Chapter 46: Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders
Learning Outcomes
Explain the pathophysiology, signs and symptoms, and complications of fractures.
Assist in planning nursing care for a patient in a splint, cast, traction, or external fixation.
Describe the causes and prevention of osteomyelitis.
Assist in planning nursing care for osteomyelitis.
Describe risk factors, pathophysiology, treatment, and nursing care for osteoporosis.
Describe the pathophysiology, treatment, and nursing care for gout.
Compare the care for osteoarthritis and rheumatoid arthritis.
Assist in planning nursing care for the patient with a fractured hip.
Assist in planning nursing care for a patient having a total joint replacement.
Explain patient teaching for a patient with a lower extremity amputation and prosthesis.
Chapter Concepts
Comfort
Mobility
Teaching and Learning
Bone and Soft Tissue Disorders
Categories include:
Strain
Sprain
Dislocation
Bursitis
Rotator cuff injury
RICE Method
Rest to protect affected area.
Ice to decrease pain, swelling, and inflammation.
Compression with an elastic bandage.
Elevate the affected area if appropriate.
Safe Patient Handling
Use lifting devices such as:
Draw sheets
Mechanical moving devices
Avoid pulling on the patient’s arms to prevent injury.
Carpal Tunnel Syndrome
Caused by median nerve compression in the wrist’s carpal tunnel, often due to swelling.
Symptoms include:
Finger, hand, and arm pain and numbness.
Treatment includes:
Relief of inflammation
Splint
Anti-inflammatory medications
Surgery
Teaching focuses on prevention strategies.
Fractures
Definition: A break in a bone.
Causes of fractures:
Trauma
Pathological issues (due to diseases)
Types of fractures:
Closed: Does not break the skin. Most common
Open: Breaks the skin, posing an infection risk.
Signs and Symptoms of Fractures
Pain
Decreased range of motion
Limb rotation
Deformity
Shortening of the limb
Swelling
Bruising
Diagnostic Tests for Fractures
X-ray
Computed tomography (CT) scan
Emergency Treatment for Fractures
Splint the fracture as it lies to prevent further damage.
Seek medical treatment for alignment and immobilization.
Management of Fractures
Closed reduction techniques include:
Manual realignment
Using elastic wraps or splints
Casts
Traction (both skin and skeletal)
Open reduction techniques may involve:
Internal fixation with metal plates and screws or prosthesis
External fixation using pins and metal frames.
Complications of Fractures
Possible complications can include:
Hemorrhage
Acute compartment syndrome
Neurovascular compromise
Infection
Nonunion
Thromboembolic complications
Fat embolism syndrome
Compartment Syndrome
Fascia surrounds each compartment in muscles, potentially leading to increased pressure and reduced blood flow, causing tissue damage.
Nursing Diagnoses Related to Fractures
Acute Pain
Impaired Physical Mobility
Risk for Peripheral Neurovascular Dysfunction
Nursing Care Focus for Fractures
Conduct neurovascular checks regularly.
Provide effective pain management.
Ensure proper cast, traction, and pin care:
Includes techniques such as palming wet casts and bivalving casts to provide relief.
Attend to skin care to prevent breakdown.
Support nutritional needs for healing.
Encourage self-care activities.
Address psychosocial aspects of care.
Patient Education for Fractures
Educate on:
Cast care
Pin care
Nutrition guidance for bone health.
Osteomyelitis
Definition: Infection of bone leading to pain, redness, warmth, swelling, and fever.
Treatment options:
Curative therapy includes debridement, reconstruction, and antibiotics.
Palliative therapy may involve chronic suppressive antibiotic therapy.
If non-responsive, amputation may be necessary.
Nursing Care for Osteomyelitis
Prevention is crucial: Emphasize hand hygiene and sterile dressing changes.
Educate on medication management and adherence.
Osteoporosis
Definition: A metabolic disorder characterized by low bone mass, leading to increased fracture risk—especially in the spine, wrist, and hip.
Key statistics include 54 million affected individuals, primarily women, emphasizing the need for screening as per Healthy People 2030 objectives.
