MSC

Lewis Ch 68 - Musculoskeletal Problems (Select)

Learning Outcomes

  • Describe the pathophysiology, clinical manifestations, interprofessional care, and nursing management of osteomyelitis.

  • Identify the causes and characteristics of acute low back pain.

  • Provide education on the Do’s and Don'ts to patients with low back pain.

  • Explain the conservative therapy of intervertebral disc damage.

  • Describe the postoperative nursing management of a patient who has undergone vertebral disc surgery.

  • Describe the etiology, pathophysiology, clinical manifestations, and nursing and interprofessional management of osteoporosis and Paget’s disease.

Osteomyelitis

Etiology and Pathophysiology

  • Definition: Severe infection of bone, bone marrow, and surrounding soft tissue.

  • Most common microorganism: Staphylococcus aureus, but can be caused by a variety of organisms.

Indirect Entry

  • Also known as hematogenous osteomyelitis (20% of cases).

  • Most often affects children less than 17 years old.

  • Other Risk Factors:

    • Older age

    • Debilitation

    • Hemodialysis

    • Sickle cell disease

    • Intravenous (IV) drug use.

Direct Entry

  • More common in adults.

  • Common entry points:

    • Open wounds

    • Presence of foreign bodies (e.g., implanted prosthesis)

    • Diabetic or vascular ulcers

    • Pressure injuries.

  • Typically involves multiple organisms.

Pathophysiological Process

  • Microorganisms enter the blood and proliferate, increasing pressure in the bone.

  • This leads to ischemia and vascular compromise of the periosteum.

  • The infection spreads through the bone, cortex, and marrow cavity, obstructing blood flow and causing necrosis.

  • Sequestrum Formation:

    • Ischemia results in bone death, leading to the separation of dead bone from living bone, forming a sequestrum.

    • The periosteum, with blood supply, forms new bone called involucrum.

Sequestrum

  • Definition: A necrotic area of bone that cannot be penetrated by white blood cells (WBCs) and antibiotics.

  • Serves as a reservoir for microorganisms that can spread to other sites.

  • If unresolved or surgically debrided, may develop a sinus tract with chronic, purulent cutaneous drainage.

Clinical Manifestations and Complications

Acute Osteomyelitis

  • Definition: Infection lasting less than 1 month.

  • Local Manifestations:

    • Constant pain that worsens with activity and is unrelieved by rest.

    • Swelling, tenderness, warmth in the affected area.

    • Restricted movement.

    • Late-stage drainage from the infection site.

  • Systemic Manifestations:

    • Fever

    • Night sweats

    • Chills

    • Restlessness

    • Nausea

    • Malaise.

Chronic Osteomyelitis

  • Definition: Infection lasting longer than 1 month or failure to respond to initial treatment.

  • Characterized by: Continuous pain and/or exacerbations and remissions.

  • Local Signs:

    • Pain, swelling, warmth.

  • Chronic Inflammation:

    • Granulation tissue may turn into avascular scar tissue, which serves as an ideal site for microbial growth due to its resistance to antibiotics.

Long-term Complications

  • Rare complications may include:

    • Septicemia

    • Septic arthritis

    • Pathologic fractures.

Diagnostic Studies

  • Bone or soft tissue biopsy.

  • Blood and/or wound cultures.

  • WBC count: Elevated levels indicate infection.

  • Erythrocyte Sedimentation Rate (ESR): Elevated in infection.

  • Imaging studies:

    • X-rays, MRI, CT scans to visualize extent of infection.

    • Bone scans.

    • Radionuclide WBC scans.

Interprofessional Care

Acute Osteomyelitis

  • Treatment Protocols:

    • Aggressive, prolonged IV antibiotic therapy is standard.

    • Cultures or bone biopsy must be performed before starting antibiotics.

    • Surgical debridement and drainage of abscesses or ulcers as needed.

Antibiotic Therapy

  • Administration of IV antibiotics via central venous access device (CVAD):

    • Initiated in hospital, may be continued at home or in skilled nursing facilities.

    • Duration: typically 4 to 6 weeks or longer.

    • Select appropriate antibiotics based on culture to combat resistance.

Chronic Osteomyelitis

  • Involves surgical removal of infected tissue and prolonged antibiotic therapy (IV and/or oral) lasting up to 8 weeks.

  • Utilization of acrylic bead chains containing antibiotics.

  • Consideration for intermittent or constant antibiotic irrigation of infected bone.

