Chapter 53-care of patients with musculoskeletal problems

Question 1

Osteoporosis pathophysiology

Answer 1

Chronic metabolic disease in which bone loss causes decreased density and possible fracture. Also known as the silent disease because the first sign maybe a fracture. Spine, hip,, wrist, and forearm are most common. There is a loss of height, progressive curvature of the spine and low back.

Osteoclastic activity is greater than osteoblastic activity resulting in a decrease bone mineral density. BMD peaks between 25 and 30 years of age. After that age bone resorption exceeds rebuilding. Estrogen does not build bone, but helps prevent loss.

Generalized
Primary in post menopausal women or men in 70-80s
Secondary due to medical condition such as
Hyperparathyroidism, long-term drug therapy, prolonged immobility.
Regional: This is secondary disease that occurs when limb is immobilized related to a fracture, injury, or paralysis. Immobility for longer than 8 to 12 weeks can cause this. Can also occur in astronauts.

The risk depends on how much bonemass is achieved and how much is later lost. Women lose about 2% of their bone mass every year in the first five years after menopause. For women of any age that do not take estrogen replacement the risk increases. Men also get it after 50 because testosterone decreases which is responsible for building bone tissue.

Question 2

Osteoporosis: Nonmodifiable risk factors

Answer 2

Older age
parental history especially the mother
history of low trauma fracture after 50 years,
being female, especially Caucasian and Asian (bone mass corresponds to amount of skin pigmentation, thats why africans have lower risk)
Low bodyweight/thin built
Endocrine disorders such as hyperthyroidism,
hyperparathyroidism, Cushing’s syndrome, or DM

Question 3

Osteoporosis: modifiable risk factors

Answer 3

chronic low calcium and or vitamin D intake.
Estrogen and testosterone deficiency.
Current smoking.
High alcohol intake over three drinks.
Lack of physical exercise or prolonged immobility.
Medications: aluminum containing antacids, anticonvulsants,
heparin, antiretrovirals, and glucocorticoids

Question 4

Osteoporosis: diet/nutrition

Answer 4

Excess caffeine can cause calcium loss.

A diet lacking calcium and vitamin D stimulates the parathyroid to release PTH which causes release of calcium from the bone.

Calcium loss increases when phosphorus intake is high. High amounts of carbonated beverages put you at high risk.

Protein deficiency can reduce bone density as 50% of serum calcium is protein-bound. Too much protein can increase calcium lost in the urine.

Excessive alcohol and tobacco use that a person at risk. Excessive exercise, weight loss dieting, eating disorders.

Activated vitamin D is needed for calcium uptake in the body.

Malabsorption of nutrients in the G.I. tract contribute to a low serum calcium level. Patients who are not exposed to sunlight maybe at a higher risk because they do not receive adequate vitamin D for metabolism of calcium

Question 5

Osteoporosis: ACCESS

Answer 5

Alcohol
Corticosteroid
Calcium low
Estrogen low
Smoking
Sedentary lifestyle

Question 6

Osteoporosis: health promotion

Answer 6

Teaching should begin with young women are at 30 years old.

Prevention to decrease modifiable risk factors.

Ensure adequate calcium intake: including food such as dairy, dark green leafy vegetables, and calcium supplements. Divide calcium into to three doses. Get sun exposure for vitamin D and also vitamin D supplements. Limit carbonated beverages. Avoid sedentary lifestyle. Continue weight-bearing exercises.

Question 7

Tests for osteoporosis

Answer 7

No lab test, but some biochemical markers. Other metabolic diseases may have change in calcium, vitamin D, phosphorus, serum protein, thyroid function tests.

DXA/dual x-ray absorptiometry of the spine and hip. Women in 40s should have a baseline done, less radiation than a chest x-ray. Best for a definitive dx

QCT-Quantitative computed tomography can measure bone density using either central or peripheral technique. Analyzes trabecular cortical bone separately and sensitive to changes in the vertebral column. More expensive

QUS-Quantitative ultrasound. Heel, tibia, and patella tested. No preparation or radiation exposure.

Question 8

Intervention for osteoporosis

Answer 8

Nutrition therapy. Same as preventions. Get adequate amounts of protein, magnesium, vitamin K, and trace minerals. Increase calcium and vitamin D. Avoid excess alcohol and caffeine. You must increase all nutrients not just one. Have exercising program that includes strengthening and weight-bearing. Walk for 30 minutes 3 to 5 times a week is most effective for prevention. Avoid high-impact activities. Avoid tobacco. Prevent falls to reduce your risk of fractures.

Question 9

Drug therapy for osteoporosis

Answer 9

Calcium and vitamin D supplements. Intake of calcium alone is not a treatment that is important for prevention. Calcium carbonate over-the-counter is good for people with G.I. upset. Take it with food and drink 6 to 8 ounces of water to prevent urinary or renal calculi. Be careful for hypercalcemia.

