Nursing care of Patients with Musculoskeletal and Connective Disorders
1. Bone and tissue disorders
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Strains- overly stretched tendon
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Sprains- overly stretch ligament
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Tx: RICE and NSAIDS]
2. Types of fractures
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Comminuted: splintered/shattered into numerous fragments. Crushing injuries
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Greenstick: fractures are bent. Seen in children
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Displaced: bone pieces are out of normal alignment
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Spiral: fractures curves around bone shaft
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Longitudinal: occurs along length of bone
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Oblique: diagonally or at oblique angle across the bone
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Stress: fractured across one cortex. Incomplete fracture
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Transverse: horizontal fracture; shortens the limb
3. Fractures
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Break in a bone caused by fall, accident, crushing injury, osteoporosis, malnutrition, bone cancer, hypercalcemia.
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S/S: tenderness on site, pain, shortening of the limb, decreased ROM,
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Diagnostic test: Xray, MRI, calcium levels,
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Splint fractures. Immobilize it.
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BOX 46.1 pg 951 – management of fractures
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Box 46.2 pg 952- nursing interventions for a patient with cast
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Complications of fractures: acute compartment syndrome, fat embolism, decreased neurovascular status,
hemorrhage, infection (osteomyelitis), thromboembolic complications, acute compartment syndrome (pain is not
relieved by opioids, 6 Ps)
4. Fat embolism syndrome
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Small fat droplets are released from yellow bone marrow into the bloodstream that may travel to lungs causing
respiratory insufficiency
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Three primary manifestations: respiratory failure, cerebral involvement, and petechiae
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S/S:
- Pulmonary dysfunction is earliest sign: tachypnea, dyspnea, cyanosis
- Cerebral changes: confusion, drowsiness,
- Petechiae, fever, tachycardia, vision changes
5. Osteomyelitis
- Infection of the bone
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S/S: Ulceration, drainage, localized pain
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Diagnostic test: high WBC, ESR, + bone biopsy, MRI, CT, xrays
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Nursing care:
- Long term IV antibiotics
- Sterile dressing change hand hygiene
6. Osteoporosis
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Low bone mass, deterioration of bone structure
Post-menopausal women
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S/S:
- Hypercalcemia (arrythmias, weak muscles)
- Kyphosis
- Pain
- Loss of height
- Increased fatigue, risk for pneumonia due to difficulty to expand spine
- Limited ADLS
Reduced socialization

TX:
- Medications
o Calcium supplements, vitamin D
o Biophosphonates: prevents, reduces the bone breakdown
 Alendronate, ibandronate, zoledronic acid “onate”
- Empty stomach with 6-8 ounces water
-Wait 30 mins before taking other meds
o Calcitonin: decrease bone loss, post menopause women
o Anabolic bone forming meds: people who are greater risk for fracture
 Teriparatide
-While taking med, increase calcium and vitamin D intake (dairy products, dark green leafy veggies)
-Weight bearing exercise, nonskid shoes.
7. Paget disease
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Metabolic bone disease
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No cure

Will see punched out areas
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Increased alkaline phosphate
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NSAIDS, calcitonin
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8. Osteosarcoma
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Primary malignant bone tumor
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Ewing sarcoma: most malignant- leukocytosis and anemia, pain, swelling, fever
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Diagnostic tests: elevated ESR, ALP
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Chemo, radiation, surgery
9. Gout

Buildup of uric acid
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Acute gout
- Severe pain
- Inflammation
- Swollen, red, hot great toe

Chronic gout: renal stones can develop
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Meds
 Cholchicine and steroids: joint inflammatory
 Pegloticase IV: chronic gout pts
 Allopurinol, febuxosat: decrease uric acid production
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Nursing interventions
- Fluids
- Cherries
- Avoid organ meats, shellfish, oily fish, alcohol
- Avoid aspirin, diuretics
- Avoid stress.
10. Osteoarthritis

