What can go wrong with What can go wrong with bones? bones?
They can become infected Osteomyelitis
They can become soft with decrease in mineralization Osteomalacia
They can become porosis Osteoporosis
They can develop abnormal remodeling andfunctioning of osteoblasts & osteoclasts Pagets
OsteomyelitisOsteomyelitis A severe infection of the:
bone bone marrow surrounding connective tissue
Most common causative organism is Staphylococcus aureus
OsteomyelitisOsteomyelitis
How does a person get an How does a person get an infection?infection?
Indirect Entry
Direct Route
Development of Development of OsteomyelitisOsteomyelitis Bacteria invade bone - inflammation
Edema develops and Pressure within bone increases
Bone abscess develops under the periosteum causing a decrease in blood supply with ischemia and bone necrosis. The dead bone tissue, called sequestrum
The abscess cavity does not liquify or drain easily.
The separated periosteum stimulates new bone growth = involcrum which surrounds the sequestrum.
Infection trapped inside sequestrum causing recurring abscesses.
Classification of Classification of OsteomyelitisOsteomyelitis
Acute Chronic
Clinical Manifestations of Clinical Manifestations of OsteomyelitisOsteomyelitis
Systemic
Local
Signs of Chronic Signs of Chronic OsteomyelitisOsteomyelitis
Chronic – an infection that persists for longer than 1 month
Signs and Symptoms
Constant bone pain Swelling Tenderness Warmth at site Continuous Drainage
Osteomyelitis Osteomyelitis DiagnosisDiagnosis
Biopsy of bone or soft tissue Cultures – blood and wound assessing for causative
organism Erythrocyte sedimentation rate (ESR) – elevated WBC - elevated X-ray, no initial bone changes Radionucleotidetide bone scan MRI
What test is the best way to determine the causative organism?
Goals of Care
Halt the InfectionRelieve Pain
Maintain Mobility
Halt the InfectionHalt the InfectionIntravenous AntibioticsIntravenous Antibiotics
Patient will need vigorous and prolonged treatment with antibiotics
Start out in hospital with aggressive antibiotic therapy usually via PICC.
Discharged to home with home health care follow up for up to 6 months
Patient taught care of PICC site and side effects of antibiotics.
OsteomyelitisOsteomyelitis
Assorted IV antibiotics Penicillin, nafcillin (Nafcil) neomycin, vancomycin cephalexin (Keflex), cefazolin (Ancef) cefoxitin (Mefoxin) gentamycin (Garamycin)
Oral Antibiotics ciprofloxacin (Cipro)
Nursing CareNursing Care Toxic effects:
Aminoglycosides - Nephrotoxic, ototoxic, optic neuritis, fluid retention • Renal function tests (creatinine and BUN) should be
done prior to administration and during therapy – therapy depends on test results.
• Vestibular and auditory function are assessed prior to therapy and again 3-4 weeks after drug discontinued.
Cephalosporins and Quinolones – jaundice, colitis,
photosensitivity, crystalluria• C&S prior to beginning treatment
Nursing Care / Patient Nursing Care / Patient TeachingTeaching
Measure peak and trough levels Dosages are adjusted to maintain peak levels
Preventive measures: Monitor I& O; Keep patient well hydrated to
prevent nephrotoxicity or crystalluria Avoid direct sunlight, wear sunscreen Monitor urinary function, hearing, vision Assess for signs of yeast infections in
genitourinary and mouth
Relieve the PainRelieve the Pain
Immobilization of the affected limb
Handle carefully , decreasing manipulation
Give meds NSAID’S Opioid analgesics Muscle relaxants
Maintain MobilityMaintain Mobility
After the initial treatment and decrease of pain, need to make sure that limb mobility is maintained ROM Assist to stand and ambulate Provide assistive devices to help with
ambulation
Surgical Treatment and Surgical Treatment and Nursing CareNursing Care
Debridement of the wound Insertion of antibiotic-impregnated
polymethylmethacrylate bead chains to combat the infection
Irrigation of wound with antibiotics
Wound vac used to draw wound together – assess wound and drainage
Treatment and Nursing Treatment and Nursing CareCare
OsteomyelitisOsteomyelitis Hyperbaric oxygen therapy – stimulates
circulation and healing of infected tissue Bone grafts If all else fails – amputation Nursing Care – good body alignment,
ROM, dressing changes, patient teaching about
antibiotics and use of assistive devices, monitor patients response to antibiotic therapy.
