Part I
Osteoporosis
Fractures
Degenerative Joint Disease/Osteoarthritis
Total Hip and Knee Prostheses
Bone Infections / Osteomyelitis
Gout

Concept Map: Selected Topics in Musculo-Skeletal Nursing
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
“Neuro / Circ Checks”
-”The 6 P’s”
Lab Monitoring
PATHOPHYSIOLOGY
Fracture
Osteoporosis
Degenerative Joint Disease
Osteoarthritis
Osteomyelitis
Gout
Amputation
Total Joint Replacement
PHARMACOLOGY
Opioids
NSAIDs
Antibiotics
Disease Specific
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, more…based
On Nursing Process:
A_D_O_P_I_E
NURSING DIAGNOSES THAT APPLY….
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary

Pain, acute
Comfort, impaired
Mobility, altered
Self-care deficit –feeding, grooming; bathing, hygeine; toileting
Falls, risk for
Skin breakdown, risk for
Constipation, risk for
Diversional activity, risk for
Mobility, Physical, impaired
Mobility, bed, risk for
Walking, impaired,
Tissue perfusion, impaired peripheral
Peripheral neurovascular dysfunction, risk for
Knowledge, deficient
Body image, disturbed
Grieving
More……

Musculoskeletal Disorders
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Compare and contrast different types of fractures
Discuss the usual healing processes for bone
Identify complications of fractures
Describe the nursing care of the client with casts or traction, including client education
Prioritize nursing care for patients who are at risk for osteopenia
Describe the role of drug therapy, diet, and exercise in management of osteoporosis.

Musculoskeletal Disorders
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See the Study Guide for Complete List of Objectives
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Describe the pain management of client with bone disorders
Prioritize nursing care for a patient who has had a hip
ORIF or knee replacement
Identify common types of amputations
Identify appropriate nursing care for patients with degenerative joint disease (DJD)
Prioritize nursing care for patients who are at risk for osteomylitis (bone infection)
Describe the role of drug therapy in prevention and management of degenerative joint disease
Describe the causes of gout and appropriate treatments.

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Musculoskeletal Disorders
Review of Bone physiology
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o o Healthy bone o

Musculoskeletal Disorders
 This is one osteoclast dissolving bone
As part of the normal healing process

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Osteoporosis– number one cause of fractures in the elderly,
>1.5 million per year
Primary Osteoporosis is caused by osteopenia or thinning of the bone. This occurs when osteoclastic bone loss is faster than osteoblastic (bone building) activity.
This is measured by BMD (bone mineral density)
Osteopenia = T-score of less than- 1.0
Treatment starts here, new guidelines 2008
Osteoporosis = T-score of > -2.5

Musculoskeletal Disorders-
-----Osteoporosis
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Low-power scanning electron microscope image of normal bone architecture in the 3 rd lumbar vertebra of a 30 year old woman marrow and other cells have been removed to reveal thick, interconnected plates of bone
Slides courtesy of the Bone Research Society BRS, UK

Low-power scanning electron microscope image of osteoporotic bone architecture in the 3 rd lumbar vertebra of a 71 year old woman marrow and other cells have been removed to reveal eroded, fragile rods of bone

Detail of a trabicular bone element perforated by osteoclast action-note pitting of the bone ‘stalagmite’

Musculoskeletal diseases
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 Age
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Post-menopause (lack of estrogen stimulation)
Thin lean body build
Asian or thin Caucasian race
Calcium and Vitamin D deficiency
Lack of weight bearing exercise
Alcohol abuse
Tobacco use
Excessive caffeine use (> 3 cups per day)
Eating disorders
Malabsorption disorders

Musculoskeletal diseases
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Diagnostics:
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DEXA Scan Screening annually of post-menopausal women
DEXA Screening for hypothyroid and hyperthyroid patients
Qualitative US – not used much
Bone Scan is used for differential diagnostics, i.e. to rule out bone cancer
Labs for Calcium, Magnesium, Phosphorus levels
Urine for pyridinium levels

