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Musculoskeletal
Overview:
โ Bone function โ Posture / shape โ Organ protection โ Makes blood cells โ Erythropoietic from the kidneys to the bones to produce RBCs โ Interruption in this can cause anemia
Arthroplasty:
โ Focus: knee and hip post and pre op โ Goal is to restore function โ Indications โ Pain control โ Improve mobility โ Pain that keeps getting worse and cannot be managed with medication โ Severe osteoarthritis (try to control pain with heat, ice and should have correct amount of activity) โ Rheumatoid arthritis โ Trauma or fractures โ Osteonecrosis โ Failed previous joint procedures โ Congenital abnormalities โ Risk factors: โ Osteoarthritis โ Older people โ Obese patients โ Medications: โ Take acetaminophen as first line for osteoarthritis โ Preoperative care: โ Access ability to learn โ Patient education on recovery โ PT โ Assistive devices โ Exercise โ Infection prevention โ Nurse must assess for infection prior to surgery โ WBC (5k-10k) โ Access blood before surgery โ Anemia? โ High risk for โ Can they clot?
โ CBC/coagulation โ Discontinue aspirin and apixaban prior to surgery! โ Med reconciliation โ NPO after midnight โ Need IV access โ Antibiotics 1-2 hours before to prevent infection โ Postoperative care โ Check operative site for bleeding and edema โ Monitor VS โ CMS check every 2-4 hours โ Color, temp, capillary refill, presence of edema, quality of pulses, sensation โ Do not allow clients to cross legs!! โ Place abduction pillow between legs โ Pain management โ Ice โ 15-20 min at a time, no direct contact with skin, need dry barrier between โ Never apply heat to a surgical site โ Analgesics โ Early ambulation with PT/OT โ Give pain meds 20-30 minutes before PT session โ Risk for DVT โ Give anticoagulants โ Leg exercises โ Compression socks โ Incentive spirometer โ Used for INspiration โ Immobility can impair breathing โ Patient should use this every 2 hours โ ABX 24 hours postoperative โ No adduction โ No hyperflexion โ Cannot sit in high fowlers โ Need to use raised toilet seat โ Client education: โ Inspect incision daily for redness, drainage, swelling (infection) โ Use assistive devices! โ Avoid driving until approved by provider โ No clutter in home (area rugs) โ Adhere to recommended exercise and limitations โ Frequent breaks and give pain meds prior โ Avoid complications โ Hip: avoid adduction, flexion, internal rotation โ Knee: use CPM machine, encourage ROM โ Monitor for: DVT, PE, infection, dislocation
โ Wear appropriate stump socks or liners (prosthetic should never have direct contact with skin) โ If skin is irritated โ discontinue prosthetic temporarily and report to provider โ Attend regular prosthetist appointments โ Rehabilitation โ Support groups and counseling! โ Occupational therapy for ADLs โ ADs: crutches, wheelchair, prosthetic โ Physical therapy for strength and gait
Traction
โ Skeletal โ Invasive โ Infection risk โ Discomfort but more mobility โ More appropriate for reduction and alignment of a fracture โ Skin traction: โ Used for muscle spasms and musculoskeletal discomfort โ Noninvasive
Back Pain
โ Causes
โ Most common mechanical causes are disorders of the spinal structures:
โ Herniated discs - inner disc pushes through outer disc
โ Nerve root pain
โ Compression fractures
โ Osteoarthritis
โ Muscle or tendon strain
โ Spinal stenosis
โ Less common causes:
โ Cancer
โ Infection
โ Inflammation
โ Bacterial infection due to:
โ Penetrating trauma
โ Recent surgery
โ Serious non-mechanical causes (IMMEDIATE intervention needed):
โ Abdominal aortic aneurysm
โ Aortic dissection
โ Angina
โ Meningitis
โ Urinary disorders causing back pain:
โ Pyelonephritis
โ Prostatitis
โ Nephrolithiasis
โ Prevention of back pain:
โ Exercise core
โ Maintain proper posture
โ Yoga
โ Emergency back pain (report immediately as there is risk for compression or infection of
spinal cord):
โ Fever/chills
โ Bowel or bladder incontinence
โ Decreased ability to move
โ Paresthesia
โ First line treatment
โ NSAIDs
โ Heat therapy can help lower back pain
Osteoporosis
โ The bone become soft and you lose it over time (think of a sponge) โ Osteopenia is the precursor for osteopenia โ Diagnosed by scoring bone mineral density โ T score of -2.5 or lower indicated osteoporosis โ Begin losing bone at 25- โ High risk: โ Women โ Postmenopausal โ Skinny people โ Intake of calcium and vitamin D are essential to maintain healthy bones โ Weight bearing exercises (pushups) โ Osteoporosis of thoracic spine โ Kyphosis - me โ Lordosis - Eddie โ Can cause SOB! โ Diagnoses โ DEXA - measures bone density โ A series of X-rays are taken โ Not a surgery, no special prep needed โ Jewelry should be taken off โ Medications
โ X-ray โ MRI
Osteoarthritis
โ Degenerative disease where cartilage breaks down โ Risks โ Older age โ Smoking โ Obesity โ Care โ Pain is very common in the morning โ Morning stiffness for over 60 minutes is more common with rheumatoid โ Use heat on affected area in the morning to loosen up โ Encourage exercise (heat beforehand) โ Activity will make pain worse โ Low impact exercise is best โ Medications โ First line: acetaminophen โ If acetaminophen does not work โ move to ibuprofen โ Non-pharm intervention โ Heat and ice can be helpful โ Increase activity (of affected area and in general)