Risk Factors for Osteoporosis
Nonmodifiable Factors: Aging, female gender, family history, prior fractures, postmenopausal status, petite body build, low testosterone in men, and ethnicity (higher prevalence in White or Asian).
Modifiable Factors: High alcohol consumption, low intake of calcium and vitamin D, high caffeine and sodium intake, sedentary lifestyle, and smoking.
Prevention Strategies for Osteoporosis
Build adequate bone mass before age 30.
Ensure adequate calcium and vitamin D intake.
Engage in weight-bearing exercises, especially during childhood.
Avoid smoking and excessive alcohol.
Signs and Symptoms of Osteoporosis
Back pain, decreased height, fractures, and kyphosis (an abnormal curvature of the spine).
Effects of Osteoporosis
Includes physical deformities, loss of functional ability, and emotional impacts like social isolation due to body image issues.
Diagnostic Tests for Osteoporosis
Dual-energy x-ray absorptiometry (DEXA) scan.
Serum testing may show decreased calcium and vitamin D, increased phosphorus, and increased alkaline phosphatase levels.
Therapeutic Interventions for Osteoporosis
Focus on reducing risk factors, calcium supplementation, vitamin D supplementation, and various medications,
Antiresorptive Medications: Bisphosphonates (e.g., Alendronate, Ibandronate, Risedronate, Zoledronic Acid).
Calcitonin (Fortical, Miacalcin).
Monoclonal Antibody: Denosumab (Prolia).
Selective Estrogen Receptor Modulator: Raloxifene (Evista).
Anabolic Medication: Teriparatide (Forteo).
Nursing Care Focus for Osteoporosis
Provide pain relief and manage symptoms.
Educate patients on:
Prevention strategies
Dietary needs for calcium and vitamin D
Exercise regiment
Medication adherence.
Implement fall prevention strategies.
Paget Disease
A rare, noncurable metabolic bone disease characterized by abnormal, weak bones that are typically painful.
Diagnosed through X-ray, with treatment involving bisphosphonates and calcitonin for pain relief and quality of life enhancement.
Bone Cancer
Primary Tumors:
Osteosarcoma (most common)
Ewing sarcoma (most malignant)
Predominantly affects children and young adults.
Symptoms include localized pain, swelling, and palpable masses, with treatment typically involving surgery, chemotherapy, and radiation.
Metastatic Bone Disease
Cancers that seek bone as a secondary site include prostate, breast, lung, and thyroid cancers.
Pathological fractures and severe pain may occur, with treatment often including radiation therapy. Nursing care mirrors supportive care given for other cancers.
Gout
A systemic connective tissue disorder characterized by the build-up of uric acid leading to urate crystals in joints. This causes severe joint inflammation.
Types of Gout
Primary: Inherited issues with purine metabolism.
Secondary: Associated with other health issues or medications.
Symptoms of Gout
Acute gout presents as swollen, red, hot, and painful inflamed joints, particularly in the great toe. Chronic gout can lead to tophi and renal stones.
Diagnostic Tests for Gout
Serum uric acid levels and joint fluid analysis to identify uric acid crystals.
Therapeutic Interventions for Gout
Acute Treatment: Medications such as Colchicine and NSAIDs.
Preventive Treatment: Febuxostat, Allopurinol, Probenecid.
Nursing Care in Gout Management
Educate patients to avoid foods high in purines, maintain hydration to prevent kidney stones, and consider the benefits of cherries/cherry juice while avoiding aspirin and alcohol.
Osteoarthritis
A common degenerative joint disease affecting over 32 million people, particularly as age increases.
Pathophysiology of Osteoarthritis
Involves deterioration of articular cartilage and the bone ends of joints, leading to narrowed joint space, bone spurs, inflammation, deformities, and pain, particularly in weight-bearing joints.
Risk Factors for Osteoarthritis
Includes heredity, aging, obesity, and excessive “wear and tear.”
Symptoms of Osteoarthritis
Joint pain that worsens with physical activity, stiffness, and bony nodules on finger joints (Heberden and Bouchard nodes).