Additional Interprofessional Measures

  • Possible interventions:

    • Application of casts or braces.

    • Negative-pressure wound therapy.

    • Hyperbaric oxygen therapy.

    • Removal of prosthetic devices as necessary.

    • Muscle flaps, skin grafts, possible amputation.

Nursing Assessment

Subjective Data

  • Past health history should include:

    • Previous bone trauma

    • Open fractures

    • Open or puncture wounds

    • Other infections

    • Immunocompromised status.

  • Medications in use including analgesics and antibiotics.

  • Previous surgeries or treatments related to bone health.

Functional Health Patterns

  • Subjective data to evaluate:

    • Health perception regarding management of current symptoms.

    • Nutritional status, including signs of anorexia or weight loss.

    • Activity levels, looking for weakness or paralysis.

    • Cognitive perception related to local tenderness and pain severity.

    • Coping mechanisms, observing for irritability or dependency issues.

Objective Data

  • General observations may include:

    • Restlessness

    • High spiking fevers

    • Night sweats.

  • Integumentary findings:

    • Signs of diaphoresis, erythema, warmth, edema.

  • Musculoskeletal observations:

    • Restricted movement, presence of wound drainage, potential fractures.

  • Diagnostic findings can include elevated WBC, positive cultures, elevated ESR, and signs of sequestrum and involucrum.

Planning Current Conditions

  • Identified Conditions:

    • Acute pain

    • Impaired mobility

    • Lack of knowledge regarding disease management.

Overall Goals:

  • Maintain satisfactory pain management and control of fever.

  • Prevent complications associated with osteomyelitis.

  • Ensure adherence to the treatment plan and follow-up care.

Nursing Implementation

Primary Prevention

  • Focus on health promotion by controlling existing infections, especially in at-risk individuals:

    • Immunocompromised patients

    • Those with diabetes, orthopedic devices, or vascular insufficiency.

  • Educate patients and caregivers on recognizing systemic and local signs of infection and the importance of contacting healthcare providers promptly.

Acute Care Interventions

  • Implement care by:

    • Ensuring immobilization and careful handling of the affected limb to alleviate pain and reduce further injury risk.

    • Assess and treat pain, possibly using NSAIDs, opioids, and muscle relaxants; explore non-drug approaches.

    • Employ sterile dressings and proper positioning/support of the extremity.

    • Prevent complications associated with immobility such as pressure ulcers and thromboembolic events.

Patient Education on Medications

  • Inform about potential adverse and toxic reactions to prolonged antibiotic therapy, particularly risks of Candida albicans and Clostridium difficile infections.

  • Provide psychologic and emotional support due to the patient's anxiety and feelings of discouragement associated with prolonged illness.

Ambulatory Care Approach

  • Educate patients and caregivers regarding:

    • Administering antibiotics and managing CVAD lines at home.

    • Necessity of completing the entire antibiotic prescription and proper wound care.

    • Continuation of physical and psychologic support during recovery.

Evaluation

  • Patient will:

    • Achieve satisfactory pain management.

    • Adhere to the prescribed treatment plan.

    • Show progressive increases in mobility and range of motion.

Low Back Pain and Intervertebral Disc Disease

Incidence of Low Back Pain

  • Affects approximately 80% of adults in the United States at least once in their lifetime.

  • Second most common pain problem, following headaches.

  • Major cause of job-related disability and an important contributor to missed workdays, often attributed to musculoskeletal problems.

Risk Factors for Low Back Pain

  • Weak muscle tone.

  • Excess body weight.

  • Pregnancy.

  • Stress and poor posture.

  • Cigarette smoking.

  • History of compression fractures.

  • Congenital spinal abnormalities.

  • Family history of back pain.

  • Occupations involving heavy lifting, bending, twisting, or prolonged sitting (e.g., nursing).

Clinical Features of Acute Low Back Pain

  • Duration of 4 weeks or less.

  • Commonly caused by trauma or undue stress.

  • Symptoms generally develop within 24 hours of nerve pressure onset or edema:

    • Range from muscle aches to shooting or stabbing pains.

    • Limited flexibility or range of motion.

    • Inability to stand upright.

Diagnostic Studies for Acute Low Back Pain

  • Few definitive abnormalities in diagnostics.

  • Straight-leg raising test: Positive for disc herniation if radicular pain occurs.

  • Imaging such as MRI and CT scans generally reserved for cases of trauma or suspected systemic disease.

Health Promotion Guidelines

  • Emphasize proper body mechanics.

  • Encourage physical therapy.

