This learning session will focus on medications used in the musculoskeletal system, diseases and disorders discussed in this unit. Before you dive into this content, be sure you are free from distractions and can give it your full attention. Be sure that you have read the textbook pages that are associated with this content. Be prepared to actively learn.
I will be sharing my knowledge and understanding with you, but you must do the learning. Participate in your learning. You will be the nurse next to that patient, not me.
You need to acquire the knowledge, skills, and attitudes to take care of that patient safely, competently, and compassionately. Think beyond your next classroom exam. Rather, think about being that nurse taking care of that patient.
That is what you are preparing for, not classroom examinations. Listen with curiosity, asking questions, seeking answers. Imagine being the nurse responsible for the care of this patient. Imagine being the patient needing this nursing care.
Think about your prior experiences that are related to this content, from both the healthcare provider's point of view, and or the patient's point of view. Think about building knowledge on the foundation of what you already know. Be prepared to change your understanding of this content if new information is presented. Take advantage of this recorded source.
Pause as needed to think about the content or write down notes or questions. Be curious about learning more. Review the content.
and your notes as needed to gain understanding that you seek. Test yourself on the content to determine if you really learned it or not. The first thing I want you to do is pause and reflect. I want you to start by stopping the recording and thinking and writing down in these three areas.
I want you to think about what you already know about this topic and write down at least three to five items. I want you to stop and think about any of your prior experiences related to the content. I want you to write down your thoughts and feelings related to your experience.
Lastly, I want you to think about what you don't know about this content. Think about your gaps of knowledge and understanding and things that you're curious about learning. Write down at least three to five items. you'll be ready to dive into the content.
This slide contains some learning objectives that you should meet upon completion of this content. I recommend that you pause the recording, read these carefully, and make sure that you understand the purpose of this learning session and that you can measure that you have accomplished them at the end. This slide lists the different musculoskeletal system conditions, diseases, disorders that we're going to discuss in this unit.
And so therefore, these are the things that we'll focus on in talking about the medications needed for patients with these kinds of conditions. So we'll talk soft tissue injuries, fractures, those with or without traction, those that do or do not require surgery, osteoarthritis, osteopenia and osteoporosis, osteomyelitis with or without a surgical amputation, and then post-operative care. I would like to discuss some things about pain as it is associated with the conditions in the musculoskeletal system. First, let's begin with a physiological definition of pain and it is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in the terms of such damage.
This definition describes pain as a complex phenomenon that can impact a person's psychosocial, emotional, and physical functioning. The clinical definition of pain reinforces that pain is a highly personal and subjective experience. Always remember that pain is whatever the experiencing person says it is and it is existing wherever and whenever they say it does. Pain is completely subjective. The self-report by the patient is the standard.
It is considered to be the most reliable indicator of pain and the most essential component of the pain assessment. Pain will affect individuals of every age, every gender, every race, every socioeconomic class, and it is actually one of the primary drivers for why people seek health care in the first place and one of the most common conditions that nurses will treat. Unrelieved pain has the potential to affect every system in the body and cause numerous harmful effects, some of which can last a lifetime. Acute pain involves tissue damage as a result of a surgery, a trauma, a burn, or a venipuncture.
and it is expected to have a short duration and resolve with normal healing. Chronic pain is another category of pain and it is pain that persists throughout the course of a person's life. It needs to be pain that takes place for several months before it's labeled as chronic. In the meantime, it's acute and we try to deal with it.
and resolve whatever's causing the pain and hopefully get it resolved. Chronic pain can be intermittent with flare-ups or it can be continuous. Some of the effects of pain, it can affect a lot of different places and systems in the body and it can cause a lot of different reactions and responses. In the endocrine system, it can increase ACTH.
and cortisol those are like stress hormones it can increase antidiuretic hormone it can increase epinephrine norepinephrine and growth hormone catecholamines renin angiotensin 2 aldosterone glucagon interleukin 1 and it can decrease insulin and testosterone metabolically pain can cause gluconeogenesis which is the creation of new glucose in the blood made by the liver can increase hepatic glycogenolosis and hyperglycemia glucose intolerance, insulin resistance, muscle protein catabolism, and lipolysis. Cardiovascularly, it increases heart rate and cardiac workload. It increases peripheral vascular resistance, which means it increases blood pressure. Okay, also increases systemic vascular resistance.
