Chapter 42 Management of Patients With Musculoskeletal Disorders

Nursing Process: The Care of the Patient With Low Back Pain—Assessment Detailed description of the pain, including location, 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 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

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

Answer A. Fracture, dislocation, infection, osteoarthritis, or scoliosis Radiography 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—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.

Nursing Process: The Care of the Patient With Low Back Pain—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

Proper and Improper Standing Postures

Proper and Improper Lifting Techniques

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.

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

Question What is bursitis? Inflammation of a fluid-filled sac in the joint New bone growth around a sequestrum Disease of a nerve root Inflammation of muscle tendons

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

Nursing Care of the Patient Undergoing Surgery of the Hand or Wrist Surgery is usually an outpatient procedure. Patient education 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

Common Foot Problems Plantar fasciitis Corn Callus Ingrown toenail Hammer toe Hallux valgus Clawfoot: pes cavus Morton’s neuroma Flatfoot: pes planus

Common Foot Deformities

Question What is pes cavus? Flexion deformity of the interphalangeal joint that may involve several toes Deformity in which the great toe deviates laterally Common disorder in which the longitudinal arch of the foot is diminished Foot with an abnormally high arch and a fixed equinus deformity of the forefoot

Answer Foot with an abnormally high arch and a fixed equinus deformity of the forefoot Hammer toe is flexion deformity of the interphalangeal joint 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.

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 (e.g., 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.

Nursing Process: The Care of the Patient Undergoing Foot Surgery— Interventions Neurovascular assessment is vital Assess swelling and neurovascular status every 1 to 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

Nursing Process: The Care of the Patient Undergoing Foot Surgery— Interventions Improving mobility Instruction in weight-bearing restrictions as prescribed Use of assistive devices (crutches or walker) Measures to ensure patient safety Measures to prevent infection Wound or pin care Keep dressing clean and dry Signs and symptoms of infections Patient education

Osteoporosis Most prevalent bone disease in the world; more than 1.5 million osteoporotic fractures occur each year 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 breaks easily under stress Frequently results in compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and Colles’ fractures of the wrist

Risk Factors for Osteoporosis

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 Calcium and vitamin D Bisphosphonates Alendronate (Fosamax) Risedronate (Actonel) Ibandronate (Boniva) Zoledronic acid (Reclast) Cacitonin Selective estrogen modulators (SERMs): Evista Teriparatide (Forteo) RANK ligand (RANKL)

Question How long does a patient taking bisphosphonates need to stay upright after administration? 10 minutes 20 minutes 30 minutes 120 minutes

Answer 30 minutes Bisphosphonates are administered on arising in the morning with a full glass of water on an empty stomach, and the patient must stay upright for 30 to 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

Nursing Process: The Care of the Patient With Osteoporosis—Assessment Dual-energy x-ray absorptiometry (DXA) World Health Organization Absolute Fracture Risk Assessment (FRAX) algorithm Serology and radiography studies

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.

Nursing Process: The Care of the Patient With Osteoporosis—Interventions Promoting understanding of osteoporosis and the treatment regimen Relieving pain Improving bowel elimination Preventing injury

Septic (Infectious) Arthritis High risk: older adults and those with comorbid conditions Most commonly knee and hip joints Prompt recognition and treatment are key Diagnosed with culture of synovial fluid Treatment includes immobilization of joint, pain relief, and antibiotics

Nursing Process: The Care of the Patient Undergoing Orthopedic Surgery—Interventions Promoting proper nutrition Administer antiemetics as prescribed Relaxation techniques Oral care Nutritional supplements Provide adequate hydration Use strict aseptic technique