Transcript Smeltzer Textbook of MEdical Surgical Nursing

Chapter 42
Management of Patients With
Musculoskeletal Disorders
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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, sensation, and muscle strength
• If obese, complete a nutritional assessment
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Question
What findings can be identified with the use of radiography
of the spine?
A. Fracture, dislocation, infection, osteoarthritis, or
scoliosis
B. Infections, tumors, and bone marrow abnormalities
C. Soft tissue lesions adjacent to the vertebral column
D. Spinal nerve root disorders
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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.
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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
• 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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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
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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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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.
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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.
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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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Tinel’s Sign: Assessment of Carpal Tunnel
Syndrome
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Dupuytren’s Contracture
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Question
What is bursitis?
A. Inflammation of a fluid-filled sac in the joint
B. New bone growth around a sequestrum
C. Disease of a nerve root
D. Inflammation of muscle tendons
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Answer
A. 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.
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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
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Common Foot Problems
• Plantar fasciitis
• Corn
• Callus
• Ingrown toenail
• Hammer toe
• Hallux valgus
• Clawfoot: pes cavus
• Morton’s neuroma
• Flatfoot: pes planus
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Common Foot Deformities
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Question
What is pes cavus?
A. Flexion deformity of the interphalangeal joint that may
involve several toes
B. Deformity in which the great toe deviates laterally
C. Common disorder in which the longitudinal arch of the
foot is diminished
D. Foot with an abnormally high arch and a fixed equinus
deformity of the forefoot
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Answer
D. 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.
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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)
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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
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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.
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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
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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
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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
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Risk Factors for Osteoporosis
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Progressive Osteoporosis Bone Loss and
Compression Fractures
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Typical Loss of Height Associated With
Osteoporosis and Aging
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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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Pharmacologic Therapy
• Calcium and vitamin D
• Bisphosphonates
– Alendronate (Fosamax)
– Risedronate (Actonel)
– Ibandronate (Boniva)
– Zoledronic acid (Reclast)
• Cacitonin
• Selective estrogen modulators (SERMs): Evista
• Teriparatide (Forteo)
• RANK ligand (RANKL)
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Question
How long does a patient taking bisphosphonates need to
stay upright after administration?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 120 minutes
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Answer
C. 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.
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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
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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
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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
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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.
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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
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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
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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
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