Try ThisTry This
Which of these manifestations should cause the nurse the MOST concern after treating a patient with osteomyelitis for two days with IV antibiotics? A. Sudden increase in temperature B. Complaints of pain at site of infection C. Drainage from wound D. Guarding of involved extremity
Metabolic Bone Disease
OsteomalaciaOsteomalacia Decalcification and softening of the bone
Caused mainly by: vitamin D deficiency **Vitamin D is required for the
absorption of calcium from the intestine and calcium
is responsible for mineralization of bone
Vitamin DCalcium
OsteomalaciaOsteomalacia
Who is at risk for developing osteomalacia?
Someone with: lack of exposure to ultraviolet rays (sun) GI malabsorption, extensive burns,
chronic diarrhea, pregnancy, drugs such as Dilantin.
OsteomalaciaOsteomalaciaSigns and SymptomsSigns and Symptoms
Most Common Bone pain Difficulty rising from a chair Difficulty walking
Additional Signs and Symptoms Low back pain, muscle weakness Weight loss, progressive deformities
DiagnosisDiagnosis Blood work – how do each of these
tests assist in diagnosing Osteomalacia? serum calcium or phosphorus alkaline phosphatase
X-Rays Show looser's transformation zone – (ribbons of decalcification in bone)
Treatment and Nursing Treatment and Nursing CareCare
OsteomalaciaOsteomalacia Medication Therapy Vitamin D supplements Calcium salts or phosphorus supplements
What would the nurse teach the patient to eat to increase vitamin D and calcium?
What is the purpose of weight bearing exercises? What are examples of weight bearing
exercises?
OsteoporosisOsteoporosis
Characterized by low bone mass and structural deterioration
Normal homeostatic bone remodeling is altered – the rate of bone resorption is greater than the rate of bone formation.
OsteoporosisOsteoporosis
Osteoporosis is more common in women than
men because?
DiagnosisDiagnosisBone Mineral Density Test Bone Mineral Density Test
(BMD)(BMD) Dual-energy x-ray absorptiometry
(DEXA)
Treatment and Nursing Treatment and Nursing CareCare
Diet Therapy Encourage a diet high in calcium – see chart
p.1636.
Weight bearing Exercises ** Impact aerobics is NOT encouraged
Decrease Risk Factors Quit smoking and decrease consumption of
alcohol
Medications used in Medications used in Treatment of OsteoporosisTreatment of Osteoporosis
Estrogen Replacement Therapy Calcium & Vitamin D supplements Calcitonin Bisphosphonates (Fosamax, Didronel,
Actonel, Boniva, Aredia, Bonefos, Skelid) Selective Estrogen receptor modulator –
Evista
Medications used in Medications used in treatment of Osteoporosistreatment of Osteoporosis
Hormone Replacement Therapy – Estrogen Controversy over use. Should discuss with health
care provider Calcium
There is a variety of calcium supplements available (See Table 64-15, p. 1636). • They should be taken with Vitamin D to aid in
absorption. • Also if taking large doses i.e. 1000 mg. / day –
take in divided doses of 500mg BID for better absorption
Medications used in Medications used in treatment of Osteoporosistreatment of Osteoporosis
Calcitonin A hormone made by the thyroid gland
that helps keep calcium levels in the body from getting too high. It does this mainly by blocking the breakdown (absorption) of bone, which slows the release of more calcium into the blood
What is needed to counter that effect?
