Chapter 36 Management of Patients w/ Musculoskeletal Disorders Flashcards
Osteoporosis
A bone disorder primarily affecting older people in which the bones become porous, brittle, and more prone to fracture
Osteoporosis Risk Factors
Small-framed women ( less bones)
Postmenopausal women (drop in estrogen)
History of bone fractures during adulthood
History of impaired glucose tolerance and diabetes
Asian, Caucasian, and African American women
Poor calcium intake due to lactose intolerance
Use of aromatase inhibitors in women with breast cancer (blocks estrogen)
Bariatric surgery (bypasses duodenum where Ca+2 is absorbed)
GI disease that cause malabsorption (e.g., celiac disease, alcoholism)
Autoimmune disease (e.g., rheumatoid disease)
Men >60 years of age
Corticosteroid therapy >3 months
What disease is the precursor to osteoporosis?
Osteopenia
Osteopenia
Thinner than average bone density
Primary Osteoporosis
Mainly occurs in post-menopausal women due to low vitamin D levels & failure to develop optimal peak bone mass
Secondary Osteoporosis
Result of medications or diseases that affect bone metabolism, such as celiac disease & hypogonadism
Meds That Can Lead to Secondary Osteoporosis
Anticonvulsants (phenytoin, [Dilantin])
Thyroid replacement agents (levothyroxine [Synthroid])
Antiestrogens (medroxyprogesterone [Depo-Provera])
Androgen Inhibitors (leuprolide [Lupron])
Proton Pump Inhibitors (esomeprazole [Nexium])
Osteomalacia
Abnormal softening of bones in adults
What vitamin deficiency s present in pts w/osteomalacia?
Activated Vitamin D
Clinical Manifestations of Osteomalacia
Soften, weakened bones
Skeletal deformities (spinal kyphosis and bowed legs)
Waddling gait
Pain and tenderness to touch
Pathologic fractures
Fall risk
Diagnostic Studies for Osteomalacia
X-ray and lab studies: serum calcium, phosphorus, and ALP
Urine test
Bone biopsy
Nursing Interventions to Decrease Risk for Fractures & Associated Disability
Early identification for at-risk teens and young adults
Increased calcium and vitamin D intake
Regular weight-bearing exercise
Lifestyle modifications
- Reduced use of caffeine, tobacco products, carbonated drinks, and alcohol
Diagnostic Studies for Osteomalacia
X-ray and lab studies: serum calcium, phosphorus, and ALP
Urine test
Bone biopsy
Nursing Interventions for Osteomalacia
Reduce discomfort and pain
Calcium and/or vitamin D supplement for malabsorption
Exposure to sunlight
Diet rich in calcium and vitamin D
Braces or surgery for persistent orthopedic deformities
Paget’s Disease
A disease of unknown origin that is characterized by extensive breakdown of bone tissue followed by abnormal bone formation.
In the initial phase of Paget’s disease…
…excessive bone reabsorption occurs
The second phase of Paget’s disease involves…
…excessive abnormal bone formation
Clinical Manifestations of Paget’s Disease
Severe, persistent pain that worsens w/weight-baring
Impaired mvmt
Cranial enlargement (frontal & occipital areas)
Headaches w/skull involvement
Impaired hearing
Visual acuity
Kyphosis
Barrel chest
Asymmetrical bowing of the tibia & femur
Waddling gait
Forward bent spine and is rigid
Chin rests on the chest
Arms are bent outward and forward, appearing long in relation to the shortened trunk
Associated Assessment & Diagnostic Findings of Paget’s Disease
Elevated serum ALP concentration and urinary hydroxyproline excretion
-Higher values suggest more active disease
Patients w/ Paget disease have normal blood calcium levels
X-rays: Local areas of demineralization and bone overgrowth in the characteristic mosaic patterns
Bone scans demonstrate extent of disease
Bone biopsy may provide differential diagnosis w/ other bone diseases
Medical Management of Paget’s Disease
NSAIDS, Bisphosphonates, and Plicamycin
Walking aids, shoe lifts, and PT
Weight control
Diets adequate in calcium and vitamin D and periodic monitoring
Gerontological Considerations
Educate patients, families, and caregivers on how to compensate for altered musculoskeletal functioning with an emphasis on the risk of falls
Assess the home environment for safety to prevent falls and reduce the risk of fracture
Develop strategies for coping with a chronic health problem and its effect on quality of life
Provide alternative communication devices (e.g., text telephone, telecommunication device for the deaf) and home safety alarms if need
Osteomyelitis
Infection of the bone that results in inflammation, necrosis, and formation of new bone
High-Risk Patients for Osteomyelitis
Older adults
Poorly nourished or obese
Impaired immune systems
Chronic illnesses (diabetes, RA)