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This is a typical bone densitometry study. A low dose x-ray is performed of the lumbar spine, hip (shown here) or wrist.
From the resulting image
/measurement, calculations can be made to determine the density of the patient's bone
(T-score) and compare it to the reference standard of a healthy thirty-year-old of the same sex and ethnicity to determine future risk of fracture.
http://www.radiologyinfo.org/en/info.cfm?pg=dexa

Musculoskeletal diseases
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Osteoporosis Treatments and Nursing Interventions
Educate – Side effects of meds
 Calcium supplementation – new evidence is 1700 mg of calcium per day, or more for post-menopausal women not on hormone therapy. May use TUMS if stomach is upset with supplements
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Exercises
Fall prevention and safety
Biphosphonates i.e. Fosamax, Actonel, Boniva– have to be taken
1 hour before any other foods or vitamins, with only water to be absorbed .
Vitamin D therapy – not usually needed in the sunny desert, found in dairy and green leefy vegetables

Musculoskeletal Disorders
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Nursing primary concern is to assess and prevent neuro-vascular dysfunction.
 Neuro / circulation checks should be done of the affected limb every
15 minutes x 4, then every 30 minutes x2, then every hour. ( The book says every hour, but that is really too long, and your patient could go into shock)
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Immobilize the limb
Control the pain
 Assess for shock

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Monitor for numbness, tingling, hyperesthesia, hypoesthesia
Monitor for DVT’s – check pulses and color
Instruct the client to examine the skin daily for any breakdown or alterations, call MD if oozing or redness occur
Instruct client to avoid crossing their legs
Instruct patient to completely abstain from tobacco
Remove home safety hazards in the home
Instruct patient not to scratch underneath the cast or around the pins/traction
Give patient anticoagulants and analgesics if ordered
Instruct patient to take vitamins, adequate amoaunts of magnesium, vitamin
C, etc…for healing.

Neurovascular
Components:
“The 6 P’s”
Pain
Early or
Late Signs
Assessment Parameters
Early
Paresthesia
Pallor
Polar
Paralysis
Pulses
Early
Early
Late
Late
Late
Client Teaching /
Symptoms to Report
Assess area involved using 0 to 10 rating scale:
0 = no pain
10 = worst pain imaginable
Increasing pain not relieved with elevation or pain medication
Assess for numbness/tingling, pins or needles sensation:
Should be absent.
Assess capillary refill.
Brisk is < 3 seconds
Numbness or tingling, pins or needles sensation
Increased capillary refill time > 3 seconds, blue fingers or toes
Assess skin temperature by touch:
Warm <or> Cool
Assess mobility:
Moves fingers or toes
Able to plantar dorsiflex the ankle area not involved or restricted by cast
Cool/cold fingers or toes
Unable to move fingers or toes
Assess pulse(s) distal to injury:
Pulse is palpable and strong
Weak palpable pulses, unable to palpate pulses, pulse detected only with
Doppler

Musculoskeletal Disorders
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 occur when abnormal force is applied, or the bone is already weakened (osteoporosis, cancers, sarcomas, benign bone cysts, etc.).
The type of fracture depends on the type of loading force and stress applied to the bone. See below.
 Closed - Greenstick -Spiral - Open (compound)

 This is a photograph of 70 year old woman who first presented like this with a massive chondrosarcoma of her right upper humerus of 8 months duration. She refused all treatment, and she died of a massive haemorrhage when the tumour burst the following week.
http://worldortho.com/dev/index.php?option=com_content& task=view&id=1814&Itemid=328

Musculoskeletal Disorders
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Fat emboli syndrome/CVA/Stroke
Hematoma (leakage from the bone marrow usually), which can also be a hemmorhage
Callus formation
DVT - thromboembolism
Infection – to Osteomyelitis
Ischemic necrosis
Fracture blisters
Delayed union, nonunion, and malunion
Osteoblastic proliferation…..

 i.e. Osgood’s Schlatter’s
 Osteoblastic proliferation:
Osgood Schlatter’s is a common disorder among athletes and runners stemming from small fractures of the tibial plateau from impact which heals builds up bone callous.

