chapter 36 - Management of Patients with Musculoskeletal Disorders

assessment of the patient with musculoskeletal pain

 Location, severity, duration, characteristics, radiation, leg weakness

• leg weakness → fall risk

 How the pain occurred and has been managed by the patient

• NSAID usage?

 Work and recreational activities

 Spinal curvature, back and limb symmetry

• Spinal curvature = age-related

 Palpate paraspinal muscles

 Movement ability and effects on ADLs

• how does pain affect it

 DTRs, sensation, and muscle strength

• muscle strength - can be hyper/hypo tonicity

 Assess posture, position changes, and gait

• gait → fall risk?

osteoarthritis (degenerative joint disease)

 Noninflammatory degenerative disorder of the joints, loss of strength, cartilage wears down

types of osteoarthritis

­Primary – idiopathic, does not arise from prior event/disease (age-related)

­Secondary - results from previous joint injury or inflammatory disease (athletes, etc)

osteoarthritis characterized by

pain that’s aggravated with movement and relieved with rest, stiffness, functional impairment, decreased ROM, swelling over joint

osteoarthritis diagnosed by

x ray

osteoarthritis treatment

­Physical: Aerobic exercise, OT/PT, weight loss

­Pharmacologic: Acetaminophen, NSAIDs ie: COX-2 enzyme, Corticosteroid intraarticular injection, Topical: capsaicin, methylsalycylate, diclofenac, OTC creams

• Tylenol or Motrin → used for pain

• COX-2 → Celebrex = increased risk of MI/stroke

­Surgical: Osteotomy, arthroplasty

• done when pt has decreased quality of life

osteoarthritis nursing education

Encourage exercise & use of orthotic devices, pain management

assessment of the patient undergoing arthroplasty

 Aimed at having the patient in optimal health for surgery (improvement of current state)

risks and complications of arthroplasty

­Bleeding

­Dislocation of the prothesis

­VTE (clot)

­Infection

­Heel pressure injury

­Heterotopic ossification (bone growth in abnormal places)

ALSO regular post-op complications can occur

nursing interventions for the patient undergoing total hip arthroplasty

 Preventing dislocation of hip prosthesis

­Correct positioning using splint, wedge, pillows (abduction pillow)

­Keep hip in abduction when turning, abduction when transferring (always keep abducted)

­Limited flexing of the hip; <90 degrees

 Mobility and ambulation

­Patients usually begin ambulation within 1 day after surgery using walker or crutches

• physical therapist normally the first to get them out of bed

­Weight bearing as prescribed by the physician

• PT must be first to get them out of bed and assess tolerance to activities

 Drain use postoperatively

Assess for bleeding and fluid accumulation

POST OP PERIOD LASTS TO 24 MONTHS

additional interventions for the patient undergoing total hip arthroplasty

 Prevention of infection

­Remove drain within 24 to 48 hours

­Strict hygiene practices

­At risk for up to 24 months

­Prophylactic antibiotic may be given

• scant → low rate, remove from patient

• purulent is not as important for removal or the drain

 Prevention of DVT (from low ambulation)

­Appropriate prophylaxis

­Instituting preventive measures

­Monitoring the patient closely for clinical signs of the development of DVT and PE

• signs of PE: are they coughing, desating, trouble breathing, using accessory muscles?

• signs of DVT: calf swelling, red, warm, growing in size compared to other calf

 Patient education and rehabilitation

avoid displacement of hip arthroplasty

keep knees apart at all times

put a pillow between the legs when sleeping

never cross legs when seated

avoid bending forward when seated in chair

avoid bending forward to pick up object on the floor

use high seated chair and a raised toilet seat

do not flex the hip to put on clothing such as pants, stocking, socks, shoes

contraindicated body positions

affected leg should not cross the center of the body

hip should not bend more than 90 degrees when sitting down

• keep back against chair, do not lean forward

affected leg should not be turned inward

osteoporosis

 An alteration in homeostatic bone turnover in which the rate of bone resorption is greater than the rate of bone formation, resulting in loss of total bone mass

osteoporosis types

­Primary – occurs in post menopausal women (rapid decrease of estrogen levels)

­Secondary – results from medications, and/or diseases that affect bone metabolism

osteoporosis risk factors

­Women older than 50 years old

­Low vitamin D levels

­Lifestyle choices during young adulthood

• alcohol, drugs, smoking

­Disease

• celiac = poor absorption

• liver disease

• GI compromise

­Medications

• synthroid

• SSRI’s

• proton pump inhibitors

• fenatoin (anticonvulsant)

• longer medications are used the more risk of osteoporosis increases

­Bariatric Surgery

• duodenum bypass decreases optimal calcium absorption

Immobilization, paralysis, disability

typical loss of height associated with osteoporosis and aging

as age increases, height also decreases, best to always check height yearly if at risk age

osteoporosis characterized by

­Early signs: compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and fractures of the wrist

­Gradual collapse of vertebrae, kyphosis & other postural changes, pulmonary insufficiency, issues with balance

• pulmonary insufficiency = due to poor posture

osteoporosis diagnosed by

xray, DEXA

• DEXA = dual-energy-xray-absorptiometry

• scans from hip to spine

• done in 65+ y/o women

osteoporosis nursing education

• DEXA Scan → most reliable way to diagnose

• Fracture Risk Assessment Tool (women)

• Male Osteoporosis Risk Estimation Score (MORES)

• regular weight bearing & weight training exercises (as tolerated)

• dietary modifications

  • vitamin D and C, calcium

osteoporosis pharmacologic treatment

 Calcium and vitamin D

 Bisphosphonates - inhibit osteoclasts which reduces bone loss and increases bone mass; (osteoclasts are cells that breakdown old/damaged bone)

• educate to take on empty stomach only with water, sit upright 30 minutes after taking

• contraindicated for barrets esophagus, low calcium levels, pregnant patients

assessment of spontaneous vertebral fracture secondary to osteoporosis

Health history

• Family history (bone issues in relatives? kyphosis?)

