG)

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Herniation of Intervertebral Disk(Herniated
Nucleus Pulposus)

• Treatment
• Bed rest
• Pain medication
• Muscle relaxants
• Physical therapy
• muscle strengthening
• ultasound
• heat - cold application
• Traction
• pelvic or cervical

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Herniation of Intervertebral Disk(Herniated
Nucleus Pulposus)

• Surgery
• Laminectomy
• Removal of the bony arches or vertebrae
• Removal of displaced vertebral disk
• Spinal Fusion
• Immobilization of joint
• Remove disk and fuse vertebrae may use bone from
  iliac crest
• Diskectomy
• Removal of extruded disk material
• Chemonucleolysis
• Injection of chymopapain to dissolve the nucleus
  pulposus

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Tumors of the Bone

• Etiology/Pathophysiology
• May be primary or secondary
• Benign or Malignant
• Osteogenic sarcoma
• primary malignant bone tumor
• seen most often in male ages 10-25
• can metastasize via bloodstream
• fast-growing and aggressive
• Osteochondroma
• benign tumor
• seen most often in males ages 10-30
• may be a single tumor or muliple tumors

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Tumors of the Bone

• Signs Symptoms
• Spontaneous fractures
• Anemia
• Pain esp. with weight bearing
• Edema and discoloration of skin at site

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Tumors of the Bone

• Diagnostic Tests
• Radiography studies
• Bone Scan
• Bone biopsy
• CBC
• Platelet count
• Serum protein levels
• serum alkaline phosphatase level

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Tumors of the Bone

• Treatment
• Surgery
• Depends on tumor size, location and extent of
  tissue involvement
• Wide excision or resection
• Bone curettage
• Leg or arm amputation
• Chemotherapy and Radiation
• Decrease size or tissue involvement before
  surgery
• Limb-salvage procedure

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Tumors of the Bone

• Prognosis
• Survival rates with aggressive treatment are
  approximately 50 at 5 years

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Traumatic Injuries

• Contusions
• An injury from a blow or blunt force which causes
  local bleeding under the skin
• Treatment
• Cold compresses for 15-20 minutes intermittently
  for 12 to 36 hours
• Elevate involved extremity

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Traumatic Injuries

• Sprains
• Results from a wrenching or hyperextension of a
  joint, tearing the capsule and ligaments
• May involve bleeding into the joint
  (hemarthrosis)
• Treatment
• Cold compresses for 15-20 minutes intermittently
  for 12 to 36 hours
• Elevate involved extremity

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Traumatic Injuries

• Whiplash
• Injury at cervical spine caused by hyperextension
• Usually caused by violent back-and-forth
  movements of the head and neck
• Symptoms
• Pain in the cervical area may radiate down the
  arm
• Headache, blurred vision, weakened hand grip
• Treatment
• Analgesics
• Muscle relaxants
• Cervical traction (neck brace)

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Traumatic Injuries

• Ankle Sprains
• Caused by a wrenching or twisting of the foot and
  ankle
• Signs Symptoms
• Edema of the ankle
• Pain with movement of ankle
• Treatment
• Elevate injured area
• Cold compresses for 15-20 minutes intermittently
  for 12-36 hours
• Warm compresses for 15-30 minutes four times a
  day after 24 hours
• Compressive dressings and splint
• Surgery
• may be necessary for torn ligaments

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Traumatic Injuries

• Strains
• Microscopic muscle tears as a result of
  overstretching muscles and tendons
• Signs Symptoms
• Sudden severe pain in affected muscle
• Ecchymosis and edema over area
• Treatment
• Analgesics
• Exercise legs
• Cold compresses 15-20 minutes for 12-36 hours
  then warm compresses 15-30 minutes after 24 hours
• Surgery
• may be required if muscle is completely ruptured

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Traumatic Injuries

• Dislocations
• Etiology/Pathophysiology
• Temporary displacement of bones from their normal
  position
• May be caused by
• congenital
• disease process
• trauma

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Traumatic Injuries

• Signs Symptoms
• Erythema
• Discoloration
• Edema
• Pain
• Limitation of movement
• Deformity or shortening of the extremity

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Traumatic Injuries

• Treatment
• Closed reduction
• Open reduction
• Cold compresses first 24 hours and warm
  compresses after 24 hours
• Elevate injured extremity
• Elastic bandage
• Immobilze
• splint
• sling
• Analgesics
• Demerol, Morphine
• Motrin, Tylenol

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Carpal Tunnel Syndrome

• Etiology/Pathophysiology
• Compression of the median nerve between the
  carpal ligament and other structures in the
  carpal tunnel

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Carpal Tunnel Syndrome

• Predisposing Factors
• Obese, middle aged women
• Employment in occupations involving repetitious
  motions of the fingers and hands
• computer usage
• basket weaving
• meat carving
• typing

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Carpal Tunnel Syndrome

• Signs Symptoms
• Paresthesia
• sensation of pricks of pins and needles
• Hypoesthisia
• decrease in sensation in response to stimulation
• Burning pain or tingling in the hands
• may be intermittent or constant
• Inability to grasp or hold small objects
• Edema of the hand, wrist, or fingers
• Muscle atrophy
• Depressed appearance at the base of the thumb on
  the palmer side

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Carpal Tunnel Syndrome

• Diagnostic Tests
• Physical exam
• Tinels sign
• increased tingling with gentle tap over tendon
  sheath on ventral surface of central wrist
• Electromyogram
• MRI

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Carpal Tunnel Syndrome

• Treatment
• Immobilizer
• cock-up splint
• Elevate extremity
• ROM exercises
• Surgery
• Release carpal ligament
• Post-op Interventions
• Elevate the hand and arm for 24 hours
• Needs to be elevated as high as possible
• ROM to thumb and fingers
• Analgesics
• Monitor vital signs
• Assess fingers for circulation, sensation, and
  movement every 1-2 hours for 24 hours

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Carpal Tunnel Syndrome

• Prognosis
• Mild symptoms may be relieved by nonsurgical
  treatment
• Severe symptoms may be relieved by surgical
  treatment
• Pregnancy induced usually subside after delivery