Diagnostic Tests for Osteoarthritis
X-rays, MRI, and synovial fluid analysis to confirm diagnosis.
Therapeutic Interventions for Osteoarthritis
While there is no cure, management includes:
Exercise and weight control.
Medications such as NSAIDs and Synvisc-One.
Heat or cold therapies.
Complementary therapies like imagery and acupuncture.
Surgical options include total joint replacement.
Nursing Diagnoses in Osteoarthritis
Common nursing diagnoses include:
Acute Pain
Activity Intolerance
Chronic Sorrow
Disturbed Body Image
Impaired Physical Mobility
Self-Care Deficit (bathing, dressing, feeding, toileting)
Rheumatoid Arthritis
A chronic, progressive systemic inflammatory disease resulting in the destruction of synovial joints and connective tissues, affecting major organs.
Pathophysiology of Rheumatoid Arthritis
Characterized by synovitis, synovial thickening, and cartilage erosion due to destructive pannus, leading to joint deformities.
Etiology of Rheumatoid Arthritis
Can involve genetic predisposition, oral pathogens, and an autoimmune response (presence of rheumatoid factor).
Symptoms of Rheumatoid Arthritis
Symptoms can include bilateral inflammation, stiffness (especially after rest), and systemic manifestations such as fatigue and low-grade fever.
Diagnostic Tests for Rheumatoid Arthritis
Tests may include rheumatoid factor, erythrocyte sedimentation rate, and other autoantibody tests.
Therapeutic Interventions for Rheumatoid Arthritis
Treatment focuses on medications such as disease-modifying antirheumatic drugs (DMARDs), NSAIDs, and corticosteroids.
Surgical options include total joint replacement as needed.
Nursing Diagnoses in Rheumatoid Arthritis
Key nursing diagnoses may include:
Acute Pain
Disturbed Body Image
Fatigue
Impaired Physical Mobility
Self-Care Deficit (bathing, dressing, feeding, toileting)
Patient Education in Rheumatoid Arthritis
Essential education encompasses understanding the disease process, medication management, and incorporating rest and exercise into daily routines.
Total Joint Replacement
Total Hip Replacement
Involves the insertion of an acetabular cup into the pelvic acetabulum and a femoral component into the femur.
Pre-admission Care for Total Hip Replacement
Includes education programs and potential autologous blood donation.
Postoperative Care for Total Hip Replacement
Key considerations include:
Prevention of hip dislocation (avoiding certain positions)
Monitoring for skin breakdown
Pain management
Prevention of infection and managing bleeding
Regular neurovascular checks
Promoting ambulation and rehabilitation efforts.
Total Knee Replacement
Components involved include femoral, tibial, and patellar buttons. Dislocations are not a major concern, but postoperative care parallels that of total hip replacements.
Amputation
Definition: Surgical removal of a body part, which may be due to ischemia, infections, or traumatic accidents.
Replantation Guidelines
Recommendations include wrapping the severed part in a clean cloth, bagging it in ice water for transport to the hospital.
Levels of Amputation
Variants include below and above the knee (BKA, AKA) and below and above the elbow (BEA, AEA).
Nursing Care Considerations for Amputation
Preoperative nursing care should address knowledge deficits and the potential for disturbed body image.
Postoperative care strategies focus on preventing hemorrhage, managing pain (including phantom pain), and promoting mobility while addressing skin integrity.
Patient education regarding prosthesis options and lifestyle adjustments is vital.
Case Studies
SBAR Communication Example
Example of a hand-off communication involving a patient (Mrs. Strahorn) with a postoperative hip replacement illustrating critical situational, background, assessment, and recommendations for patient care.
ISBARR Communication Example
A case study involving Mr. Maynor, illustrating how to report critical findings due to active bleeding after a surgical procedure.
Patient Case with Concept Map
Involves a patient (Katie) who experiences complications from a hip fracture, demonstrating the interrelationship between nursing concepts such as tissue integrity and mobility.
Review Questions and Answers
Various review scenarios covering assessment and management strategies for fractures, fractures risk evaluations, prevention of osteoporosis, and nursing interventions related to fractures and transformations in mobility.