Musculoskeletal Med Surg 3d492r

Chapter 68

Management of Patients With Musculoskeletal Disorders

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question What findings can be identified with the use of a x ray of the spine? A. Fracture, dislocation, infection, osteoarthritis, or scoliosis B. Infections, tumors, and bone marrow abnormalities C. Soft tissue lesions adjacent to the vertebral column D. Spinal nerve root disorders


Answer A X-ray of the spine may demonstrate a fracture, dislocation, infection, osteoarthritis, or scoliosis. Bone scan and blood studies may disclose infections, tumors, and bone marrow abnormalities. Computed tomography is useful in identifying soft tissue lesions adjacent to the vertebral column. An electromyogram is used to evaluate spinal nerve root disorders.


Nursing Process: The Care of the Patient with Low Back Pain—Assessment • Detailed description of the pain including severity, duration, characteristics, radiation, associated symptoms such as leg weakness, description of how the pain occurred, and how the pain has been managed by the patient • Work and recreational activities • Effect of pain and/or movement limitation on lifestyle and ADLs

• Assess posture, position changes, and gait • Physical exam: spinal curvature, back and limb symmetry, movement ability, DTRs, sensation, and muscle strength • If obese, complete a nutritional assessment Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with Low Back Pain—Diagnoses • Acute pain • Impaired physical mobility • Risk for situational low self-esteem • Imbalanced nutrition


Nursing Process: The Care of the Patient with Low Back Pain—Planning • Major goals may include relief of pain, improved physical mobility, use of back conservation techniques and proper body mechanics, improved self-esteem, and weight reduction.


Interventions • Pain management • Exercise • Body mechanics • Work modifications • Stress reduction • Health promotion; activities to promote a healthy back • Dietary plan and encouragement of weight reduction


Positioning to Promote Lumbar Flexion


Question Is the following statement True or False? Proper standing posture occurs when the abdominal muscles contract, giving a feeling of upward pull, and the gluteal muscles contract, giving a downward pull.


Answer True Proper standing posture occurs when the abdominal muscles contract, giving a feeling of upward pull, and the gluteal muscles contract, giving a downward pull.


Proper and Improper Standing Postures


Proper and Improper Lifting Techniques


Question What is bursitis? A. Inflammation of a fluid-filled sac in the t. B. New bone growth around a sequestrum. C. Disease of a nerve root. D. Inflammation of muscle tendons.


Answer A Bursitis is inflammation of a fluid-filled sac in the t. Involucrum is new bone growth around a sequestrum. Radiculopathy is disease of a nerve root. Tendinitis is inflammation of muscle tendons.


Common Conditions of the Upper Extremities • Bursitis and tendonitis • Loose bodies • Impingement syndrome • Carpal tunnel syndrome • Ganglion • Dupuytren’s contracture


Tinel’s Sign: Assessment of Carpal Tunnel Syndrome


Dupuytren’s Contracture


Nursing Care of the Patient Undergoing Surgery of the Hand or Wrist • Surgery is usually an outpatient procedure • Patient teaching is a major nursing need for a patient undergoing outpatient surgery • Neurovascular assessment is vital—every hour for the first 24 hours—assess motor function only as prescribed, instruct patient in signs and symptoms to assess and report • Pain control measures—medication, elevation, intermittent ice or cold • Prevention of infection—keep dressing clean and dry, wound care, signs and symptoms of infection • Assistance with ADLs and measures to promote independence Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question What is pes cavus? A. Flexion deformity of the interphalangeal t that may involve several toes.

B. Deformity in which the great toe deviates laterally. C. Common disorder in which the longitudinal arch of the foot is diminished. D. Foot with an abnormally high arch and a fixed equinus deformity of the forefoot.


Answer D Hammer toe is flexion deformity of the interphalangeal t that may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally. Pes planus is a common disorder in which the longitudinal arch of the foot is diminished. Pes cavus is a foot with an abnormally high arch and a fixed equinus deformity of the forefoot.