Hypertension is an effect of this. increases coronary vascular resistance so the heart vessels themselves become more resistant to the flow, increases myocardial oxygen consumption, it makes for hypercoagulation and therefore can contribute to deep pain thrombosis. Pain can decrease the flows and the volumes in the respiratory system. can cause atelectasis, shunting, hypoxemia. It can decrease the person's cough, therefore retaining those secretions, and then maybe perhaps leading to an infection like pneumonia.
In the genital urinary system, it decreases urinary output, it increases urinary retention, and therefore contributes to fluid overload, and also can impact hypokalemia. In the GI system, pain decreases the gastric and the bowel motility. In the musculoskeletal system, it increases muscle spasms, impairs muscle function, causes an increase in fatigue, and contributes to immobility. Cognitively, there can be a reduction in cognitive function and even cause mental confusion in some patients. In the immune system, it can actually depress the immune response, and that kind of goes along with what we saw in the endocrine system when we have that elevation in cortisol and those glucocorticoids creating, like those two go hand in hand.
It's an immune response, and one can actually cause a person to get an infection. Developmentally, it can impact a patient. It can change behavior and physiologic response to pain.
That can happen, especially when you're talking about children who have a lot of pain in their childhood years. It can impact the way they're going to respond to pain the rest of their life. It can alter a person's temperament.
It can... lead to higher somatization, a possible alteration in the development of the pain system, increases vulnerability to stress disorders, addictive behavior, and anxiety states. It impacts a patient's quality of life.
It can contribute to sleeplessness, anxiety, fear, hopelessness, and increased thoughts of suicide. It's a very important task for the nurse to do a really good pain assessment. You want to make sure that you get the whole picture, you ask all the questions, and you don't make assumptions.
So you'll want to pick a reliable tool, and you can use the PQRST, you can use the ColdSpa. There are a number of them, and it doesn't really matter. which one you use because they're all designed to get the complete picture of all the elements and facets of the pain so that we can get the right treatment for it. There's even tools like the FACES tools and other tools that are for patients who can't communicate verbally.
And so you look for other indicators of pain and those tools will guide you in making an accurate assessment. I would like to stress that empathy is really important, especially for patients who have pain. Nurses who show empathy and caring towards patients who have pain can build better relationships with the pain, and in turn, the patients get better outcomes from their conditions. We have pharmacological methods, which will include over-the-counter and prescription meds.
These will be prescribed based on the type of pain being experienced by the patient as well as the severity. No pain intervention should ever be done without a complete assessment of pain and the overall patient condition. The nurse should never give any medication until a complete head-to-toe assessment has been done and the nurse must know this baseline data in order to determine if the medication is appropriate to the patient's situation and safe to administer at this time.
And that's how we're going to measure the impact of this intervention to determine if it's been effective. If you don't have good baseline data, you won't know if the outcome is what you expect it to be. Know that some medications will impact certain lab results, and the nurse needs to review some of the labs to ensure that the medication is safe for this patient at this time.
Remember that we are responsible for every intervention that we do. We have to complete an assessment to know where the patient is right now and to measure if the intervention was effective. and if any unintended or adverse effects have happened as a result of this intervention. You cannot know this unless we assess before and after our interventions. Now some specifics about medications.
Over-the-counter medications generally include acetaminophen, ibuprofen, and aspirin and these are often taken by patients even at home because they're available readily. When assessing the home use of these meds, always ask how frequently they use it, what dosage they take, and how effective it is to treat their pain. Often patients will misunderstand the label or they consider that the information on the label is more like a suggestion than really guidelines for safe usage. Some patients will take too small of a dose and not get the desired effect and then think that the med is no good. Others will take a larger dose and maybe unknowingly do damage to their liver or their kidneys.
Generally, over-the-counter medications are appropriate for mild to moderate pain. That would be pain that's rated from a 1 to 6 on a 10-point scale. Pain that is more severe or unmanaged by over-the-counter will likely need a prescription strength medication, and some of the frequently used ones include tramadol.
hydrocodone, codeine, morphine, and fentanyl. All right, for this pause and think, I'd like you to consider empathy and the nurse's impact on the patient with pain. So think about what impact can empathy have on the outcomes for the patient with pain and how can the nurses attitude towards the patient's report of pain impact the nurse-patient relationship? Take a few minutes and think about these. Another consideration for patients with musculoskeletal disorders and diseases is the issue of immobility.
I would like to talk about the systemic effects of immobility and some specific concerns and treatments for different kinds of problems that come up because of immobility. I'd like you to consider the questions that are on this slide. How does immobility impact the patient? What systems are going to be impacted and what effects can be seen? How can nurses prevent or treat these effects?