Receiving long-term corticosteroid therapy or immunosuppressive agents
IV drug users
Risk Factors of Osteomyelitis
Older age
Diabetes
Long-term corticosteroid therapy
History of previous injury, infection, or
orthopedic surgery
Clinical Manifestations of Osteomyelitis
Bloodborne infections:
-Clinical and lab s/s of sepsis (e.g., chills, high fever, rapid pulse, general malaise)
-Systemic symptoms may shadow local s/s at first
- Infected area becomes painful, swollen and extremely tender as the infection extends
-Patient reports constant, pulsating pain that intensifies with movement
No systemic s/s when spread of adjacent infection or from direct contamination
Non-healing ulcer with intermittent and spontaneous pustulous drainage with chronic osteomyelitis
Diabetic osteomyelitis can occur without external wound:
- Non-healing fracture
- Foot ulcer > 2 cm in diameter
Physical Exam of Osteomyelitis
Signs & Symptoms of localized pain
Warm, inflammed, edematous area, tender to touch
Erythema
Fever
Recurrent purulent drainage of an infected sinus
Altered gait
Associated Assessment & Diagnostic Findings for Osteomyelitis (Acute vs. Chronic): Wound & Blood Cultures
Acute: only positive in 50% of cases; antibiotic treatment initiated without results
Chronic: frequently unreliable for isolating organism, therefore, open bone biopsy is indicated
Associated Assessment & Diagnostic Findings for Osteomyelitis (Acute vs. Chronic): X-Rays
Acute: soft tissue edema in early findings; periosteal elevation and bone necrosis evident after 2-3weeks
Chronic: large, irregular cavities, raised periosteum, sequestra, or dense bone formations
Associated Assessment & Diagnostic Findings for Osteomyelitis (Acute vs. Chronic): Radioisotope Bone Scans
Acute: (isotope-labeled WBC scan) and MRI help with early definitive diagnosis
Chronic: identify areas of infection
Associated Assessment & Diagnostic Findings for Osteomyelitis (Acute vs. Chronic): Blood Studies
Acute: leukocytosis and elevated ESR
Chronic: ESR and WBC count usually normal; anemia may be evident
Medical Care of Osteomyelitis
Goal is prevention
Elective orthopedic surgery postponed if infection present
Urinary catheters and drains removed asap Pharmacological Therapy - Antibiotics
-Prophylactic treatment at time of surgery and for 24hrs post op
-Longer therapy than other infections; typically continues for 3-6 weeks; oral antibiotics when infection is controlled
Surgical management: Debridement indicated if infection is chronic and not responsive to antibiotic therapy
- All dead, infected bone and cartilage must be removed before healing can occur
-Closed suction irrigation system may be used to remove debris
-May be staged over time to ensure healing
-Weakens bone, so internal fixations or external supportive devices may be needed to prevent pathologic fractures
Nursing Interventions for Osteomyelitis
Relieve pain
Improve physical mobility
Control the infectious process
Educate patient about self-care
Adherence to therapeutic regimen of antibiotics
Maintenance of IV access and administration
equipment at home
Medication name, dosage, frequency, admin rate, safe storage and handling, adverse reactions, and necessary laboratory monitoring
Home health nurse if support questionable or if patient lives alone to assist with IV antibiotic therapy
Stress importance of follow-up care appointments
Hematogenous Osteomyelitis
Caused by bloodborne spread of infection
Low Back Pain Causes
Acute lumbosacral strain
Unstable lumbosacral ligaments & weak muscles
Intervertebral disc problems
Unequal leg length
Gerontological Considerations for Low Back Pain
Older adults may experience back pain associated w/ osteoporotic vertebral fractures, osteoarthritis of the spine, & spinal stenosis
Diagnostic Studies for Low Back Pain: Spinal X-Rays
May demonstrate a fracture, dislocation, infection, osteoarthritis or scoliosis
Diagnostic Studies for Low Back Pain: Bone Scan & Blood Studies
May disclose infections, tumors, & bone marrow abnormalities
Diagnostic Studies for Low Back Pain: CT Scan
Useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column & problems of the vertebral discs
Diagnostic Studies for Low Back Pain: MRI Scan
Permits visualization of the nature & location of the spinal pathology
Diagnostic Studies for Low Back Pain: Electromyogram (EMG) & Nerve Conduction Studies
Used to evaluate spinal nerve root disorders (radiculopathies)
Diagnostic Studies for Low Back Pain: Myelogram
Permits visualization of segments of the spinal cord that may have herniated or may be compressed
Indications: When an MRI cannot be performed
