Chapter 68 Management of Patients With Musculoskeletal Disorders

1. Chapter 68Management of Patients With Musculoskeletal Disorders

2. Nursing Process—Assessment of the Patient With Low Back Pain • 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

3. Nursing Process—Assessment of the Patient With Low Back Pain (cont.) • Assess posture, position changes, and gait • Physical exam: assess spinal curvature, back and limb symmetry, movement ability, DTRs, sensation, and muscle strength • If patient is obese, complete a nutritional assessment

4. Nursing Process—Diagnosis of the Patient With Low Back Pain • Acute pain • Impaired physical mobility • Risk for situational low self-esteem • Imbalanced nutrition

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

6. Interventions • Pain management • Exercise • Body mechanics • Work modifications • Stress reduction • Health promotion; see Chart 68-3 (Activities to Promote a Healthy Back) • Dietary plan and encouragement of weight reduction • See Chart 68-2

7. Positioning to Promote Lumbar Flexion

8. Proper and Improper Standing Postures

9. Proper and Improper Lifting Techniques

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

11. Tinel’s Sign—Assessment of Carpal Tunnel Syndrome

12. Dupuytren’s Contracture

13. 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 about signs and symptoms to assess and report

14. Nursing Care of the Patient Undergoing Surgery of the Hand or Wrist (cont.) • Pain control measures: medication, elevation, and intermittent ice or cold • Prevention of infection: keep dressing clean and dry, provide wound care, and assess for signs and symptoms of infection • Assist with ADLs and measures to promote independence

15. Common Foot Problems • Plantar fasciitis • Corn • Callus • Ingrown toenail • Hammer toe • Hallux valgus • Claw foot: pes cavus • Morton’s neuroma • Flatfoot: Pes planus

16. Common Foot Deformities

17. Nursing Process—Assessment of the Patient Undergoing Foot Surgery • Surgery is usually performed as an outpatient procedure • Perform routine outpatient preoperative assessment • Determine patient knowledge • Perform neurovascular assessment of the foot • Assess ambulation and balance • Explore the need for home assistance and the structural characteristics of the home, eg, distances required to walk and the presence of stairs or steps

18. Nursing Process—Diagnosis of the Patient Undergoing Foot Surgery • Risk for ineffective peripheral tissue perfusion • Acute pain • Impaired physical mobility • Risk for infection

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

20. Interventions • Neurovascular assessment is vital • Assess swelling and neurovascular status every 1 to 2 hours for the first 24 hours • Instruct patient about signs and symptoms to assess and report • Relive pain • Elevate foot • Use ice intermittently • Administer medications and oral analgesics

21. Interventions (cont.) • Improve mobility • Instruct on weight-bearing restrictions as prescribed • Use assistive devices (crutches or walker) • Implement measures to ensure patient safety • Implement measures to prevent infection • Provide wound or pin care • Keep dressing clean and dry • Assess for signs and symptoms of infections • Patient teaching: see Chart 68-6

22. Osteoporosis • Affects approximately 40 million people over the age of 50 in the U.S. • 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: see Chart 68-7

23. Progressive Osteoporosis Bone Loss and Compression Fractures

24. Typical Loss of Height Associated With Osteoporosis and Aging

25. Pathophysiology of Osteoporosis

26. Prevention • Follow a balanced diet high in calcium and vitamin D throughout life • Use calcium supplements to ensure adequate calcium intake: take in divided doses with vitamin D • Regular weight bearing exercises: walking • Weight training stimulates bone mineral density (BMD) • See Chart 68-8

27. Pharmacologic Therapy • Biphosphonates • Alendronate: Fosamax • Risendronate: Actonel • Ibandronate: Boniva • Selective estrogen receptor modulators (SERMs): Evista • Calcitonin • Teriparatide: Forteo • Need adequate amounts of calcium and vitamin D

28. 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

29. 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

30. Paget’s Disease • Also called osteitis deformans, Paget’s disease is a disorder of localized bone turnover • Incidence: 2% to 3% of the population over 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, and highly vascular • Patients are at risk for fractures, arthritis, and hearing loss

31. Paget’s Disease (cont.) • 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 although most patients do not have symptoms • Pharmacologic management • NSAIDs for pain • Calcitonin • Biphosphonates (etidronate: Didronel) • Plicamycin (Mithracin): a cytotoxic antibiotic that may be used for severe disease resistant to other therapy

32. Osteomyelitis • Infection of the bone occurs due to: • 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 • Staphylococcus aureus (70% to 80%) • Other: Proteus, Pseudomonas, and E. coli

33. Osteomyelitis (cont.) • Prevention of osteomyelitis is the goal • Early detection and prompt treatment of osteomyelitis are required to reduce potential for chronic infection and disability

34. Nursing Process—Assessment of the Patient With Osteomyelitis • Risk factors • Signs and symptoms of infection, localized pain, edema, erythema, fever, and drainage • 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 include signs and symptoms of superinfections • Ability to adhere to prescribed therapeutic regimen: antibiotic therapy

35. Nursing Process—Diagnosis of the Patient With Osteomyelitis • Acute pain • Impaired physical mobility • Risk for extension of infection: bone abscess formation • Deficient knowledge

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

37. Interventions • Relieve pain • Immobilization • Elevation • Handle with great care and gentleness • Administer prescribed analgesics • Improve physical mobility • Activity is restricted • Perform gentle ROM to joints above and below the affected part • Participate in ADLs within limitations

38. Interventions (cont.) • Promote good nutrition including vitamin C and protein • Encourage adequate hydration • Administer and monitor antibiotic therapy • Patient and family teaching • Long-term antibiotic therapy and management of home IV administration • Mobility limitations • Safety and prevention of injury • Follow-up care • Referral for home health care

39. Bone Tumors • Primary tumors • Benign tumors are more common, generally 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

40. Nursing Process—Assessment of the Patient With a Bone Tumor • 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

41. Nursing Process—Postoperative Assessment of the Patient With a Bone Tumor • Postoperative assessment resembles that for a patient who has had orthopedic surgery • Motif VS, LOC, neurovascular status, and pain • Assess for signs and symptoms of complications • Monitor laboratory results: WBC and serum calcium level • Assess for signs and symptoms of hypercalcemia

42. Nursing Process—Diagnosis of the Patient With a Bone Tumor • Deficient knowledge • Acute and chronic pain • Risk for injury • Ineffective coping • Risk for situational low self-esteem

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

44. Nursing Process—Planning the Care of the Patient With a Bone Tumor • 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

45. Interventions • Care is similar to that of other patients who have undergone orthopedic surgery • Provide patient and family teaching regarding diagnosis, disease process, and treatment • Prevent 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 assistive devices

46. Interventions (cont.) • Promote proper nutrition • Administer antiemetics as prescribed • Implement relaxation techniques • Provide oral care • Administer nutritional supplements • Provide adequate hydration • Use strict aseptic technique