And we're going to talk pharmacological and non-pharmacological methods. Let's begin with immobility can lead to a patient developing a DVT, which can in turn lead to a PE. So pharmacologically, we're going to look at prophylactic treatment with some different medications.
We have short-term subcutaneous injections of heparin and anoxaparin. Sometimes patients will be on long-term. anticoagulant therapy including warfarin, apixaban, or clopidogrel. And then there are non-pharmacological or mechanical means that are used as well.
The best treatment or prevention of DVTs is walking, but sometimes patients with these immobility issues are not going to be able to do that. So we might be talking about trying to get them to move as much as they possibly can if they can't get up and walk. We're also maybe looking at putting on some kind of compression hose to keep the legs from retaining excess fluid.
And then in the hospital, often the patients are given the sequential compression devices, which are just abbreviated SCDs, and those cuffs go on their calves and they go on and off. They blow up a little bit with a pump. pump that pushes air through a tube, blows up a little bladder in the cuff, and that squeezes on the leg and then it deflates. And then the other side, the other leg will blow up and deflate and then just goes back and forth. And that helps to increase the venous return and prevent blood clots.
Another consequence of immobility can be constipation. Pharmacologically speaking, we can give stool softeners like docosate calcium and docosate sodium. We can give a stimulant laxative like Senna or Biscadol.
We can give a saline laxative like magnesium salts or phosphates. We can do bulk forming agents which include psyllium and polycarbophyll. We can do osmotic cathartics like lactulose or polyethylene glycol. There are some non-pharmacological means that can be used either with or instead of the farm methods, and that might be increasing fluids, increasing movement and exercise if the patient's able to, and increasing their dietary fibers intake. Consequence of immobility can be muscle weakness, atrophy, or contractures.
There's not really a lot of pharmacological methods to help with that. Those need movement, so we need patients to be doing at least as much as possible active range of motion if they're able, and if they're not, then we can work with them and help them with passive range of motion as much as possible. Use whatever parts of the body can be used.
So if the patient is stuck in the bed because their lower limbs are in traction, we can still exercise the arms. If they're in the bed because they've got an injury to their shoulder, then they can still do ankle pumps and different exercises with their legs and feet. We also want to work on repositioning using wedges and pillows to position them.
to try to prevent them from developing any contractures or stiffening up in a set position. Another consequence of immobility can be moisture and that can be just simply from incontinence or it could be food that spills in the bed. Remember the patient is stuck in the bed because of this immobility so we want to watch for The bedding to stay clean and dry. We want to use absorbent pads and briefs if there's incontinence going on.
We can apply barrier creams as ordered to protect the skin from moisture when there's incontinence. We want to watch for moisture in the skin folds and that's in places where skin and skin stay in contact with each other. This can be under the breasts in females and also can be in the stomach folds of anybody that has an enlarged abdomen. We want to keep these areas dry to prevent fungal infections, which is usually yeast.
There is a wicking material that is often used that you can tuck into the skin folds so that it prevents the skin from sitting on top of other skin and it wicks and pulls the moisture out. of those areas. There can be medicated powders that are sometimes used as ordered.
Nystatin is one that is frequently seen. Another consequence of immobility can be mood, psychosocial, or anxiety issues related to pain, stress, fear, anxieties of the patients being immobilized. They may worry about many things. They may worry about their responsibilities at home not being taken care of.
Maybe their job. Maybe their kids or their grandkids. Maybe their pets. Maybe they are unable to participate in their hobbies. These are legitimate concerns and they need to be addressed by the nurse.
Sometimes empathetic listening is all that is required. Sometimes the patient will also require some outside resources to help meet these needs. So as the nurse, we may need to bring in a social worker or a case manager to aid in linking the patient to the resources that they need. We may need to help bring in a spiritual or religious person to help. We may need to advocate to the provider that the patient may need some anxiety medication in order to help them deal with the stresses and anxiety.
Some of the commonly used and xylitic medications are diazepam, buspirone, alprazolam, and lorazepam, but there are others. Additionally, we can aid the patient in non-pharmacological methods like distraction or guided imagery, helping them with learning how to meditate, offering prayer, or journaling. or maybe deep breathing and relaxation strategies that will help them with the stresses.