• ­Previous fractures (within anytime of living)

• ­Dietary consumption of calcium

• Exercise patterns (mobile or sedentary lifestyle?)

• ­Onset of menopause

• ­Use of corticosteroids (longterm?)

• Lifestyle habits: alcohol, smoking, and caffeine intake (impairs nutrient absorption)

• Symptoms such as back pain

Physical assessment

• Localized pain

• Kyphosis of the thoracic spine

• Shortened stature

nursing goals of spontaneous vertebral fracture secondary to osteoporosis

­Knowledge about the osteoporotic process and the treatment regimen

­Relief of pain

­Improved bowel elimination

­Absence of additional fractures

stages of osteoporosis

normal bone → osteopenia → osteoporosis→ severe osteoporosis

interventions for spontaneous vertebral fracture secondary to osteoporosis

 Promoting understanding of osteoporosis and the treatment regimen, patient education

 Relieving pain

• ­Short periods of rest

• ­Supportive mattress

• Intermittent local heat and back rubs

Improving bowel elimination

• ­High fiber diet, increase fluids, stool softeners (decreases straining to prevent potential incidents)

Preventing injury

• ­Physical activity to strengthen muscles, improve balance, and prevent disuse atrophy

• continue to move → usage decreases risk

osteomalacia

 A metabolic bone disease in which inadequate bone mineralization weakens the long bones

osteomalacia caused by

 Deficiency of activated vitamin D, calcium & phosphate causes lack of bone mineralization, liver/kidney disease

• liver/kidney disease = increased risk of osteomalacia

osteomalacia characterized by

pain, tenderness, deformities ie: kyphosis, bowing of bones and pathologic fractures

osteomalacia diagnosed by

 Xray, lab studies (low calcium & phosphate, high alkaline phosphatase), bone biopsy

osteomalacia treatment

Correct underlying disorder, calcitriol, vitamin D, calcium, sunlight therapy, osteotomy

• sunlight therapy → replace vitamin D

• osteotomy → to repair bone

paget disease

unknown cause Disorder of localized, rapid bone turnover that commonly affects the skull, femur, tibia, pelvic bones, and vertebrae

paget disease cause

 Unknown

­Pathophysiology: proliferation of osteoclasts followed by compensatory increase in osteoblasts. The rapid cycle of bone turnover creates a disorganized skeletal structure that is weak and highly vascular, prone to fractures

• tends to be more common in men

paget disease diagnosed by

xray

paget disease characterized by

 asymptomatic, skeletal deformities, impaired hearing with skull deformity, bow legs, warmth & tenderness over bone, pain

paget disease treatment

NSAIDS (for pain), orthotic devices (to keep shape), PT, bisphosphonate drugs, calcitonin, plicamycin

• bisphosphonate drugs = stabilize rapid turnover of bone

• plicamycin = a cytotoxic antibiotic that may be used for severe paget disease resistant to other therapy

paget disease complications

fractures, arthritis, hearing loss

• hearing loss = due to CNS compression

osteomyelitis

 Infection of the bone that results in inflammation, necrosis, and formation of new bone

osteomyelitis types

­Extension of soft tissue infection

­Contiguous-focus - direct bone contamination, commonly from bone surgery involving placement of hardware

­Hematogenous – infection arises due to bloodborne infection from another site within the body

­Complication of vascular insufficiency (diabetes, peripheral vascular disease)

osteomyelitis causative bacterial agents

­Methicillin-resistant Staphylococcus aureus

­Proteus, Pseudomonas, Escherichia coli

assessment of the patient with osteomyelitis

 Characterized by:

• Localized pain that may be pulsating

• Edema

• Erythema

• Fever

• Drainage (with incision or seen on xray)

• Chronic osteomyelitis may have ulcer over site of infection

• ­Non healing fracture or foot ulcer greater than 2cm (diabetics)

osteomyelitis treatment

­Supportive therapy

­Immobilization (cast from fracture)

­Long term abx (6-12 weeks)

­Surgical debridement & exchange of hardware if indicated

• drain out pus and vegetation, etc.

• exchange of hardware from old to new hardware

planning and goals for the patient with osteomyelitis

 Prevention of osteomyelitis is the goal

major goals include:

• Relief of pain

• ­Improved physical mobility within therapeutic limitations

• Control and eradication of infection

• Knowledge of therapeutic regimen

osteomyelitis interventions

 Relieving pain

• ­Immobilization

• ­Elevation (increased circulation promotes healing)

• 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

more nursing interventions for osteomyelitis

 Prophylactic antibiotics

 Encourage adequate hydration, vitamins, and protein (heals bone)

 Administer and monitor antibiotic therapy

 Patient and family education

• Long-term antibiotic therapy and management of home IV administration

• ­Mobility limitations

• Safety and prevention of injury

• Postoperative and follow-up care

 Referral for home health care

septic (infectious) arthritis

caused Most commonly single knee and hip joints

• mostly seen in people over 80, but can occur in athletes.

• diabetes, RA, skin infections (MRSA) can make septic arthritis secondary

septic (infectious) arthritis characterized by

warm, painful, swollen joint with decreased range of motion, systemic chills, fever, and leukocytosis are sometimes present

septic (infectious) arthritis treatment

abx treatment, joint aspiration, immobilization of joint, analgesic medications

septic (infectious) arthritis nursing education

 adherence to medications, promote ROM