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Perform/assist with relevant laboratory, diagnostic, and therapeutic procedures within the nursing role, including:
Preparation of the client for the procedure.
Client teaching (before and following the procedure).
Accurate collection of specimens.
Accurate interpretation of procedure results (compare to norms) and appropriate notification of the primary care provider.
Assessment and evaluation of the client’s response (expected, unexpected adverse response, comparison to baseline) to the procedure.
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Planning and implementing body system specific interventions as appropriate.
Monitoring and taking actions, including client education, to prevent or minimize the risk of complications.
Recognizing signs of potential complications and reporting to the primary care provider.
Recommending changes in the test/procedure as needed based on client findings.
Protect the client from injury.
Monitor therapeutic devices
(drainage/irrigating devices, chest tubes), if inserted, for proper functioning.
Identify the client’s prognosis based on knowledge of pathophysiology and understanding of the client’s pathology report.

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 Casts
Casts are more effective than splints or immobilizers because they cannot be removed by the client.
Types of casts include:
Short and long arm casts.
Short and long leg casts.
Spica cast, which refers to a portion of the trunk and one or two extremities.
Body cast, which encircles the trunk of the body.
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 Splints and Immobilizers
Splints are removable and allow for monitoring of skin swelling or integrity.
Splints can be used to support fractured/injured areas or used for postparalysis injuries to avoid joint contracture.
Immobilizers are prefabricated and are fastened with
Velcro straps.

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 Traction
Traction uses a pulling force to promote and maintain alignment to the injured area. In straight or running traction, the countertraction is provided by the client’s body. In balance suspension traction, the countertraction is produced by devices such as slings or splints.
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 Goals of traction include:
Realignment of bone fragments.
Decreasing muscle spasms and pain.
Correcting or preventing further deformities
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 Types of Traction
Manual
Skin
Skeletal
Halo Traction

* Pin care is done frequently throughout immobilization (skeletal traction and external fixation methods) to prevent and to monitor for signs of infection including:
--Drainage (color, amount, odor).
--Loosening of pins.
--Tenting of skin at pin site
(skin rising up pin).
Pin care protocols (use of hydrogen peroxide, povidone iodine) are based on provider preference and institution policy.
A primary concept of pin care is that one cotton-tip swab is used per pin to avoid cross-contamination.
Every 8 hr is a common parameter for pin care schedule.

Immobilization: (Casts, Splints, & Traction)

Stryker Frame

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External fixation involves fracture immobilization using percutaneous pins and wires that are
attached to a rigid external frame.
Used to treat:
Comminuted fracture with extensive soft tissue.
Leg length discrepancies from congenital defects.
Bone loss related to tumors or osteomyelitis.
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Advantages include:
Immediate fracture stabilization.
Allows three plane correction of the injury.
Minimal blood loss occurs in comparison with internal fixation.
Allows for early mobilization and ambulation.
Disadvantages include:
Risk of pin tract infection.
Potential overwhelming appearance to client.

Musculoskeletal Disorders
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 A serious condition which can lead to a loss of life and limb, usually an arm or a leg. The swelling of an injury or trauma causes lack of innervation and compromised circulation to the affected part of the body, causing tissue death and necrosis. Edema causes this.
 Treatment is mandated by alleviating the pressure.
 The most common type of acute compartment syndrome in the hospital is infiltration of IV fluids, and in trauma victims.

Musculoskeletal Disorders
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Musculoskeletal Disorders
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 ACS can lead to renal failure, shock, and loss of the limb or life.

Musculoskeletal Disorders
 Acute Compartment Syndrome (ACS)

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Musculoskeletal Disorders
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Treatment
 Determine the cause of swelling,
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If the cast is too tight then it needs to be cut off.
If the dressing is too tight, loosening the bandage will release the pressure
Surgical release of tissue pressure is often required. (Fasciotomy)

Musculoskeletal Disorders
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Color or pallor of patient
Color of the limb distal to the injury
Movement
Sensation
Distal pulses
Pain
Skin temperature
Capillary refil

 Assess/monitor the client’s need for pain medication, and plan and provide care to meet the client’s needs for pain intervention.
 Assess/monitor the client for actual/potential specific food and
medication interactions.
 Assess/monitor the effectiveness of pain intervention, and advocate for the client’s needs as indicated.
 Identify contraindications, actual/potential incompatibilities, and
interactions between medications, and intervene appropriately.
 Provide appropriate client
education, and reinforce client teaching regarding the purposes and possible effects of pain medications.
 Identify symptoms/evidence of an
allergic reaction, and respond appropriately.
 Evaluate/monitor and document the therapeutic and adverse/side
effects of medications.
 Assess/monitor the client for
expected effects of medications.
 Assess/collect data regarding the client’s medication use over time.
 Assess/monitor the client for
side/adverse effects of medications.

