1. Care of Patients with Musculoskeletal Problems
Chapter 53
Care of Patients with Musculoskeletal Problems
Osteoporosis. A, Comparing the size of a normal vertebral body (left) with one affected by osteoporosis (right). B, Image of normal bone (electron microscopic image). C, Osteoporotic bone (electron microscopic image).

2. Metabolic Bone Disease
Osteoporosis
Osteomalacia
Paget’s disease (osteitis deformans)
Osteomyelitis

3. Common and Contrasting Characteristics
Risk factors
History
Genetic
Culture
Diet
Physical signs/symptoms

4. Osteoporosis
A normal spine at age 40 years of age and osteoporotic changes at ages 60 and 70 years. These changes can cause a loss of as much as 6 inches in height and can result in the so-called dowager’s hump (far right) in the upper thoracic vertebrae.

5. Diagnostic Testing
Laboratory tests
Imaging
DEXA

6. Primary Problems in Metabolic Bone Disease
Strength
Risk for fracture
Injury prevention
Nutritional status

7. Interventions Safety precautions Medications Surgical management
Patient teaching
Collaborative health care team roles
Community resources

8. Benign Bone Tumor vs Bone Cancer
Benign bone tumors
Often asymptomatic
May be discovered on routine x-ray or as a cause of pathologic fracture
Bone cancer

9. Interventions Benign bone tumors Bone cancer
Nondrug pain-relief measures
Drug therapy (analgesics, NSAIDs)
Surgical therapy (curettage, joint replacement, arthrodesis)
Bone cancer
Surgical intervention
Radiation, chemotherapy
Psychosocial resources

10. Other Musculoskeletal Disorders
Hand
Dupuytren’s contracture
Ganglion
Foot
Deformities
Morton’s neuroma
Plantar fasciitis

11. Other Musculoskeletal Disorders
Back
Scoliosis
Progressive muscular dystrophies

12. Priority Concers with other Musculoskeletal Disorders
Contractures
Pain
Mobility impairment
What types of nursing care are common to any of these disorders?

13. Case Study
A 64-year-old woman is seen in the adult outpatient clinic. She was measured as standing 65 inches tall last year. You note that the patient now measures 64 inches. She has mild kyphosis. What assessment questions would you be sure to ask at this time?
Ask the patient if she feels she has gotten shorter. Ask if she experiences pain with lifting, bending, or stooping. Ask if the pain is worse with activity and relieved by rest.

14. Case Study
(cont’d)
The patient is diagnosed with possible osteoporosis.
Which diagnostic tests do you anticipate will be ordered? (Select all that apply.)
Sodium
Phosphorus
Serum calcium
Electrocardiogram
Thyroid function tests
24-hour urine collection
Dual x-ray absorptiometry (DXA)
ANS: B, C, E, F, G
All tests listed, except for ECG and sodium, are tests used to gather information about the bones, or in the case of thyroid function tests, to check for hyperthyroidism.

15. Case Study
(cont’d)
The patient is diagnosed with osteoporosis. Which intervention would be appropriate?
Suggest a diet that is high in protein and calcium but low in vitamin D.
Recommend walking for 30 minutes 3 to 5 times a week.
Teach her to cut down on her cigarette-smoking.
Tell her to include high-impact activities, such as running, in her exercise regimen.
ANS: B
The single most effective exercise for osteoporosis is walking 30 minutes 3 to 5 times a week. Patients should include increased vitamin D along with calcium in the diet. Smoking should be avoided as should high-impact exercises, which may cause vertebral compression fractures.

16. Case Study
(cont’d)
Which patient statement about self-care indicates a need for further teaching by the nurse?
“I am going to swim at the YWCA.”
“My husband is getting rid of our throw rugs.”
“Low-fat yogurt is on my grocery list.”
“Joining a bowling team will help me exercise.”
ANS: D
Bowling should be avoided for patients with osteoporosis because it can contribute to compression fractures. Swimming, eating yogurt, and eliminating throw rugs in the house are all appropriate things to consider for the patient with osteoporosis.

17. Case Study
(cont’d)
The provider orders calcium 1.5 g orally twice a day (1 g in the morning and 500 mg at bedtime). The patient asks why she must drink extra fluids with this medication. What is your best response?
The patient also asks why she can’t just take the calcium once a day. What is your best response?
Increased fluid intake helps prevent the formation of calcium-based urinary stones.
A third of the daily dose should be given at bedtime because calcium is most readily utilized by the body when the patient is fasting and immobile.

18. Audience Response System Questions
Chapter 53
Audience Response System Questions 18

19. Question 1
What are the odds of a woman over the age of 50 breaking a bone because of osteoporosis?
1 out of 10
1 out of 7
1 out of 5
1 out of 2
Answer: D
Rationale: One in two women over the age of 50 will break a bone because of osteoporosis. A woman’s risk of breaking a hip due to osteoporosis is equal to her risk of breast, ovarian, and uterine cancer combined. Women have lighter, thinner bones than men. Many women also lose bone quickly after menopause. Up to one in four men over the age of 50 will break a bone because of osteoporosis. A man older than age 50 is more likely to break a bone due to osteoporosis than he is to get prostate cancer.
(Source: Accessed August 12, 2011, from

20. Question 2
A patient with Paget’s disease is at greatest risk for developing:
Chronic fatigue syndrome
Kidney stones
Cardiac failure
Pathologic bone fractures
Answer: D
Rationale: Pathologic fractures may be the presenting clinical manifestation of the disorder. The femur and the tibia are most often affected, and fracture of these bones can result from minimal trauma. Patients with Paget’s disease frequently are fatigued and, although less common, may develop kidney stones, gout, and heart failure.

21. Question 3
Which symptom is particular to older patients presenting with acute osteomyelitis?
Pain
Fatigue
Low-grade fever
Elevated leukocyte count
Answer: C
Rationale: Common presenting symptoms of osteomyelitis are pain, fever, edema, elevated leukocyte count, fatigue, and general malaise. However, older adults may not have an extreme temperature elevation because of lower core body temperature and compromised immune system that occur with normal aging.