Respiratory
Flu
โ Prevention โ #1 is hand hygiene โ Vaccines โ Masks โ Vaccines โ Assess for egg allergy โ Inactive flu shot โ 6mo and older โ Nasal spray (live) โ 2-49 y/o โ No immunocompromised or pregnant! โ RIV โ For patients with egg allergy โ Management
โ Do not give antibiotics for flu โ Manage with fluids and rest โ Alternate between acetaminophen and ibuprofen โ Oseltamivir (Tamiflu) if started within 24-48 hours โ Do not give aspirin to children โ Reye's syndrome โ Inflames brain and liver
Sinusitis
โ S/S โ Dental pain โ Facial pain โ Colored discharge (yellow or green) โ Fever โ 14Headache โ Nasal congestion โ Poor response to antihistamines and decongestants
Pneumonia
โ Inflammation of the lungs โ Risks: โ Old age โ Smoking โ Pre Existing conditions: asthma, COPD, cystic fibrosis โ Surgery โ Antivax โ Dehydration is a risk factor! โ Considerations โ Adults 65+ should be getting a pneumococcal, flu and covid vaccine every year โ Types of pneumonia โ Lobar โ only affects one lobe of the lung โ Bronchial โ inflammation of bronchi around whole lung โ Bacterial causes โ Streptococcus pneumonia โ most common bacteria (typical) โ Treated with amoxicillin โ Atypical (walking pneumonia) bacteria โ Mycoplasma pneumoniae โ Chlamydia pneumoniae โ Legionella pneumophila โ Important to note because these are treated differently โ Commonly use azithromycin โ Aspiration pneumonia โ aspiration of food causes bacterial growth โ Chemical pneumonia โ toxins trigger inflammatory response in the lungs
Asthma
Chronic inflammation of airway
โ S/S โ Wheezing โ Cough (worse at night/early morning) โ Dyspnea and chest tightness โ Tachypnea โ Prolonged expiratory phase โ Complications โ Status asmaticus โ Life threatening โ Not responsive to treatment โ First line is albuterol โ Severe airway obstruction
Asthma/COPD Meds
โ SABA (albuterol) โ Rescue drug โ Should only be used twice a week โ S/E - rapid heart rate, tremors, nervousness โ A/E - cardiac arrhythmias, paradoxical bronchospasms โ Always give before other inhaled meds โ LABA (Salmeterol) โ Not a rescue drug โ Used for maintenance โ Can have same side effects as LABA โ Inhaled corticosteroids โ Med: fluticasone budesonide โ MOA: reduces airway inflammation โ Side effects: oral thrush, hoarseness, cough โ Adverse reactions: โ Immunosuppression w/ prolonged use โ โ risk of pneumonia โ Instructions: โ Rinse mouth after to prevent thrush โ Use bronchodilator 1st โ Imatropium โ Inhaled bronchodilator โ Can cause dry mouth โ rinse mouth out after
โ Prednisone PO โ Can be given for uncontrolled asthma โ Inhaler steps โ Shake inhaler โ Sit up right, tilt head back โ Exhale fully โ Place between lips โ Press canister down simultaneously with inhalation โ Hold breath for 10 seconds โ Wait 20-60s seconds if doing another puff of albuterol โ Wait 2-5 minutes between different drugs (albuterol โ inhaler)
Tuberculosis
โ S/S โ Hemoptysis โ Cough โ Night sweats โ Weight loss โ Fever โ Precautions: โ Airborne: โ Fitted N- โ Negative pressure room โ Surgical mask when patient leaves the room โ Universal precautions โ Hand hygiene โ Gloves with patient contact โ Diagnosis โ NAAT: nucleic acid amplification test โ Fastest, accurate โ If positive, confirm with sputum culture to assess drug resistance โ Can be available in 2 hours โ First line! โ If NAAT is negative: โ Chest x-ray: looks for Ghon complexes, granulomas, cavitations โ Used if TST is positive but doesnโt confirm active TB โ Sputum culture and acid-fast bacillus (AFB) smear โ Gold standard for active TB diagnosis โ Requires 3 early morning sputum samples on separate days โ Definitive diagnosis: growth of Mycobacterium tuberculosis โ Latent TB: โ QuantiFERON-TB Gold Test (QFT-G): blood test that detects latent TB
โ D-dimer โ Blood test that shows if clots are present โ Should be less than 0. โ CT pulmonary angiography โ gold standard โ Assess for dye allergy โ V/Q scan if allergic to contrast/pregnant/kidney disease โ X-ray does not show PE โ Doppler ultrasound: look for additional clots in LE โ S/S โ Dyspnea โ Sudden chest pain โ sharp & worse on inhale โ Tachycardia โ Anxiety โ Hypoxia โ Lightheaded โ Severe: โ Change in mental status, feeling of impending doom โ Hemoptysis (coughing up blood) โ ABGs โ Respiratory alkalosis โ PH above 7. โ CO2 below 35 โ Anticoagulation Therapy โ Heparin: prevents new clots, does NOT dissolve existing clots โ Given to critical pts โ Monitor aPTT โ Enoxaparin (Lovenox): for stable pts โ Warfarin: monitor INR (2-3) and PT โ Apixaban (Eliquis): prevents platelets from sticking together โ Prevents stroke, PE, afib โ Thrombolytics (tPA) โ CLOT BUSTER! โ Only used in massive/life-threatening PE โ Only med that can break down a clot โ Risk: bleeding
Sepsis
โ Any infection can lead to sepsis โ Antibiotics MUST be given IV โ Give fluids IV โ Monitor closely โ Hypotension โ Fever โ Tachycardia โ Tachypnea
โ Increased WBC โ Altered mental status