Musculoskeletal Pharmacology : Medications for Pain & Inflammation
NSAIDs—Non Steroidal Anti-Inflammatory Drugs
Prototypes: 1 st Generation: Aspirin 2 nd Generation: celecoxib (Celebrex®)
Pharmacological Action
Inhibition of cyclooxygenase: Inhibition of
COX-2 results in ↓ inflammation, pain, and fever. Inhibition of COX-1 results in the ↓ of platelet aggregation
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Aspirin contraindications include:
Peptic ulcer disease.
Bleeding disorders (e.g., hemophilia, vitamin K deficiency)
Hypersensitivity to aspirin and other NSAIDs.
Pregnancy (Pregnancy Risk Category D).
Children with chickenpox or influenza.
Therapeutic Uses
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Inflammation suppression
Analgesia for mild to moderate pain
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Fever reduction
Dysmenorrhea
Low level suppression of platelet aggregation
 Use NSAIDs cautiously in older adults,
clients who smoke cigarettes, and in clients with H. pylori infection, hypovolemia, hay fever, chronic
urticaria, and/or a history of alcoholism.

Musculoskeletal Pharmacology : Medications for Pain & Inflammation
NSAIDs—Non Steroidal Anti-Inflammatory Drugs
Prototypes: 1 st Generation: Aspirin 2 nd Generation: celecoxib (Celebrex®) CONTINUED…
Therapeutic Nursing Interventions and
Client Education
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Advise the client to stop aspirin 1 week before an elective surgery or expected date of childbirth.
Advise the client to take aspirin with food, milk, or a full glass of water to reduce gastric discomfort.
Instruct the client not to chew or crush enteric-coated or sustained-release aspirin tablets.
Advise the client to notify the primary care provider if signs and symptoms of gastric discomfort or ulceration occur.
Clients unable to tolerate aspirin due to GI ulceration, risk of bleeding, or renal impairment should be prescribed a 2nd generation NSAID, such as
celecoxib (Celebrex).
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One 1st generation NSAID, ketorolac (Toradol), is used for short-term treatment of moderate to severe pain such as that associated with postoperative recovery.
Ketorolac provides analgesia without antiinflammatory effect.
When ketorolac is used concurrently with opioids, the analgesic effect of opioids is enhanced without the occurrence of adverse effects associated with opioids
(e.g., respiratory depression, constipation).
When ketorolac is used with other NSAIDs serious adverse effects can occur; therefore, ketorolac should be used no more than 5 days. Usually started as parenteral administration and then progresses to oral doses.
Depending on therapeutic intent, effectiveness of NSAID USE may be evidenced by:
Reduction in inflammation.
Reduction of fever.
Relief from mild to moderate pain or dysmenorrhea.
Platelet aggregation suppression.

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Musculoskeletal Pharmacology : Medications for Pain & Inflammation
Acetaminophen
Prototypes: acetaminophen (Tylenol® )
Pharmacological Action
 Nursing Interventions and Client
Education
Acetaminophen slows the production of prostaglandins in the central nervous system.
Therapeutic Uses
Analgesic (relief of pain) effect
Antipyretic (reduction of fever) effects
Side/Adverse Effects:
Nursing Interventions and Client Education
Acute toxicity that results in liver damage with early symptoms of nausea, vomiting, diarrhea, sweating, and abdominal discomfort progressing to hepatic failure, coma, and death
Advise the client to take acetaminophen as prescribed and not to exceed 4 g per day.
Administer the antidote,
Acetylcysteine (Mucomyst® ).
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Acetaminophen is a component of multiple prescribed and over-the-counter medications. Keep a running total of daily acetaminophen intake and follow recommended dosages as prescribed by the primary care provider to prevent toxicity, not to exceed 4 g per day.
In the event of an acetaminophen overdose, liver damage can be reduced by administering a weightbased dosage of the antidote acetylcysteine
(Mucomyst) in a diluted form via an oroduodenal tube (has an unpleasant odor that ↑ risk of emesis).
Nursing Evaluation of Medication
Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Relief of pain.
 Reduction of fever.
Use cautiously in clients who consume three or more alcoholic drinks/day and those taking warfarin (interferes with metabolism).