Medications used in Medications used in treatment of Osteoporosistreatment of Osteoporosis
Bisphosphonates – (Fosamax, Boniva) Inhibit osteoclast-mediated bone resorption thereby
increasing BMD and total bone mass.
Side effects – anorexia, weight loss, gastritis
Patient Teaching• Take on an empty stomach, in the morning, at least 30
minutes before any food, beverages or medications. • Do not take within 2 hours of any calcium- containing food• To decrease esophageal irritation - take with a full glass of
water, and the patient must remain upright for at least 30 minutes after taking the medication.
Medications used in Medications used in treatment of Osteoporosistreatment of Osteoporosis
Selective Estrogen Receptor Modulators Mimic effect of estrogen on bone by
reducing bone resorption without stimulating the breasts or uterus.
Side effects•Leg cramps•Hot flashes
Paget’s DiseasePaget’s Disease
Excessive bone resorption followed by replacement of normal marrow by vascular, fibrous connective tissue.
The new bone is larger, disorganized, and weaker Most often affect the pelvis, long bones, spine, ribs, sternum, and cranium
Paget’s DiseasePaget’s Disease Clinical Manifestations
Bone pain Fatigue CV disease (vasodilation of vessels in skin/tissues
overlying affected bones) Waddling gait; bowing of legs; Hip or knee
involvement can lead to limping, as well as pain and stiffness of the hip or knee.
Headaches, visual deficits, loss of hearing occur as skull becomes enlarged and thickened
Enlarged vertebrae cause spinal cord compression/ pinch of adjacent nerves causing tingling and numbness.
Pagets DiseasePagets Disease
bowing of legs
skull becomes enlarged and thickened
Waddling gait
Hip or knee involvement
can lead to limping
Loss of hearing
Spinal cord compressed
Paget’s DiseasePaget’s Disease Diagnosis
Elevated serum alkaline phosphatase
X-ray will show increase in bone size
Will the bone return to normal size and shape following treatment?
Goal of Treatment
Relieve the Pain
Drug Therapy for Paget’sDrug Therapy for Paget’s
Human calcitonin (Cibacalcin) or Calcitonin-salmon (Miacalcin)
NSAIDS
Bisphosphonates
Paget’s DiseasePaget’s Disease
Other treatments and Nursing Care Back support by firm mattress Teaching about use of Splints or braces
to support bones and joints and help prevent weakened bones - skin care, circulation, etc.
Teach how to correctly use canes or walkers
Physical Therapy
Etiology and Etiology and Pathophysiology of Pathophysiology of
Rheumatoid ArthritisRheumatoid Arthritis Rheumatoid arthritis is an autoimmune disease. This means that the body's immune system mistakenly attacks the tissues it is supposed to protect.
RF antibodies are formed in synovium against body’s IgG antigens.
This leads to formation of immune complexes which cause inflammation of synovium –synovitis.
1. Synovitis causes release of WBC and enzymes which damage the bone and breakdown cartilage of the joint and the surrounding tissues.
2. Vascular granulation tissue grows across the surface of the cartilage (pannas) with loss of cartilage beneath the expanding pannas
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Etiology and Etiology and Pathophysiology of Pathophysiology of
Rheumatoid ArthritisRheumatoid Arthritis3. Inflammatory pannus causes cartilage
destruction and bone erosion.