Diagnostic Studies for Low Back Pain: Ultrasound
Useful in detecting tears in ligaments, muscles, tendons, & soft tissues in the back
Prevention Strategies for Acute Low Back Pain
Weight reduction as needed
Stress reduction
Avoid high heels
Walk daily & gradually increase the distance & pace of walking
Avoid jumping & jarring activities
Stretch to enhance flexibility
- Do strengthening exercises
Body Mechanics for Acute Low Back Pain
Practice good posture
Avoid twisting, lifting above waist level, & reaching up for any length of time
Push objects rather than pull them
Keep load close to the body when lifting
Lift w/ large leg muscles & not back muscles
Squat while keeping back straight when it is necessary to pick something up off the floor
Bend your knees & tighten your abdominal muscles when lifting
Avoid overreaching or a forward flex position
Use a wide base of support
Work Modification for Acute Low Back Pain
Adjust the height of chair using a footstool to position knees higher than the hips
Adjust height of work area to avoid stress on the back
Avoid bending, twisting, & lifting heavy objects
Avoid prolonged standing & repetitive tasks
Avoid work involving continuous vibrations
Use lumbar support in straight back chair w/ arm rests
When standing for any length of time, rest one foot on small stool/box to relieve lumbar lordosis
Bursitis
Inflammation of a fluid-filled sac in a joint
Bursae
Fluid-filled sacs that prevent friction between joint structures during joint activity & are painful when inflamed
Tendonitis
Inflammation of muscle tendons
Conservative Treatment of Bursitis & Tendonitis
Rest of the extremity
Intermittent ice & heat to the joint
NSAIDs for pain control
(T/F) True or False: Tendon & bursae inflammatory conditions go away w/ or w/out treatment
True
Treatment is primarily aimed at symptom relief, not cure
Impingement Syndrome
Generalized term that describes impaired movement of the rotator cuff of the shoulder
Radiculopathy
Pain radiating from a diseased spinal nerve root (down the leg)
Sciatica
Pain radiating from an inflamed sciatic nerve
Carpal Tunnel Syndrome
An entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass
Risk Factors for Carpal Tunnel Syndrome
Women between the ages of 30-60
Women going through menopause or are taking estrogen & birth control pills (HIGHEST RISK!!)
People employed in occupations that frequently require repetitive hand movements or flexing of the wrist
- Hairdressers
- Assembly-line workers
Those exposed to vibrations when doing such tasks
- Construction workers
- Machinists
Carpal Tunnel Syndrome Causes
It is caused by repetitive hand & wrist movements
Associated w/ RA, diabetes, acromegaly, hyperthyroidism, or trauma
Clinical Manifestations of Carpal Tunnel Syndrome
Pain, numbness, paresthesia &/or weakness along median nerve distribution
- Thumb, index, & middle fingers
Night pain &/or fist clenching upon waking
Positive Tinel Signs: Elicited by percussing lightly over the median nerve near the inner aspect of the wrist
- Reports tingling, numbness, or pain
Contusion
Soft tissue injury produced by blunt force
Signs & Symptoms of Contusions
Pain, swelling, and ecchymosis
Ecchymosis
Bruising/discoloration
Strain
Pulled muscle injury to the musculotendinous unit
Signs & Symptoms of Strains
Pain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded 1st, 2nd, and 3rd degree
Sprain
Injury to ligaments & supporting muscle fiber around a joint
Signs & Symptoms of Sprains
Pain (may increase with motion), edema, tenderness; severity graded according to ligament damage and joint stability
Dislocation
Articular surfaces of the joint are not in contact
Signs & Symptoms of Dislocations
A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb & loss of mobility
Subluxation
Partial or incomplete dislocation (Does not cause as much deformity as a complete dislocation)
Management of Soft Tissue Injuries
Rest
Ice
Compression
Elevation
What should the nurse assess to evaluate the effectiveness of alendronate (Fosamax) therapy for a patient with Paget’s disease?
A) Oral intake
B) Daily Weight
C) Grip strength
D) Pain intensity
D) Pain intensity
Which information should the nurse include in the discharge teaching for a patient after 1 week of IV antibiotic therapy for acute osteomyelitis?
A) How to apply warm packs to the leg to reduce pain
B) How to monitor for & care for a long-term IV catheter
C) The need for daily aerobic exercise to help maintain muscle strength
D) The reason for taking oral antibiotics for 7-10 days after discharge
B) How to monitor for & care for a long-term IV catheter