Cartilage and bone ends deteriorate, inflamed joint
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Risk factors: obesity, age, heredity, activities causing stress. Secondary: sepsis, metabolic disorders
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S/S:
- Joint pain, stiffness
- Pain increases with activity, decreases with rest
- Nodes on joints of fingers (Heberden, Bouchard nodes)
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Medications/therapeutic measures:
- NSAIDS: watch for GI beeding/distress
- Acetaminophen
- Steroids
- Muscle relaxants
- Balance rest and exercise
- Yoga, acupuncture, massage
- Surgery
- Synvisc- one: three injection directly into osteoarthritic knee to replace synovial fluid
- Heat and cold therapy
- Meds: page 966-967
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Nursing interventions:
- Rest periods
- Don’t overwork joints
- Offer pain relief before activity
- Weight bearing exercises
11. Rheumatoid arthritis

Chronic, progressive, systemic inflammatory disease that destroys the synovial fluid and other connective tissue,
including major organs
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Inflammation causes thick synovium which causes joint swelling and pain
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Connective tissues are affected such as nerves, kidneys, blood vessels, lungs

Rheumatoid factor (RF) is found in patients with RA
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S/S:
- Reddened, warm, swollen, stiff, painful
- Malaise
joints
- Depression
- Morning stiffness
- Fatigue
- Low grade fever
- Weight loss

Diagnostic tests:
- RF in serum
- Low RBC
- High ESR

- +CRP, antibody test
- Cloudy, milky, dark yellow synovial fluid in arthrocentesis
Therapeutic measures
-
-
DMARDs drugs prevents joint destruction: methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide
(RA ONLY)
NSAIDs, steroids
Complementary therapy: capsaicin cream, fish oil, Vit C,E,A
Heat, cold applications.
 Stiffness, makes exercise easier: heat
 Inflamed, “hot” joints: cold
Surgery: Total joint replacement
12. Total joint replacement / arthroplasty

Performed to pts who have a connective tissue disease in which joints become severely deteriorated

May be on long term steroid therapy, which causes avascular necrosis (bone tissue death)
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Goal of TJR: relieve chronic pain and improve ADLs
13. Total hip replacement

Elective procedure

Preop
- Assess neurovascular status
- Assess pain, mobility
- Administer antibiotic
- Educated about post op exercises
- Autologous blood donation
- May be in same day surgery

Post op : educate
- Hip cannot bend more than 90 degrees
- Do not adduct hip
- Do not cross legs
- Do not do anything below level of waist
- Use straight back chair high enough to prevent flexion, raised toilet seat
- IV analgesics
- Ambulation to prevent DVT

Complications
- Hip dislocation- “audible pop” with pain right after. May see shortening of the leg.
 Correct the position of the leg
 Prevent hip adduction
 Supine position with head slightly elevated
 Trapezoid abduction pillow between legs to prevent adduction
- Skin breakdown
 Turn q hours
 Heels off bed
 Keep clean and dry. Protective barrier cream
 Cushioning dressings to decrease chance of skin breakdown
- Infection
 Aseptic care for dressing changes
-
-
 Monitor for s/s of infection. Older client may experience confusion.
Bleeding
 Monitor for blood loss.
 s/s of shock
Neurovascular
 Check 6 PS
DVT
 Thigh high elastic stockings
 Anticoagulants (lovenox)
 Ambulate, passive ROM
14. Amputation

Due to ischemia from peripheral vascular disease occurring in the older adult

Loss of great toe: affects balance and gait

If lower leg is amputated, a below the knee amputation is preferred

The higher the level of amputation, the more energy required for ambulation
15. Phantom pain:
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Arises from spinal cord and brain

Burning cramping, shooting, stabbing, throbbing

Trigger: weather changes, touching residual limb, emotional stress

Phantom sensation: feels that limb is still present

Therapeutic measures
- Meds that treat phantom pain
 Anticonvuslants (gabapentin)
 Pregablin (Lyrica)
 Beta blocker (propranolol)
 Antidepresants (amitriptyline)
- Complimentary therapy
 Biofeedback, nerve stimulation, acupuncture, imagery
 Lying prone on stomach for 30 minutes prevents hip contractures
16. Prosthesis care
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Clean with mild soap and water
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Clean inserts and liners regularly
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Garters to keep socks in place
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Grease parts instructed by PROSTHETIST!