4. This leads to joint deformities.
Loss of Bone Density
Destruction of bone cartilage
Joint Deformity
Erosion o f edges o f
bone
Increased soft tissue swelling due to
Inflammation and thickening of synovium
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Rheumatoid ArthritisRheumatoid ArthritisSigns and SymptomsSigns and Symptoms
Fatigue Anorexia Weight loss Generalized stiffness Joints are tender, painful,
and warm to touch Rheumatic nodules Multi-system involvement
Rheumatoid ArthritisRheumatoid ArthritisDeformitiesDeformities
BoutonniereBoutonniere
Swan neckSwan neck
SynotenovitisSynotenovitis
Ulnar Drift
Rheumatoid ArthritisDeformities
Mutlans deformity (rapidly progressing RA)
Hitch-hiker thumbGenu valgus (knee away from midline)
Hallux valgus (bunion)
Hammer Toe
Extraarticular Extraarticular ManifestationsManifestations
See page 1652 in Lewis
Nodules
Diagnostic TestingDiagnostic Testing Blood Studies
↑ Rheumatoid factor (RF) – 80% ↑ Erythrocyte sedimentation rate (ESR) ↑ C-reactive protein (CRP)
Synovial fluid analysis
X-rays Will not diagnosis – only show bone changes
Goals of CareGoals of Care
Control disease activity
Relieve pain
Maintain functionality and activities of daily living (ADLs)
Maximize quality of life
Treatment and Nursing Treatment and Nursing Care for Rheumatoid Care for Rheumatoid
ArthritisArthritis See Table 65-3 for meds used for arthritis p.
1646-1647. Salicylates NSAIDs Antibiotics Topical analgesics Corticosteroids DMARDs Gold compounds Antimalarials Immunosupressants Biologic/Targeted therapy
Drug TherapyDrug TherapyDisease-Modifying Antirheumatic Disease-Modifying Antirheumatic
DrugsDrugs
Methotrexate (Rheumatrex)is know as the cornerstone medication in treating RA –
explain.
What are the side effects?
What are important nursing implications?
Drug TherapyDrug Therapy Antimalarials – Plaquenil and Azulfidine Second choice of drug treatment
May suppress formation of antigens
Side effects: • Ocular toxicity - changes in vision, • Ototoxicity - changes in hearing or tinnitus, • Peripheral neuritis - muscular weakness
Nursing Care• Monitor CBC and hepatic function• Tell patient to report any above changes immediately
Drug TherapyDrug Therapy Gold Compounds
Parenteral – Myochrysine, Solganal Oral - Ridaural
Side effects:• Common - Stomatitis, dermatitis, photosensitivity,
proteinuria• Serious - Leukopenia, thrombocytopenia, anemia
Nursing Care:• Observe for pruritis, rash, sore mouth, metallic taste• Monitor CBC, UA
Drug TherapyDrug Therapy Immunosuppressant's – Imuran, Cytoxan
Used to decrease DNA. RNA, protein synthesis Assess for GI irritation Advise patient to report unusual bleeding or bruising Avoid during pregnancy
Biologic/ targeted therapy Used to decrease inflammatory process and slow disease
process Report persistent fever; it may be the only sign of an
infection. Assess for signs of CHF. The response to a PPD may be suppressed and a false
negative may result Giving a live vaccine could result in contracting disease
Relieve PainRelieve Pain NSAID’s
DMARD’s
Non-Pharmacological Heat or Cold applications Rest Relaxation techniques
Treatment and Nursing Treatment and Nursing CareCare
Diet Therapy Rest Heat and cold applications Exercise Patient and Family Teaching Protection of joints – page 1658.
Causes of GoutCauses of Gout
Inflammatory response related to: increase in the production uric acid underexcretion of uric acid increase consumption of foods that
contain purines
Thereby causing high levels uric acid in blood (hyperuricemia)
Causes of GoutCauses of Gout Urate salts deposited in articular, periarticular and
subcutaneous tissue
Primary gout – related to heredity error of purine metabolism in 90% of cases
Secondary gout - to increased cell turnover and related to medications, diseases, leukemia, etc.
Clinical Manifestations of Clinical Manifestations of GoutGout
Stage 1: asymptomatic; hyperuricemic
Stage 2: acute gouty arthritis; affect single joint due to trauma, stress; high level uric acid; joint hot, red swollen; generally metatarsophalangeal joint great toe.