Pressure injuries are another consequence of immobility and our number one concern is prevention of injuries. Think about the Braden scale assessment that we do for every patient. The questions that are used to assess this patient's risk are the ones that we will focus on.
to identify their specific needs. So if your patient is at a higher risk because of poor quality of food intake, then our focus should be on improving their protein and nutrition. If the patient is incontinent and so moisture is an issue, our focus needs to be on keeping them clean and dry at all times. So do the Braden assessment and then use the information from that to determine the approach. appropriate interventions to help prevent injury.
Once an injury has occurred, we're going to do all these things, plus wound assessment and wound care, per whatever the provider's orders are. Another consequence of immobility can be atelectasis and or pneumonia. And this...
As long as it's not contraindicated for the patient, if a patient is in a certain kind of traction or immobility device, then it may not be possible to sit them up in the bed. But if possible, we want to keep that head of the bed elevated because that allows for deeper respirations and helps to prevent atelectasis and then subsequently pneumonia to develop. We want to work on the incentive spirometer.
encourage them to do deep breathing and coughing and then if they can we want them turning in the bed. Another consequence of immobility is urinary stasis and that can lead to a UTI. Being immobilized can cause stasis and incomplete emptying of the bladder and that leaves extra fluid urine sitting in the bladder which is a perfect environment for bacterial growth. So that can often lead to a UTI development. We want to teach the patient about proper hygiene, especially females, teaching them wiping from front to back.
And we want them to avoid to, we want them to avoid frequently and completely as, as their situation allows. Monitor for the development of UTI symptoms, which would include fever. burning pain with urination, frequent urination, hesitancy in starting the stream, and general malaise and fatigue. Another consequence of immobility can be anorexia. The loss of appetite can occur for many reasons, but not eating a nutritious diet will hinder their healing and contribute to other problems associated with immobility.
In some cases, the provider may order an appetite stimulant such as Magesterol. Take a minute now and pause and think. I'd like you to consider empathy as it regards the patient that's immobilized.
I'd like you to consider how you would feel if you were immobilized and in traction. Think about what would be your greatest concern about being in that position and how would you want someone to treat you and your concerns. Take a few minutes and think about that and practice some empathy.
Inflammation is one of the body's normal responses to injury, infection, or allergies. It is actually designed to increase blood flow to the area where it's needed, bringing white blood cells to aid in the area and to release chemical toxins. These responses are designed to protect the body from invasion of foreign organisms or to aid in repairing injured tissues.
Normal signs of local inflammation include redness, heat, swelling, pain, and loss of function of that body part. wherever the injury or infection is. Systemically, we'll see inflammation looking like a fever, joint and muscle pain, organ dysfunction, and malaise.
In regard to soft tissue injuries and fractures, inflammation will be localized and can be treated with the PRICE series of interventions, and that includes protection, rest, ice, compression, and elevation. You should see the lesson on soft tissue injuries for full information on this. Osteoarthritis may manifest with some inflammation.
It is sometimes treated with over-the-counter NSAIDs. like ibuprofen to address edema and the pain, and some patients find relief with OTC, topical mentholated rubs. Osteopenia and osteoporosis are not inflammatory conditions, so you shouldn't see inflammation with those. Osteomyelitis, that's an infection, and therefore is an inflammatory state.
This is usually treated with antibiotics to kill whatever the infecting bacteria is, and then the other symptoms are treated with symptom management, as you would for inflammation or pain. That will help to increase the comfort of the patient as the body heals from this infection. And the antibiotics will be very specific to whatever the infecting organism is.
All right, osteopenia is a significant decrease in the amount of bone mineral density that is normally found in an individual. When the bone mineral density is between 1 and 2.5 standard deviations from the norm, then the patient is considered to have osteopenia. And when it is greater than 2.5, Standard deviations from the norm is when the patient will be diagnosed as osteoporosis.
Prevention is key for this. It includes increasing bone mass at an early age with calcium-rich foods, vitamin D-rich foods, and sun exposure, and then weight-bearing exercises to help build up the bones. Once osteopenia and osteoporosis are diagnosed, the patient should continue with those same interventions and then perhaps even add some pharmacological medications as ordered.
Some of the medications used to treat osteoporosis include bisphosphonates, alendrononate, risedrononate, iben... drononate, zoldronic acid, reloxifab, denosavab, and teriparide. As always when administering or teaching about medications make sure that you understand the mechanism of action because they each work in a different way. What is the expected patient response to the medication? So what are we looking to actually have happen?
What are the side effects and the adverse effects so that we can monitor for things that might come alongside when the patient takes this medication? Another aspect that might require medications for a patient with musculoskeletal Injury or disease would be infections. Infections can occur from traumatic open fractures or surgical interventions. Any injury that causes a break in the skin can potentially lead to an infection.