Estrogen or hormone therapy. It reduces bone loss, increases bone density and reduces the risk of fractures in postmenopausal women.

Biphosphonate: drug of choice for preventing and treating. they are potent inhibitors of bone resorption that preserve bone mass and increased density such as Fosamax, Boniva, intestinal. Side effects include heartburn, difficulty swallowing, jaw pain. Report them. Prior to beginning having oral assessment and preventative dentistry. Tell any dentist that you are taking these. Take early in the morning with 8 ounces of water and remain upright for 30 to 60 minutes before eating. Discontinue if chest discomfort. Do not take if you have decreased renal function, hypocalcemia, or GERD.
Hypocalcemia may occur and you need to maintain adequate intake of calcium and vitamin D. Calcium interferes with the drug and should be taken at a different time.

Reclast and Aredia Are given IV. Reclast is given once a year and Aredia is given every 3 to 6 months. Both have a complication of jaw osteonecrosis. Have dentistry prior to beginning drug.

Zometa IV once a year, but contraindicated with aspirin sensitivity. Check creatinine prior because of renal problems.

Selective Estrogen Receptor modulators: SERMs prevent bone loss by mimicking estrogen. Reduces risk of breast cancer. Evista, Nolvadex, Tamofen

Calcitonin is a thyroid hormone that inhibit osteoclastic activity. Have analgesic effect after vertebral fracture.

Question 10

Osteomalacia: pathophysiology

Answer 10

Osteomalacia is the loss of bone related to Vitamin D deficiency. Causes softening of the bone. Calcification doesn’t occur. Called rickets in children. It is more common in poor and famine countries. Older adults most at risk. Vegans, homeless, and alcoholics also at risk. Dark skin is more at risk than light skin

Question 11

Osteomalacia causes

Answer 11

Vitamin D disturbances can come from inadequate production, lack of sunlight, dietary deficiency, abnormal metabolism, drug therapy with Dilantin, fluoride, or barbiturates, liver disease, renal disease, post gastrectomy, malabsorption, inflammatory bowel.

Kidney disease including acidosis and hypophosphatemia

Question 12

Osteomalacia prevention, teaching, and treatment:

Answer 12

Increase vitamin D through the diet, and exposure, entrance supplements. Foods with vitamin D include milk and food that has vitamin D added, eggs, swordfish, chicken, liver, enriched cereals and bread. Cheese and yogurt do not normally have vitamin D in it. Read food labels to find out. At least five minutes a day of sunlight for homebound.

400 to 800 units Vitamin D needed

Question 13

Osteomalacia Assessment

Answer 13

Take a thorough nutritional and sun exposure assessment. Include any history of chronic diseases of the G.I. tract and renal disease. Medication history. They may have hypophosphatemia leading to muscle weakness and hypocalcemia leading to muscle cramping. The muscle strength and gait. If the patient has pain it’s usually aggravated by activity and gets worse at night.

Question 14

Osteomalacia diagnosis

Answer 14

X-rays show decrease in cancellous bone and lack of osteoid sharpness. The classic diagnostic finding is the presence of radiolucent band called losers lines or zones. They represent stress fractures that are not mineralized. They appear in the neck, ribs, and pelvis. Bone biopsy may be needed. DXA scan may help

Question 15

Paget’s disease pathophysiology

AKA osteitis deformans

Answer 15

Metabolic disorder in which bone is excessively broken down and reformed. The bones are weak with increased risk for bowing and fractures. It can be familial or sporadic.
Active phase: Rapid increase in osteoclast that breakdown bone and cause destruction and deformity.
Mixed phase: osteoblasts form new bone causing it to be vascular, structurally weak, and deformed.
Inactive phase: When osteoblast exceed osteoclast activity. The newly formed bone becomes sclerotic and hard

Most common areas include the vertebrae, fever, skull, clavicle, humerus, and pelvis.

It is possibly a result of a viral respiratory infection or an autosomal dominant pattern (identical twins). Offer genetic counseling

Men over 50, Europeans are at risk

Question 16

Paget’s disease manifestations

Answer 16

80% are asymptomatic. It is usually accidentally discovered during routine lab or x-ray work. assess fracture history and bone pain especially in the hip and pelvis. Bone pain is aching, poorly described, deep, worsened with pressure and weight bearing, most notable at night when resting. They may have redness and warmth at the site. Low back and sciatic nerve pain, bowing of long bones,loss of spinal curvature, enlarged thick soft skull, bone cancer, hyperparathyroidism, gout, urinary or renal stones, heart failure from fluid overload. Arthritis and nerve impingement is common. Possible decrease in height. Flexion contracture of the hip. Apathy, lethargy, and fatigue.