Gout Gout
Stage 3: Chronic Tophi occur if gout untreated >urate pool increases > develop in multiple areas (esp. ear, bursae, toes) > compress nerves and erode through tissues.
Diagnostic TestsDiagnostic Tests Serum Uric acid – elevated; usually above 6
mg/dl; not specifically diagnostic of gout
WBC- elevated as high as 20,000/mm3 during acute attack
ESR: elevated
24 hour urine collection-determine uric acid production and excretion (evaluate if from decreased renal excretion or overproduction of uric acid)
Most commonly diagnosed via clinical symptoms such as Tophi seen – indicator of chronic disease
Drug Therapy for GoutDrug Therapy for Gout
Colchicine
NSAIDs
Corticosteroids
Uricosuric Agents Probenecid (Benemid) Sulfinprazone (anturan)
Drug TherapyDrug Therapy Xanthine-oxidase inhibitors
Decrease uric acid productionDecrease uric acid production
Allopurinal (zyloprim) – can lead to agranulocytosisAllopurinal (zyloprim) – can lead to agranulocytosis
ULORIC (febuxostat)
Force Fluids while on these medications!!Force Fluids while on these medications!! to keep urine alkalineto keep urine alkaline
Treatment and Nursing Treatment and Nursing CareCare
Diet Therapy Avoid foods high in Purine such as?
Treatment and Nursing Treatment and Nursing CareCare
Bedrest and position for comfort
Joint immobilization and protect joint from pressure
Local application of heat or cold
Assess for complications Formation of kidney stones Hypertriglyceridemia Hypertension
Chronic multisystem disease involving vascular and connective tissue
Pathophysiology of SLEPathophysiology of SLE
Lupus is an autoimmune disease characterized by acute and chronic inflammation of various tissues of the body.
Patients with lupus produce abnormal antibodies in their blood that target tissues within their own body rather than foreign infectious agents.
Because the antibodies and accompanying cells of inflammation can affect tissues anywhere in the body, lupus has the potential to affect a variety of areas
Causes of SLECauses of SLE The precise reason for the abnormal
autoimmunity that causes lupus is unknown.
Inherited genes, viruses, ultraviolet light,
Dozens of medications have been reported to trigger SLE.
Clinical Manifestations of Clinical Manifestations of SLESLE Fatigue; Low-grade fever
Loss of appetite Muscle aches; arthritis; polyarthralgia Ulcers of the mouth and nose Facial rash ("butterfly rash") Photosensitivity Pleuritis and pericarditis, tachypnea, Poor circulation to the fingers and toes with cold
exposure (Raynaud’s syndrome) Proteinuria and development of glomerulonephritis Focal seizures, peripheral neuropathy, organic brain
syndrome
DiagnosisDiagnosis
Autoantibody Testing: Anti-DNA- specific Anti- smith antibody (Anti-Sm) Anti nuclear antibody (ANA)
ESR – elevated C-reactive protein – elevated These are not diagnostic for SLE, but help in
the diagnosis
Treatment and Nursing Treatment and Nursing CareCare
What is the single most important medication used in the treatment of SLE?
Other Medications : Anitmalarial Immunosuppressive agents
Treatment and Nursing Treatment and Nursing CareCare
Relieve pain and discomfort and Fatigue Application of heat and cold Encourage to alternate Rest and activity Support devices – braces, splints, firm mattress Analgesics and anti-inflammatory medications
Nursing CareNursing Care
Maintain Skin Integrity Apply topical anti-inflammatory Avoid direct sunlight. Use sunscreens and
protective clothing, sun hats
Increase Mobility ROM Assistive devices – walkers, canes, crutches
Treatment and Nursing Treatment and Nursing CareCare
Facilitate self care Provide adaptive equipment for eating, bathing,
toileting, dressing Allow patient extra time to complete care
Improve body image Encourage patient to verbalize feelings,
perceptions, and fears Monitor for complications
Assess for serious adverse effects of medications used in treatment
Avoid immunizations with live viruses