NURSING CARE OF CLIENTS WITH MUSCULO-SKELETAL DISORDERS

SYSTEMIC LUPUS ERYTHEMATOSUS

• It is chronic, multisystem, collagen disorder.

• Collagen is a protein made up of amino-acids, which are in turn built of carbon, oxygen and hydrogen.

• Collagen contains specific amino acids – Glycine, Proline, Hydroxyproline and Arginine.

• 1.5 million cases of lupus• Prevalence of 17 to 48 per 100,000

population• Women > Men - 9:1 ratio• 90% cases are women• African Americans > Whites• Onset usually between ages of 15 and

45 years, but• Can occur in childhood or later in life

ETIOLOGY• The cause(s) of lupus is currently

unknown, but there are environmental and genetic factors involved.

• Some environmental factors which may trigger the disease include :o Infectionso antibiotics (especially those in the

sulfa and penicillin groups)o ultraviolet lighto extreme stresso certain drugso hormones.

Blood tests in the diagnosis of SLE

The anti-nuclear antibody test (ANA) to determine if autoantibodies to cell nuclei are present in the blood.

The anti-DNA antibody test to determine if there are antibodies to the genetic material in the cell . Tests to examine the total level of serum (blood) complement (a group of proteins which can be consumed in immune reactions), and specific levels of complement proteins C3 and C4.

TREATMENTSDrug therapy

o NSAIDS and antimalarials o Cytotoxic agents (Methotrexate,

Cyclophosphamide)

NURSING CARE OF CLIENTS WITH MUSCULO-SKELETAL DISORDERS

o Anticoagulantso ASAo SteroidsLifestyle changes

-avoiding direct sunlight, covering up with sun-protective clothing, and using strong UVA/UVB sunblock lotion

- Weight loss is also recommended to alleviate some of the effects of the disease, especially where joint involvement is significant.

MUSCULOSKELETAL

-Polyarthritis, mild to disabling, occurs most frequently in hands, wrists, knees. Occurs 90%

• Joint deformities occur in only 10%

• Arthritis of SLE tends to be transitory

• If single joint has persistent pain, consider osteonecrosis (prevalence increased in SLE over general population, especially if on steroids.)

• Myositis with elevated CK and weakness rarely occurs

• Arthritis

-Serositis - PulmonaryPleuritis with or without effusion

if case is mild, tx: NSAIDSif case is severe, tx: steroids

• Life-threatening manifestations: interstitial inflammation which can lead to fibrosis and intra-alveolar hemorrhage.

• Also pneumothorax and pulmonary HTN can occur

- Serositis – Cardiac• Pericarditis: most common

cardiac manifestation and usually responds to NSAIDs.

• Myocarditis (rare) and fibrinous endocarditis (Libman-Sacks) may occur.

Steroids plus treatment for CHF/arrhythmia or embolic events.

• MI due to atherosclerosis can occur in <35 y/o

b. Neuro • Cranial or peripheral neuropathy

occurs in 10-15%, • Diffuse CNS dysfunction:

memory and reasoning difficulty• Headache• Seizures of any type• Psychosis• TIA, Stroke: mostly increased

among patients that are APLA positive

• 50-fold increase in risk of vascular events in women under 45 compared to healthy women

-Treatment for clotting event is long-term anticoagulation

a. Heme • Anemia: usually Normochromic,

normocytic• Leukopenia: almost always consists

of lymphopenia, not granulocytopenia

• Thrombocytopenia

b. Renal

• Nephritis: usually asymptomatic, so always check UA if patient has known or suspected SLE

Additional work-up• Serum cr. and albumin• CBC w/ diff• U/A• ESR• Complement levels• Renal biopsy if warranted

Conservative Management • NSAIDs: to control pain,

swelling, and fever

NURSING CARE OF CLIENTS WITH MUSCULO-SKELETAL DISORDERS

• Caution w/ NSAIDS though. SLE pts are at increased risk for aseptic meningitis

• Antimalarials: Generally to treat fatigue joint pain, skin rashes, and inflammation of the lungs

• Commonly used: Hydroxycholorquine

• Used alone or in combination with other drugs

• Corticosteroids (Mainstay of SLE treatment)- To rapidly suppress inflammation

• Usually start with high-dose IV pulse and convert to PO steroids with goal of tapering and converting to something else.

• Commonly used: prednisone, hydrocortisone, methylprednisolone, and dexamethasone

Immunosuppressives

Azathioprine (imuran): requires several months to be effective, effective in smaller percentage of patients

Methotrexate: for treatment of dermatitis and arthritis, not life-threatening disease

Cyclosporine: used in steroid-resistant SLE, risk of nephrotoxicity

Cyclophosphamide (cytoxan) Almost all trials performed on patients with nephritis

Nursing Management• Complete bed rest – to relieve

muscle and joint pain• ROM exercises – to prevent

contractures• Prevent infection – the client is

immunocompromised• Avoid exposure to sunlight – to

prevent exacerbationo Sunblock with SPFo Long-sleeved clothing

o Hatso Sunglasses

OSTEOMYELITISOsteomyelitis is a bone infection caused by bacteria or other germs.

ETIOLOGY

Bacteria may spread to a bone from infected skin, muscles, or tendons next to the bone. This may occur under a skin sore.

The infection can also start in another part of the body and spread to the bone through the blood.

RISK FACTORS

o Diabeteso Hemodialysiso Poor blood supplyo Recent injuryo Use of illegal injected drugso SYMPTOMSo Bone pain and fevero General discomfort, uneasiness,

malaiseo Local swelling, redness, warmtho Chillso Excessive sweatingo Swelling of ankles, feet and legs

DIAGNOSTIC EXAMS

o Blood cultureo Bone biopsy (which is then cultured)o Bone scan and bone x-rayo Complete blood count o C-reactive protein o Erythrocyte sedimentation rate (ESR)o MRI of the boneo Needle aspiration of the area around

affected

TREATMENT

NURSING CARE OF CLIENTS WITH MUSCULO-SKELETAL DISORDERS

o Antibiotics – to get rid on infectiono Surgery – sequestrectomy – removal of

dead, infected bone and cartilageo Analgesicso Dressing changes – sterile techniqueo Maintain body alignment to prevent

deformities

CARPAL TUNNEL SYNDROME-It is a painful condition caused by compression of the median nerve.

SYMPTOMS

(+) Phalen’s sign – tingling sensation on holding the wrist in flexion for few minutes(+) Tinel’s sign – tingling sensation on percussion on inner wristPain from the wrist to shouldersNumbness, paresthesiaWeak grip of hands

TREATMENT

Rest and splint the affected wristAvoid repetitive flexion of the wristNSAIDs as prescribedCarpal canal cortisone injectionsSurgical release of transverse carpal ligament