  • Advise appropriate body weight management.

  • Recommend proper sleep positioning and a firm mattress.

  • Advocate for smoking cessation.

Acute Care Management of Low Back Pain

  • Treat as an outpatient if symptoms are not severe:

    • NSAIDs and muscle relaxants.

    • Consider massage and back manipulation.

    • Incorporate acupuncture and hot/cold compresses.

  • In cases of severe pain, corticosteroids and opioids may be prescribed.

  • A brief rest period (1-2 days) may be necessary, but prolonged bed rest should be avoided.

  • Educate patients to identify pain triggers and preventive strategies, including exercises for strengthening and flexibility.

Patient Education on Do’s for Low Back Pain

  • Sleep in a side-lying position with knees and hips flexed.

  • Use pillows to maintain hip and knee flexion while sleeping.

  • Prevent lower back strain by using a footstool during prolonged standing.

  • Engage in regular 15-minute exercise sessions.

  • Carry lightweight items close to the body.

  • Utilize local heat or cold applications.

  • Use a lumbar roll or pillow while sitting.

Patient Education on Don’ts for Low Back Pain

  • Avoid leaning forward without bending the knees.

  • Do not lift objects above elbow level.

  • Refrain from standing in one position for prolonged periods.

  • Limit sleeping on the abdomen or with legs extended.

  • Avoid exercising without obtaining healthcare advice if experiencing severe pain.

Intervertebral Disc Disease Overview

  • Intervertebral discs act as shock absorbers between vertebrae.

  • Conditions may involve deterioration, herniation, or dysfunction of discs affecting the cervical, thoracic, and lumbar spine.

Etiology and Pathophysiology of Degenerative Disc Disease (DDD)

  • Characterized by loss of fluid, leading to reduced elasticity, flexibility, and shock-absorbing ability:

    • Related to aging unless chronic pain is present.

    • Disc thinning occurs as the nucleus pulposus dries, eventually leading to a herniated or slipped disc through shifting pressures on the annulus fibrosus.

Clinical Manifestations of Lumbar Disc Disease

  • Low back pain is the most common symptom.

  • May include radicular pain that follows the sciatic nerve.

  • Positive straight leg raise test.

  • Potential signs:

    • Decreased or absent reflexes.

    • Paresthesia.

    • Muscle weakness.

Conservative Interprofessional Care for Intervertebral Disc Disease

  • Conservative therapy aims to limit spinal movement, applying local heat/cold, and using ultrasound/massage:

    • Skin traction may help some patients.

    • Consider Transcutaneous Electrical Nerve Stimulation (TENS) for pain management.

  • Drug therapy options:

    • NSAIDs, corticosteroids, opioids, muscle relaxants, antiseizure drugs, and antidepressants.

    • Epidural corticosteroid injections may also be appropriate.

Patient Education for Intervertebral Disc Disease

  • Encourage back-strengthening exercises performed twice a day.

  • Educate on proper body mechanics and avoiding extreme spinal flexion and torsion.

  • Rehabilitation generally allows for healing within 6 months for most patients.

Surgical Considerations for Intervertebral Disc Disease

  • Surgical intervention is indicated if:

    • Conservative treatment fails.

    • Patient experiences worsening radiculopathy.

    • There is loss of bowel or bladder control, constant pain, or persistent neurologic deficits.

  • Types of Surgical Procedures:

    • Laminectomy: Removal of protruding disc through excision of part of the vertebra (lamina).

    • Discectomy: Decompression of the nerve root by excising the damaged portion of the disc.

Nursing Management Post-Spinal Surgery

Postoperative Care Assessment

  • Evaluate peripheral neurologic status for movement and sensation every 2-4 hours during the first 48 hours post-surgery.

  • Monitor circulation including temperature, capillary refill, and pulses.

GI and Bladder Function Monitoring

  • Track gastrointestinal (GI) function, watching for paralytic ileus and constipation.

  • Administer stool softeners and laxatives as needed.

  • Bladder emptying support may be necessary; inform of potential loss of tone indicating nerve damage.

  • Catheterization may be required if necessary, and notify the surgeon immediately if bowel or bladder incontinence occurs.

Osteoporosis and Paget's Disease

Osteoporosis

  • Definition: A chronic, progressive metabolic bone disease characterized by low bone mass and deterioration of bone tissue, leading to increased fragility.

Risk Factors for Osteoporosis

  • Advancing age, especially over 65 years; higher risk for postmenopausal women.