Nurses will need to assess any open wound or surgical incision for signs and symptoms of infection and then perform meticulous wound care and dressing changes. You should expect to have orders for wound care, including the type of dressing to use and any medications that need to be applied to the wound. Additionally, the patient may be prescribed antibiotics, IV or oral. That therapy will address the specific pathogen that is causing the infection whenever possible.
Signs and symptoms of wound infection would include increased pulse rate and temperature, elevated white blood pressure, blood cell count, wound swelling, warmth, tenderness, or discharge, and or increased incisional pain. And these signs might be absent, the local signs might be absent, if the infection is deep within. And that kind of leads me to talk about occasionally a patient that's had a joint replaced develop an infection.
following that surgery and that infection is in that area where the hardware that they placed is is there when this happens the patient will often have to have a surgery to remove the hardware then they have to receive iv antibiotics for several weeks sometimes 6 to 12 weeks and then they have to go back in and put in new hardware to complete that so the patient has a stable joint again. When a wound infection is diagnosed in a surgical incision, sometimes the surgeon will go in and remove sutures or staples and use an antiseptic precaution, separate the wound edges and try to insert a drain or clean out that area. If If the infection is deep, then the drain and incision may not be necessary and then they will just use antimicrobial therapy and wound care. Regarding osteomyelitis, bone infections are more difficult to heal than soft tissue infections because the bone is considered mostly avascular and has less access to the body's immune response. So there is decreased penetration by the medication.
And so antibiotic therapy can go on for several weeks, much longer than it would if it was another kind of an infection. And then after the infection is under control, then often the antibiotics will be switched from IV to oral. The initial goal of therapy is to control and halt the infective process. So in the meantime, we're also doing general supportive measures to try to help the patient be the best they can be in order to heal. So this would include hydration, diets that are high in vitamins and protein, fixing any problems like anemia that the patient might have.
The area affected with osteomyelitis is generally immobilized to decrease discomfort and to prevent pathological fractures from the weakened bone. And once again, antibiotics in this case would be specific to the invading organism. It's time again to pause and think in this. we're going to look at empathy for the patient with an infection. I would like you to imagine you are the nurse caring for a patient admitted with an infection in their newly replaced hip.
This patient is now facing the surgical removal of the infected hardware, eight weeks of IV antibiotic therapy on a daily basis, and another surgery to place new hardware in their hip. at the end of that therapy. Considering all of this, I would like you to think if you could list five concerns that you imagine this patient having, and then list ways that you could help this patient deal with these concerns. Regarding post-operative concerns, in regard to the musculoskeletal system, we're talking about operative joint replacement surgeries, amputations, and open reductions with internal fixations that happen with fractures. And some of the considerations that we want to think about are the patient could develop atelectasis afterwards.
And so we want to consider the fact that the patient might need oxygen to be applied. Oxygen is considered a medication, and so you want to go ahead and assess your patient for their oxygen saturation and their breathing, respiratory assessment, and then apply oxygen as needed. We want to also consider non-pharmacological methods like deep breathing and coughing, the volume incentive spirometer, these kind of things that will help prevent. pneumonia and keep the patient from needing antibiotics. Occasionally, when a patient has one of these kinds of surgeries, they'll be receiving prophylactic antibiotics, and that will vary per procedure and per the provider orders.
For post-op amputations or osteomyelitis, expect the patient to have long-term antibiotic therapy, like several weeks of IV infusions. The patient will likely have a peripheral IV central line, put in a PICC line, inserted, and attend daily infusion treatments either at a facility or sometimes they can administer the meds at home if they are deemed competent to safely do this for themselves. The drug that will be ordered will depend upon whatever the infectious organism is.
Another post-op concern is pain management, and I would refer you back to the earlier slide in information about pain. Another concern is nausea post-operatively. Anti-emetics may be needed, PRN for a patient after surgery. Frequently, we use ondansetron and promethazine.
Those are the ones that I've seen most frequently used. Additionally, we might be worried about promoting adequate cardiac output. And so we're monitoring the patient for hemorrhage at surgical sites. And we're also monitoring blood pressure and heart rate to make sure that we have good profusion going on and cardiac output. And we may have to give the patient IV fluids to help maintain the vascular system.
Now it's time for you to review the content, review your notes, review your readings, test yourself to see if you have met these learning objectives. If you still have gaps, then you need to dig in deeper and look for the answers to the questions so that you can say that you have mastered this content and achieved these learning objectives.