NURSING CARE OF CLIENTS WITH MUSCULO-SKELETAL DISORDERS SYSTEMIC LUPUS ERYTHEMATOSUS It is chronic, multisystem, collagen disorder.

Collagen is a protein made up of aminoacids, 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 Infections o antibiotics (especially those in the sulfa and penicillin groups) o ultraviolet light o extreme stress o certain drugs o 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. TREATMENTS Drug therapy o NSAIDS and antimalarials o Cytotoxic agents (Methotrexate, Cyclophosphamide)

NURSING CARE OF CLIENTS WITH MUSCULO-SKELETAL DISORDERS o Anticoagulants o ASA o Steroids Lifestyle 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 - Pulmonary Pleuritis with or without effusion if case is mild, tx: NSAIDS if case is severe, tx: steroids Life-threatening manifestations: interstitial inflammation which can lead to fibrosis and intraalveolar 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 longterm 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 o o Hats Sunglasses

OSTEOMYELITIS
Osteomyelitis 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 o o o o o o o o o o o Diabetes Hemodialysis Poor blood supply Recent injury Use of illegal injected drugs SYMPTOMS Bone pain and fever General discomfort, uneasiness, malaise Local swelling, redness, warmth Chills Excessive sweating Swelling of ankles, feet and legs DIAGNOSTIC EXAMS o o o o o o o o Blood culture Bone biopsy (which is then cultured) Bone scan and bone x-ray Complete blood count C-reactive protein Erythrocyte sedimentation rate (ESR) MRI of the bone Needle aspiration of the area around affected TREATMENT o Antibiotics to get rid on infection

Immunosuppressives Azathioprine (imuran): requires several months to be effective, effective in smaller percentage of patients Methotrexate: for treatment of dermatitis and arthritis, not lifethreatening 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 exacerbation o Sunblock with SPF o Long-sleeved clothing

NURSING CARE OF CLIENTS WITH MUSCULO-SKELETAL DISORDERS o o o o Surgery sequestrectomy removal of dead, infected bone and cartilage Analgesics Dressing changes sterile technique Maintain body alignment to prevent deformities

CARPAL TUNNEL SYNDROME

-It is a painful condition caused by compression of the median nerve. SYMPTOMS (+) Phalens sign tingling sensation on holding the wrist in flexion for few minutes (+) Tinels sign tingling sensation on percussion on inner wrist Pain from the wrist to shoulders Numbness, paresthesia Weak grip of hands TREATMENT Rest and splint the affected wrist Avoid repetitive flexion of the wrist NSAIDs as prescribed Carpal canal cortisone injections Surgical release of transverse carpal ligament