  • Female gender and low body weight; racial factors (predominantly white or Asian).

  • History of previous fractures, sedentary lifestyle, and risk factors including osteopenia, estrogen deficiency, family history.

  • Diet low in calcium/Vitamin D, excessive alcohol intake (>2 drinks/day), caffeine, and long-term use of certain medications (e.g., corticosteroids).

Epidemiology of Osteoporosis

  • Peak bone mass is reached around age 20; inevitable bone loss follows from age 35-40, accelerating for women during menopause.

  • Bone loss rate slows for men to parallel women's rates by ages 65 to 70.

Patophysiology of Osteoporosis

  • Remodeling Process:

    • Osteoblasts are responsible for building bone tissue, while osteoclasts resorb bone; in osteoporosis, resorption outpaces deposition.

Clinical Manifestations of Osteoporosis

  • Commonly affects the spine, hips, and wrists, presenting as:

    • Back pain

    • Spontaneous fractures

    • Gradual height loss

    • Kyphosis or “dowager’s hump”.

Diagnostic Studies for Osteoporosis

  • Comprehensive assessment through history and physical examination, X-rays, and lab studies.

  • Screening Guidelines:

    • Initial bone density test for women over age 65.

    • Bone Mineral Density (BMD): Assessed through Dual-energy X-ray Absorptiometry (DXA), also effective for monitoring treatment efficacy.

Nursing and Interprofessional Management

  • Focus on proper nutrition (calcium and Vitamin D), exercise engagement, and fall/fracture prevention:

    • Fall precautions with interventions identified.

Calcium Supplement Recommendations

  • Adequate calcium intake should be 1000 mg/day:

    • For women ages 19-50 and men ages 19-70.

    • Increase to 1200 mg/day for women over 51 and men over 71.

Dietary Sources of Calcium

  • Recommended sources include:

    • Dairy (milk, yogurt), dark leafy greens (spinach, turnip greens), cottage cheese, sardines, and ice cream.

Vitamin D in Osteoporosis Management

  • Essential for calcium absorption/function and bone formation; advisable to obtain 20 minutes of sunlight exposure for vitamin D synthesis.

Lifestyle Modifications

  • Encourage weight-bearing exercises to enhance and maintain bone mass; recommend activities like walking, hiking, weight training, stair climbing, dancing.

  • Advise on smoking cessation and reducing alcohol intake.

Procedures for Osteoporotic Fractures

  • Introduce minimally invasive treatments such as vertebroplasty and kyphoplasty for managing fractured vertebrae.

Drug Therapy for Osteoporosis

Bisphosphonates (e.g., Alendronate/Fosamax)

  • Mechanism: Inhibit bone resorption and slow remodeling.

  • Side effects can include anorexia, weight loss, gastritis, and rare occurrences of osteonecrosis.

  • Administration guidelines to include:

    • Take with a full glass of water and ensure the patient stays upright for 30 minutes post-dose to avoid esophagitis.

  • Continued treatment advised for 5 years.

Paget’s Disease

Definition

  • Paget’s Disease, or osteitis deformans, is characterized by chronic skeletal bone disorder marked by excessive bone resorption followed by irregular replacement with vascular, fibrous connective tissue. New bone formed tends to be larger, disorganized, and weaker.

Incidence

  • Affects approximately 5% of adults in the United States:

    • Higher prevalence in males, who are affected twice as often as females.

    • Generally uncommon in individuals aged less than 40.

    • Possible etiologies include viral or genetic factors; about 40% of affected individuals have a familial connection.

Clinical Manifestations

  • Severity varies; symptoms may range from asymptomatic to severely painful.

  • Notable symptoms include gradual and increasingly severe bone pain, fatigue, reduced mobility, waddling gait, increasing head size, headaches, dementia, vision disturbances, and hearing loss. There may also be risk for spinal cord or nerve root compression.

Treatment Strategy for Paget’s Disease

Interprofessional Care

  • Treatment primarily aims at providing symptomatic relief and supportive care:

    • Pain management and surgical interventions when necessary (e.g., braces).

    • Use of bisphosphonate drugs and ensuring adequate intake of calcium and vitamin D.

    • Regular monitoring of serum alkaline phosphatase levels to gauge disease activity.

Ongoing Management

  • Use of a firm mattress, proper body mechanics training, and physical therapy are recommended.

  • Nutritional strategies should stress adequate protein, Vitamin D, and calcium intake.

  • Implement fall prevention strategies through environmental controls and assistive devices when needed.