During assessment pay attention to the skull which is soft thick and enlarged. It may lead to deafness and vertigo. There may be compression of any of the cranial nerves. Assess vision, swallowing, and speech. May have hydrocephalus.

Complication could be osteogenic sarcoma most often in the men from 70 to 80. Usually occurs in the femur, humerus, and fracture sites. It metastasizes to the lung.

Question 17

Paget’s disease Labs and Dx

Answer 17

ALP serum alkaline phosphatase increased
urinary hydroxyproline increased (reflects bone collagen turnover)
Increased uric acid from overactive bone metabolism
X-rays
Radionuclide bone scan
CT shows cancerous tumors

Question 18

Paget’s disease non surgical trtmnt

Answer 18

Primary intervention is drug therapy and first treat the pain. Over the counter NSAIDS can control the pain. Oral bisphosphonates are the first line treatment for Paget’s disease. Oral: Fosamax and Actonel most common. Didronel and Skelid. IV:Aredia and Reclast

1500mg calcium divided
800 U Vitamin D for 2 weeks after Reclast by IV

Calcitonin subQ: reduces bone resorption. May give nausea, flushing, and skin rash

If Bisphosphate and calcitonin do not work a potent chemotherapeutic agent called Mithracin may be used for severe cases. It’s toxic to liver, G.I. tract, and kidneys. Monitor liver and kidney function daily and intake output. Watch for electrolyte imbalance. Watch for bleeding.

Physical therapy maybe used to increase mobility.
Surgical management includes a tibial osteotomy, total joint replacement, or surgical decompression and stabilization of the spine for relief of pain.

Question 19

Osteomyelitis pathophysiology

Answer 19

Infection of the bone caused by bacteria, viruses, fungi. Can be sever and very diffiuclt to treat.
Inflammation, ischemia, and bone necrosis occur.
Exogenous is when the infectious organism is from outside the body and direct contamination
Endogenous is from inside the body, also hematogenous because is is carried in the blood stream. (usually samonella)
Contiguous is from skin infection of adjacent tissues. (usually staph areus)

Malnutrition, alcoholism, diabetes, kidney or liver disease, immunosuppressive disorders increase the risk. common sites are in the vertebrate and long bones. Compromised blood supply put you at risk.

Adults over 50 are most at risk. Immune function declines. Circulatory status is compromised. At risk for pressure ulcers. Does not show typical signs of infection.

Question 20

Osteomyelitis assessment and manifestation

Answer 20

Bone pain which is constant, localized, pulsating, and worsens with movement. With acute osteomyelitis fever occurs. The area is swollen with redness and heat. Ulcers and drainage may be present. These symptoms are less common with chronic osteomyelitis. Chronic osteomyelitis have ulceration of the skin, sinuses formed, local pain, and drainage.

Possible increase in white blood cell count, erythrocyte sedimentation rate increases as the condition worsens. Possible septic shock. Bone scan is helpful in diagnosis

Systemic affects: lymoh nodes, high temp, lethargic, anorexia,

Question 21

Osteomyelitis nursing diagnosis

Answer 21

Acute or chronic pain related to inflammation.
Hyperthermia related to pathogenic invasion of the bone. Ineffective tissue perfusion related to tissue swelling.
Potential for sepsis and septic shock.

Question 22

Osteomyelitis treatment

Answer 22

IV antimicrobial therapy for several weeks. Possibly more than one drug will be used. For chronic osteomyelitis prolonged therapy of more than three months may be needed. Oral therapy may be needed for weeks or months after IV therapy. Possible wound irrigation. Pain control medications.

If on antibiotics watch for toxicity, drink adequate fluids, eat high calorie diet to decrease kidney problems, yeast infection, and GI upset.

Hyperbaric oxygen therapy may be needed to increase tissue perfusion. This is useful for anaerobic infections.

Open surgical debridement (sequestrectomy) of the necrotic bone and bone graft maybe needed. After surgery check the six Ps frequently (neurovascular compromise). Last resort surgeries include a muscle flap and amputation.

Question 23

Benign bone tumors

Answer 23

Often asymptomatic

Chondrogenic from cartilage
Osteogenic from bone
Firbrogenic from fibrous tissues

Osteochondromas are the most common type and usually start after injury.
Giant cell tumors can spread fast, even to the lungs. Women over 20 get them the most.

Pain, swelling, muscle atrophy, muscle spasm. X-rays. MRI or CT and is used if in the spine. 
Drug therapy (NSAIDS) and surgery is used in combination. Removal of the tumor with possible bone grafting may be needed.