Common Foot Problems • Plantar fasciitis • Corn • Callus • Ingrown toenail • Hammer toe • Hallux valgus • Clawfoot: Pes cavus • Morton’s neuroma • Flatfoot: Pes planus Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common Foot Deformities


Nursing Process: The Care of the Patient Undergoing Foot Surgery—Assessment • Surgery is usually performed as an outpatient procedure • Routine outpatient preoperative assessment • Patient knowledge • Neurovascular assessment of the foot • Ambulation and balance • Explore the need for home assistance and the structural characteristics of the home—for example, distances required to walk and presence of stairs or steps


Nursing Process: The Care of the Patient Undergoing Foot Surgery—Diagnoses • Risk for ineffective peripheral tissue perfusion • Acute pain • Impaired physical mobility • Risk for infection


Nursing Process: The Care of the Patient Undergoing Foot Surgery—Planning • Major goals may include adequate tissue perfusion, relief of pain, improved mobility, and absence of complications.


Interventions • Neurovascular assessment is vital – Assess swelling and neurovascular status every 1–2 hours for the first 24 hours

– Instruct patient in signs and symptoms to assess and report • Reliving pain – Elevate foot – Use of intermittent ice – Medications; oral analgesics Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Interventions • Improving mobility – Instruction in weight-bearing restrictions as prescribed

– Use of assistive devices (crutches or walker) – Measures to assure patient safety • Measures to prevent infection

– Wound or pin care – Keep dressing clean and dry – Signs and symptoms of infections

• Patient teaching Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Osteoporosis • Affects approximately 40 million people over the age of 50 in the United States. • Normal homeostatic bone turnover is altered and the rate of bone resorption is greater than the rate of bone formation, resulting in loss of total bone mass. • Bone becomes porous, brittle, and fragile, and break easily under stress • Frequently result in compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and Colles’ fractures of the wrist • Risk factors.


Progressive Osteoporosis Bone Loss and Compression Fractures


Typical Loss of Height Associated with Osteoporosis and Aging


Prevention • Balanced diet high calcium and vitamin D throughout life • Use of calcium supplements to ensure adequate calcium intake—take in divided doses with vitamin C

• Regular weight-bearing exercises—walking • Weight training stimulates bone mineral density (BMD)


Pharmacologic Therapy • Biphosphonates – Alendronate: Fosamax – Risedronate: Actonel – Ibandronate: Boniva • Selective estrogen modulators (SERMs): Evista • Cacitonin • Teriparatide: Forteo • Also need adequate amounts of calcium and vitamin D Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question How long does a patient taking biphosphonates need to stay upright after istration? A. 10 minutes

B. 20 minutes C. 30 minutes D. 120 minutes


Answer C Biphosphonates are istered on arising in the morning with a full glass of water on an empty stomach and the patient must stay upright for 30–60 minutes.


Nursing Process: The Care of the Patient with Osteoporosis—Assessment • Occurrence of osteopenia and osteoporosis • Family history • Previous fractures • Dietary consumption of calcium • Exercise patterns • Onset of menopause • Use of corticosteroids as well as alcohol, smoking, and caffeine intake Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with Osteoporosis—Diagnoses • Deficient knowledge about the osteoporotic process and treatment regimen • Acute pain related to fracture and muscle spasm

• Risk for constipation related to immobility or development of ileus (intestinal obstruction) • Risk for injury: additional fractures related to osteoporosis


Nursing Process: The Care of the Patient with Osteoporosis—Planning • The major goals for the patient may include knowledge about osteoporosis and the treatment regimen, relief of pain, improved bowel elimination, and absence of additional fractures.


Interventions • Promoting understanding of osteoporosis and the treatment regimen • Relieving pain

• Improving bowel elimination • Preventing injury


Osteomalacia • A metabolic bone disease characterized by inadequate bone mineralization • Softening and weakening of the long bones causes pain, tenderness, and deformities caused by the bowing of bones and pathologic fractures • Deficiency of activated vitamin D causes lack of bone mineralization and low extracellular calcium and phosphate • Causes include gastrointestinal disorders, severe renal insufficiency, hyperparathyroidism, and dietary deficiency Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Treatment of Osteomalacia • Correct underlying cause • Increased doses of vitamin D and calcium are usually recommended

• Handle patient gently; patient is at high risk for fractures • Address pain and discomfort


Paget’s Disease • AKA osteitis deformans • Disorder of localized bone turnover • Incidence: 2–3% of the population older than age 50