Musculoskeletal Pharmacology : Medications for Pain & Inflammation
Opioid Agonists
Prototypes: Morphine sulfate
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Pharmacological Action
Opioid agonists, such as morphine, codeine, meperidine, and other morphine-like medications (fentanyl), act on the mu receptors, and to a lesser degree on kappa receptors.
Activation of mu receptors produces analgesia, respiratory depression, euphoria, and sedation, whereas kappa receptor activation produces analgesia, sedation, and ↓ GI motility.
Therapeutic Uses
Relief of moderate to severe pain (e.g., postoperative pain, myocardial infarction pain, cancer pain)
Sedation
Reduction of bowel motility
Codeine: cough suppression
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Contraindications/Precautions
Contraindicated: after biliary tract surgery.
for premature infants (during and after deliverydue to respiratory depressant effects).
Used Cautiously: because of respiratory depression asthma, emphysema, and/or head injuries
Infants and older adult clients
Pregnant clients
Clients in labor
Clients with inflammatory bowel disease
Clients with an enlarged prostate

Morphine Sulfate
Side Effects / Adverse Effects
Respiratory depression
Constipation
Orthostatic hypotension
Urinary retention
Cough suppression
Sedation
Biliary colic
Emesis
Opioid overdose triad of coma, respiratory depression, and pinpoint pupils
Nursing Interventions /
Client Education
--Monitor the client’s vital signs.
--Stop opioids if the client’s respiratory rate is less than 12/min, and then notify the primary care provider.
--Avoid the use of opioids with CNS depressant medications (e.g., barbiturates, benzodiazepines, and consumption of alcohol).
-↑ fluid intake and physical activity.
--Administer a stimulant laxative, such as bisacodyl (Dulcolax), to counteract ↓ bowel motility, or a stool softener, such as docusate sodium (Colace), to prevent constipation.
--Advise the client to sit or lie down if symptoms of lightheadedness or dizziness occur.
--Avoid sudden changes in position by slowly moving the client from a lying to a sitting or standing position.
--Provide assistance with ambulation as needed.
--Advise the client to void every 4 hr.
--Monitor I&O.
--Assess the client’s bladder for distention by palpating the lower abdomen area every4 to 6 hr.
--Advise the client to cough at regular intervals to prevent accumulation of secretions in the airway.
--Auscultate the client’s lungs for crackles, and instruct the client to ↑ intake of fluid to liquefy secretions.
--Advise the client to avoid hazardous activities such as driving or operating heavy machinery.
--Avoid giving morphine to clients who have a history of biliary colic. Use meperidine as an alternative.
--Administer an antiemetic such as promethazine (Phenergan).
--Monitor the client’s vital signs.
--Place the client on a ventilator.
--Administer opioid antagonists, such as naloxone (Narcan) or nalmefene (Revex).

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Musculoskeletal Pharmacology Medications for Pain & Inflammation
Agonist – Antagonist Opioids
Prototypes: pentazocine (Talwin ®)
Contraindications/Precautions
Pharmacological Action
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Compared to pure opioid agonists, agonistantagonists have:
 Use cautiously in clients with a history of myocardial infarction ( ↑ cardiac workload) and clients who are physically dependent on opioids.
--A low potential for abuse causing little euphoria. In fact, high doses can cause adverse effects (e.g., anxiety, restlessness, mental confusion).
 Nursing Interventions and Client
Education
--Less respiratory depression. Kappa receptors will cause a certain degree of respiratory depression and then no more (have a
“ceiling”).
 Take the client’s baseline vital signs. If the client’s respiratory rate is less than 12/min, withhold the medication and notify the primary care provider.
Therapeutic Uses
 Warn the client not to ↑ dosage without consulting the primary care provider.
Agonists-antagonists opioids relieve mild to moderate pain; not used for treatment of severe pain.
 Nursing Evaluation of Medication
Effectiveness
--Monitor for improvement of symptoms, such as relief of pain.

