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 (deep tendon reflexes), 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 (fragments of cartilage or bone floating in joint space) Impingement syndrome (tendons of rotator cuff become inflamed and irritated) Carpal tunnel syndrome Ganglion (nerve cell cluster) Dupuytren’s contracture (fixed flexion contracture of the hand)

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 (aka “jogger’s heel”) Corn Callus Ingrown toenail Hammer toe (contracted toe) Hallux valgus (bunion) Clawfoot: pes cavus (very high arch) Morton’s neuroma (benign tumor of plantar nerve) 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) Calcitonin 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

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

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 Also known as osteitis deformans Disorder of localized bone turnover Incidence: 2% to 3% of the population older than age 50 years 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, and highly vascular Patients are at risk for fractures, arthritis, and hearing loss

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 Bisphosphonates (etidronate—Didronel) Plicamycin (Mithracin): a cytotoxic antibiotic may be used for severe disease resistant to other therapy

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

Osteomyelitis Infection of the bone Occurs because of Extension of soft tissue infection Direct bone contamination Bloodborne spread from another site of infection This typically occurs in an area of bone that has been traumatized or has lowered resistance. Causative organisms Methicillin-resistant Staphylococcus aureus Other: Proteus and Pseudomonas spp., Escherichia coli

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 the 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

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 Prevention of osteomyelitis is the goal. Major goals may include relief of pain, improved physical mobility within therapeutic limitations, control and eradication of infection, and knowledge of therapeutic regimen.

Nursing Process: The Care of the Patient With Osteomyelitis— Interventions Reliving pain Immobilization Elevation Handle with great care and gentleness Administer prescribed analgesics Improving physical mobility Activity is restricted Gentle ROM to joints above and below the affected part Participation in ADLs within limitations

Nursing Process: The Care of the Patient With Osteomyelitis— Interventions Prophylactic antibiotics Encourage adequate hydration, vitamins, and protein Administer and monitor antibiotic therapy Patient and family education Long-term antibiotic therapy and management of home IV administration Mobility limitations Safety and prevention of injury Postoperative and follow-up care Referral for home health care

Bone Tumors Primary tumors Benign tumors are more common, generally are slow growing, and present few symptoms Malignant Prognosis depends on the 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

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 support and coping Physical examination of area, including neurovascular status and ROM Mobility and ADL abilities

Nursing Process: The Care of the Patient With a Bone Tumor—Postoperative Assessment Postoperative assessment as for a patient who has had orthopedic surgery Monitor VS, LOC, neurovascular status, pain Signs and symptoms of complications Monitor laboratory results: WBC and serum calcium level Signs and symptoms of hypercalcemia

Hypercalcemia S/S Stones (renal or biliary) Bones (bone pain) Groans (abdominal pain, nausea and vomiting) Thrones (polyuria) Psychiatric overtones (Depression 30–40%, anxiety, cognitive dysfunction, insomnia, coma) Also-Fatigue, anorexia, ECG changes

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 and 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 self- esteem, and absence of complications.

Nursing Process: The Care of the Patient With a Bone Tumor— Interventions Care is similar to that of patients who have undergone orthopedic surgery. Patient and family education regarding diagnosis, disease process, and treatment. Prevention of pathologic fractures Support affected extremities at all times and handle gently External supports or fixation devices may be required Restrict weight bearing and activity as prescribed Use of assistive devices

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