Transcript Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 24

Chapter 68
Management of Patients
With Musculoskeletal
Disorders
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Nursing Process: The Care of the Patient
with Low Back Pain—Assessment
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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
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
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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
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Nursing Process: The Care of the Patient
with Low Back Pain—Planning
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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.
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Interventions
Pain management
 Exercise
 Body mechanics
 Work modifications
 Stress reduction
 Health promotion; activities to promote a
healthy back
 Dietary plan and encouragement of
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weight reduction
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Positioning to Promote Lumbar
Flexion
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Proper and Improper Standing
Postures
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Proper and Improper Lifting
Techniques
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Common Conditions of the Upper
Extremities
Bursitis and tendonitis
 Loose bodies
 Impingement syndrome
 Carpal tunnel syndrome
 Ganglion
 Dupuytren’s contracture
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Osteoporosis
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 break easily under stress
 Frequently result in compression fractures of
the spine, fractures of the neck or
intertrochanteric region of the femur, and
fractures of the wrist
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Risk Factors
Female
 Caucasian, non-Hispanic, or Asian
 Increased age
 Low weight and body mass index
 Estrogen deficiency or menopause
 Family history
 Low initial bone mass
 Contributing, coexisting medical conditions
(eg, celiac disease) and medications (eg,
corticosteroids, antiseizure medications),
thyroid hormone
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Risk Factors
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Lifestyle Risk Factors
Diet low in calcium and vitamin D
Cigarette smoking
Use of alcohol and/or caffeine
Lack of weight-bearing exercise
Lack of exposure to sunshine
Sedentary life
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Progressive Osteoporosis Bone
Loss and Compression Fractures
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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)
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Clinical Manifestations
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Dowager’s hump, kyphosis, shortened height
Sharp, acute back pain
Tenderness, restriction of spinal movement
Vertebral compression fracture(s)
Constipation/abdominal discomfort/reflux
esophagitis
Most common fractures:
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Between T8 and L3
Distal end of radius and hip
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Typical Loss of Height Associated
with Osteoporosis and Aging
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Primary Osteoporosis:
Interventions
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Drug therapy
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Estrogen/calcium/vitamin D
Biphosphonates (drugs alter phosphorus absorption
Selective estrogen receptor modulators (SERMs)
Calcitonin/androgens
Diet therapy
Prevention of falls
Exercise
Pain management
Orthotic devices
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Osteomalacia
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A metabolic bone disease due to 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
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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
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Paget’s Disease
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Is a disorder of localized rapid bone turnover, most
commonly affecting the skull, femur, tibia, pelvic
bones, and vertebrae
Incidence: 2–3% of the population older than 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 an highly
vascular
Patients are at risk for fractures, arthritis, and
hearing loss
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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
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NSAIDs for pain
 Calcitonin
 Adequate daily intake of calcium (1500 mg) and
vitamin D (400 to 600 IU) is required during
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therapy.
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Osteomyelitis
Infection of the bone
 Occurs due to:
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Extension of soft tissue infection
 Direct bone contamination
 Blood-borne spread from another site of
infection
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• This typically occur in an area of bone that has been
traumatized or has lowered resistance
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Causative organisms
Staphylococcus aureus (70–80%)
 Other: Proteus and Pseudomonas species, E.
coli
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Osteomyelitis
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Prevention of osteomyelitis is the goal.
Postpone Elective orthopedic surgery if
patient has current infection.
 During surgery, be careful not to contaminate
bone
 Aseptic wound care.
 Early detection and prompt treatment of
osteomyelitis is required to reduce potential
for chronic infection and disability.
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Osteomyelitis: Interventions
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Nonsurgical
Drug therapy
 Infection control
 Hyperbaric oxygen therapy
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Surgical
Surgical débridement (The infected bone is
surgically exposed, the purulent and necrotic
material is removed, and the area is irrigated
with sterile saline solution).
 The débrided cavity may be packed with bone
graft to stimulate healing.
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Nursing Process: The Care of the Patient
with Osteomyelitis—Assessment
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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 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
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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
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Nursing Process: The Care of the Patient
with Osteomyelitis—Planning
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Major goals may include
Relief of pain,
 Improved physical mobility, within therapeutic
limitations,
 Control and eradication of infection, and
 Knowledge of therapeutic regimen.
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Interventions
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Reliving pain
Immobilization
 Elevation
 Handle with great care and gentleness
 Administer prescribed analgesics
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Improving physical mobility
Activity is restricted
 Gentle ROM to joints above and below the
affected part
 Participation in ADLs within limitations
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Interventions
Promote good nutrition: vitamin C and
protein
 Encourage adequate hydration
 Administer and monitor antibiotic therapy
 Patient and family teaching
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Long-term antibiotic therapy and management of
home IV administration
 Mobility limitations
 Safety and prevention of injury
 Follow-up care
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Carpal Tunnel Syndrome
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Occurs when the median nerve in the wrist is
compressed by inflamed, edemetous flexor
tendons.
Symptoms: pain, paresthesia, and weakness of
the thumb, index finger, middle and part of the
ring finger but never the pinky.
Caused by repetitive motion via occupational or
sports motions
Nonsurgical management: drug therapy and
immobilization
Possible surgical management
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Bone Tumors
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Primary tumors
Benign tumors are more common and
generally are slow growing and present few
symptoms
 Malignant
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• Prognosis depends upon type and whether the
tumor has metastasized
• Osteogenic sarcoma is the most common, and
most often fatal, primary malignant bone tumor
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Metastatic bone tumors
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More common than primary tumors
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Malignant Bone Tumors
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Clinical manifestations: non-specific c/o (pain, local
swelling, and tender, palpable mass)
Lab: ↑ serum alkaline phosphatase (ALP)
Dx: xrays, CT, Bone scan
Nonsurgical
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Drug therapy
Radiation
Surgical
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Wide or radical resection
Limb salvaging procedures
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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
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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
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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
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Collaborative Problems/Potential
Complications
Delayed wound healing
 Nutritional deficiency
 Infection
 Hypercalcemia
 Fracture
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Nursing Process: The Care of the Patient
with a Bone Tumor—Planning
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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.
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Interventions
Care is similar to that of other patients who
have undergone orthopedic surgery.
 Patient and family teaching regarding
diagnosis, disease process, and treatment.
 Prevention of pathologic fractures
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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
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Interventions
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Promoting proper nutrition
Administer antiemetics as prescribed
 Relaxation techniques
 Oral care
 Nutritional supplements
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Provide adequate hydration
 Use strict aseptic technique
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