Question 24

Osteosarcoma

Answer 24

The primary malignant bone tumor which occurs in the distal femur more than half the time. They are usually large, causing pain and swelling, and warmth. Usually metastasizes to the lung within two years resulting in death. More often in males between 10 and 30 and in older patients with Paget’s disease. Having prior radiation increases your risk.

Question 25

Ewings sarcoma

Answer 25

Not as common but the most malignant. It also has systemic manifestations such as a low-grade fever, leukocytosis, anemia. The pelvis and lower extremity are most affected. Death results from metastasis to the lungs and other bones. Occurs most often in children and young adults in their 20s, men.

Question 26

Chondrosarcoma

Answer 26

dull pain, and swelling for a long period. Usually affects the pelvis and proximal femur. Arises from Cartlidge. Occurs in middle aged and older people and men.

Question 27

Fibrosarcoma

Answer 27

Malignant fibrous histiocytoma is the most malignant. It is gradual without specific symptoms. local tenderness. occurs in long bones of the lower extremity. Typically in middle aged men.

Question 28

Bone seeking cancer

PTLKB

Answer 28

Tumors of the prostate, breast, kidney, thyroid, and lung. They usually metastasize to the vertebrae, pelvis, fever, and ribs. They may cause pathological fractures. They are more common than primary tumors and usually affect people over 40 with a history of cancer.

Particular Tumors Love Killing Bone
Prostate Thyroid Lung Kidney Breast

Question 29

Nursing diagnosis for bone cancer

Answer 29

Acute and chronic pain, grieving. Additional diagnoses include fear and anxiety, ineffective coping, compromise family coping, dysfunctional grieving, imbalance nutrition, disturb sleep pattern, self-care deficit, ineffective role performance, spiritual distress, potential for pathological fractures.

Question 30

Treatment of bone cancers

Answer 30

Nonsurgical treatment includes the management radiation, chemotherapy, drug therapy including bisphosphonate.

Surgical management can vary in severity. Limb salvage procedures are often extensive with a large incision and a wound vac for several days. It will result in a impaired physical mobility and self-care deficit. Patients may have allografts, metallic implants, total joint replacement. Surrounding tissues including nerves and blood vessels may also be removed during surgery. Cordotomy cutting the spinal cord roots to reduce pain.

Question 31

Dupuytren’s contracture

Answer 31

A slowly progressive thickening of the palmar fascia resulting in flexion contracture of the fourth and fifth finger. Surgical release may be indicated. Care like carpal tunnel release

Familial, European men

Question 32

Ganglion

Answer 32

A benign cyst on the wrist or foot. Painless, but may have joint discomfort. May be aspirated followed by a Cortizone injection. It may be excised. Avoid activity for 48 hours after surgery.

Question 33

Hallux valgus

Answer 33

The great toe drift laterally resulting in a bunion. Women more than men. Usually from poorly fitted shoes. Arthritis and family history can cause them. Bunionectomy removes the bony overgrowth. Possible osteotomy’s or bone resection. Often occur along with hammertoe.

Question 34

Mortons neuroma

Answer 34

Tumor grows in the digital nerve of the foot. acute pain and burning in the webspace and the entire third and fourth toe. Surgical removal and pressure dressing

Question 35

Planter fasciitis

Answer 35

Inflamation of the plantar fascia located in the arch of the foot. Seen in older adults, athletes, and runners. Obesity contibutes to it. Conservative management includes rest, ice, stretching, support and orthotics. NSAIDs or steroids maybe needed.

Question 36

Scoliosis

Answer 36

Vertebrae rotate and begin to compress causing lateral curve in the spine. Curvature increases during periods of growth. More than 50° is unstable. More than 60° compromises the cardiopulmonary function. Female more than males and adolescents. Can be congenital, neuromuscular, and idiopathic.
Lordosis (flat back) often occurs. Assess for leg length discrepancy. Surgical treatment includes fusion, insertion of instrumentation including plates, screws, and rods. After surgery patients can usually return to work in three weeks and swim and bike, some activities in six weeks, and others in 3 to 6 months.

Usually seen in children and corrected with early prevention with braces, physical therapy.

After surgery, make sure pts are log rolled and kept in alignment.

Postural when the curve corrects with bending
Structural when it does not correct with bending

Question 37

Muscular dystrophy

Answer 37

Slow or progressive. Causes include poor blood flow to muscle resulting in reduced tissue oxygenation. Disturbance in nerve muscle interaction. Loss of cell membrane integrity is the result of increased enzyme activity. The primary problem is progressive muscle weakness. Death usually is caused by respiratory failure from weakness. Cardiac failure may also occur. Muscle biopsy often confirms a difficult diagnosis. Care is supportive and includes therapy to maintain function. Steroids may slow the progression of the disorder.

Genentics xlinked recessive are Duschene and Becker. They are the most common kinds