1. Chapter 42 Management of Patients With Musculoskeletal Disorders

2. 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

3. 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

4. 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.

5. 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

6. 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.

7. 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

8. Positioning to Promote Lumbar Flexion

9. Proper and Improper Standing Postures

10. Proper and Improper Lifting Techniques

11. 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.

12. 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.

13. 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)

14. Tinel’s Sign: Assessment of Carpal Tunnel Syndrome

15. Dupuytren’s Contracture

16. 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

17. 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.

18. 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

19. 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

20. Common Foot Deformities

21. 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

22. 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.

23. 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)

24. 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

25. 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.

26. 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

27. 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

28. 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

29. Risk Factors for Osteoporosis

30. Progressive Osteoporosis Bone Loss and Compression Fractures

31. Typical Loss of Height Associated With Osteoporosis and Aging

32. 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)

33. 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)

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

35. 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.

36. 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

37. 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

38. 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

39. 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.

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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.

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. Collaborative Problems and Potential Complications
Delayed wound healing
Nutritional deficiency
Infection
Hypercalcemia

58. 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.

59. 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

60. 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