• More common in men and risk increases with aging; familial predisposition has been noted • Pathophysiology: excessive bone resorption by osteoclasts is followed by increased osteoblastic activity. Bone structure disorganized, weak an highly vascular • Patients are at risk for fractures, arthritis, and hearing loss Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Paget’s Disease • Manifestations include skeletal deformities, mild to moderate aching pain, and tenderness and warmth over bones. Symptoms may be insidious and may be attributed to old age or arthritis. Most patients do not have symptoms. • Pharmacologic management – NSAIDs for pain – Calcitonin – Biphosphonates (etidronate—Didronel) – Plicamycin (Mithracin): a cytotoxic antibiotic may be used for severe disease resistant to other therapy Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Osteomyelitis • Infection of the bone • Occurs due to: – Extension of soft tissue infection – Direct bone contamination

– Blood-borne spread from another site of infection • This typically occur in an area of bone that has been traumatized or has lowered resistance • Causative organisms – Staphylococcus aureus (70–80%) – Other: Proteus and Pseudomonas species, E. coli Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Prevention of osteomyelitis is the goal. • Early detection and prompt treatment of osteomyelitis is required to reduce potential for chronic infection and disability.


Nursing Process: The Care of the Patient with Osteomyelitis—Assessment • Risk factors • Signs and symptoms of infection localized pain edema, erythema, fever, drainage

• Note: With chronic osteomyelitis fever may be low grade and occur in afternoon or evening • Signs and symptoms of adverse reactions and complications of antibiotic therapy including signs and symptoms of superinfections • Ability to adhere to prescribed therapeutic regimen— antibiotic therapy Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with Osteomyelitis—Diagnoses • Acute pain • Impaired physical mobility • Risk for extension of infection: bone abscess formation • Deficient knowledge


Nursing Process: The Care of the Patient with Osteomyelitis—Planning • Major goals may include relief of pain, improved physical mobility, within therapeutic limitations, control and eradication of infection, and knowledge of therapeutic regimen.


Interventions • Reliving pain – Immobilization – Elevation

– Handle with great care and gentleness – ister prescribed analgesics • Improving physical mobility – Activity is restricted – Gentle ROM to ts above and below the affected part – Participation in ADLs within limitations Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Interventions • Promote good nutrition: vitamin C and protein • Encourage adequate hydration • ister and monitor antibiotic therapy • Patient and family teaching – Long-term antibiotic therapy and management of home IV istration – Mobility limitations – Safety and prevention of injury – Follow-up care • Referral for home health care Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bone Tumors • Primary tumors – Benign tumors are more common and generally are slow growing and present few symptoms

– Malignant • Prognosis depends upon type and whether the tumor has metastasized • Osteogenic sarcoma is the most common, and most often fatal, primary malignant bone tumor • Metastatic bone tumors – More common than primary tumors Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with a Bone Tumor—Assessment • Onset and course of symptoms • Knowledge of disease and treatment • Pain • Patient coping • Family and coping • Physical examination of area including neurovascular status and ROM • Mobility and ADL abilities Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with a Bone Tumor—Postoperative Assessment • Postoperative assessment as for a patient who has had orthopedic surgery

• Motif VS, LOC, neurovascular status, pain • Signs and symptoms of complications • Monitor laboratory results: WBC and serum calcium level

• Signs and symptoms of hypercalcemia


Nursing Process: The Care of the Patient with a Bone Tumor—Diagnoses • Deficient knowledge • Acute and chronic pain • Risk for injury • Ineffective coping • Risk for situational low self-esteem


Collaborative Problems/Potential Complications • Delayed wound healing • Nutritional deficiency • Infection • Hypercalcemia


Nursing Process: The Care of the Patient with a Bone Tumor—Planning • Major goals include knowledge of disease process and treatment regimen, control of pain, absence of pathologic fractures, effective coping patterns, improved selfesteem, and absence of complications.


Interventions • Care is similar to that of other patients who have undergone orthopedic surgery.

• Patient and family teaching regarding diagnosis, disease process, and treatment. • Prevention of pathologic fractures – affected extremities at all times and handle gently – External s or fixation devices may be required – Restrict weight-bearing and activity as prescribed

– Use of assistive devices


Interventions • Promoting proper nutrition – ister antiemetics as prescribed – Relaxation techniques – Oral care – Nutritional supplements • Provide adequate hydration • Use strict aseptic technique


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