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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 68

Management of Patients With
Musculoskeletal Disorders


Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
What findings can be identified with the use of a x ray 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

X-ray 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 PainAssessment
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 PainDiagnoses
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 PainPlanning
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 weight reduction

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Positioning to Promote Lumbar Flexion
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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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Proper and Improper Standing Postures
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Proper and Improper Lifting Techniques
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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

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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Common Conditions of the Upper
Extremities
Bursitis and tendonitis
Loose bodies
Impingement syndrome
Carpal tunnel syndrome
Ganglion
Dupuytrens contracture

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Tinels Sign: Assessment of Carpal Tunnel
Syndrome
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Dupuytrens Contracture
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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 vitalevery hour for the first 24
hoursassess motor function only as prescribed, instruct patient
in signs and symptoms to assess and report
Pain control measuresmedication, elevation, intermittent ice or
cold
Prevention of infectionkeep dressing clean and dry, wound care,
signs and symptoms of infection
Assistance with ADLs and measures to promote independence
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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

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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Common Foot Problems
Plantar fasciitis
Corn
Callus
Ingrown toenail
Hammer toe
Hallux valgus
Clawfoot: Pes cavus
Mortons neuroma
Flatfoot: Pes planus
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Common Foot Deformities
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Nursing Process: The Care of the Patient
Undergoing Foot SurgeryAssessment
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 homefor example, distances
required to walk and presence of stairs or steps
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Nursing Process: The Care of the Patient
Undergoing Foot SurgeryDiagnoses
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 SurgeryPlanning
Major goals may include adequate tissue perfusion, relief
of pain, improved mobility, and absence of complications.
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Interventions
Neurovascular assessment is vital
Assess swelling and neurovascular status every 12
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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Interventions
Improving mobility
Instruction in weight-bearing restrictions as
prescribed
Use of assistive devices (crutches or walker)
Measures to assure patient safety
Measures to prevent infection
Wound or pin care
Keep dressing clean and dry
Signs and symptoms of infections
Patient teaching

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Osteoporosis
Affects approximately 40 million people over the age of
50 in the United States.
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 Colles fractures of the wrist
Risk factors.


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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
intaketake in divided doses with vitamin C
Regular weight-bearing exerciseswalking
Weight training stimulates bone mineral density (BMD)

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Pharmacologic Therapy
Biphosphonates
Alendronate: Fosamax
Risedronate: Actonel
Ibandronate: Boniva
Selective estrogen modulators (SERMs): Evista
Cacitonin
Teriparatide: Forteo
Also need adequate amounts of calcium and vitamin D
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Question
How long does a patient taking biphosphonates need to
stay upright after administration?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 120 minutes
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Answer
C

Biphosphonates are administered on arising in the morning
with a full glass of water on an empty stomach and the
patient must stay upright for 3060 minutes.
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Nursing Process: The Care of the Patient
with OsteoporosisAssessment
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 OsteoporosisDiagnoses
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 OsteoporosisPlanning
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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Interventions
Promoting understanding of osteoporosis and the
treatment regimen
Relieving pain
Improving bowel elimination
Preventing injury
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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
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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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Pagets Disease
AKA osteitis deformans
Disorder of localized bone turnover
Incidence: 23% 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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Pagets 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
Biphosphonates (etidronateDidronel)
Plicamycin (Mithracin): a cytotoxic antibiotic may be
used for severe disease resistant to other therapy

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Osteomyelitis
Infection of the bone
Occurs due to:
Extension of soft tissue infection
Direct bone contamination
Blood-borne spread from another site of infection
This typically occur in an area of bone that has
been traumatized or has lowered resistance
Causative organisms
Staphylococcus aureus (7080%)
Other: Proteus and Pseudomonas species, E. coli

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Prevention of osteomyelitis is the goal.
Early detection and prompt treatment
of osteomyelitis is required to reduce
potential for chronic infection and
disability.

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Nursing Process: The Care of the Patient
with OsteomyelitisAssessment
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 OsteomyelitisDiagnoses
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 OsteomyelitisPlanning
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
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

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Interventions
Promote good nutrition: 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
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Bone Tumors
Primary tumors
Benign tumors are more common and generally are
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
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Nursing Process: The Care of the Patient
with a Bone TumorAssessment
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 TumorPostoperative
Assessment
Postoperative assessment as for a patient who has had
orthopedic surgery
Motif 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 TumorDiagnoses
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
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Nursing Process: The Care of the Patient
with a Bone TumorPlanning
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
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
Promoting proper nutrition
Administer antiemetics as prescribed
Relaxation techniques
Oral care
Nutritional supplements
Provide adequate hydration
Use strict aseptic technique