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Musculoskeletal Pharmacology Medications for Pain & Inflammation
Opioid Antagonists
Prototypes: naloxone (Narcan ®)
Pharmacological Action
Opioid antagonists interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no effect in the absence of opioids.
Therapeutic Uses
Treatment of opioid overdose
Reversal of effects of opioids, such as respiratory depression
Reversal of respiratory depression in an infant
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Therapeutic Nursing Interventions and Client Education
Naloxone has rapid first-pass inactivation and should be administered IV, IM, or SC.
Do not administer orally.
Observe the client for withdrawal symptoms and/or abrupt onset of pain. Be prepared to address the client’s need for analgesia (e.g., if given for postoperative opioid-related respiratory depression).
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Contraindications/Precautions
Hypersensitivity
Opioid dependency
Pregnancy Risk Category B
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Nursing Evaluation of Medication
Effectiveness
Reversal of respiratory depression (e.g., respirations are regular, client is without shortness of breath, respiratory rate is 16 to
20/min in adults and 40 to 60/min in newborns)

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Musculoskeletal Pharmacology Medications for Pain & Inflammation
Adjuvant Pain Medications
Prototypes:Tricyclic anti-depressants; anticonvulsants; CNS Stimulants; antihistamines; glucocorticoids; & biphosphonates
Tricyclic antidepressants:
amitriptyline (Elavil)
Anticonvulsants: carbamazepine
(Tegretol), gabapentin (Neurontin), phenytoin (Dilantin
CNS stimulants: methylphenidate (Ritalin), dextroamphetamine (Dexedrine)
Antihistamines: hydroxyzine
(Vistaril)
Glucocorticoids: dexamethasone
(Decadron), prednisone (Deltasone)
Bisphosphonates: etidronate
(Didronel), pamidronate (Aredia)
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Pharmacological Actions
Adjuvant medications for pain enhance the effects of opioids.
Therapeutic Uses
Used in combination with opioids – cannot be used as a substitute for opioids
Treating pain with an adjuvant medication allows for lower dosages of opioids, and thereby ↓ the adverse effects experienced with opioids (e.g., sedation and constipation).
Help alleviate other symptoms that aggravate pain (e.g., depression, seizures, dysrhythmias)
Used in the treatment of neuropathic pain (e.g., cramping, aching, burning, darting and lancinating pain).
Used in cancer-related conditions (e.g.,
↑ intracranial pressure, spinal cord compression, bone pain).

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Musculoskeletal Pharmacology Medications for Pain & Inflammation
Antigout Medication
Prototypes: colchicine
 Contraindications/Precautions
Pharmacological Action
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Colchicine and indomethacin ↓ inflammation in clients with gout by possibly preventing infiltration of leukocytes. These medications do not effect uric acid production or excretion.
Allopurinol inhibits uric acid production.
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Avoid use of colchicine during pregnancy (FDA Pregnancy
Risk Category C, if used orally; Category D, if used intravenously).
Use colchicine cautiously in older adults, debilitated clients, and clients with renal, cardiac, and gastrointestinal dysfunction.
Probenecid inhibits uric acid reabsorption by the renal tubules.
Therapeutic Uses
 Therapeutic Nursing Interventions and
Client Education
Colchicine and indomethacin:
--Treatment of acute gout attacks.
--If given in response to precursor symptoms of an acute gout attack, can abort the attack.
 Instruct the client to concurrently take preventive measures such as avoiding alcohol and foods high in purine (e.g., red meat, scallops, cream sauces). The client should ensure an adequate intake of water, exercise regularly, and maintain an appropriate body weight.
-↓ in the incidence of acute attacks for clients with chronic gout.
 Nursing Evaluation of Medication
Effectiveness
Allopurinol and probenecid:
 Depending on the therapeutic intent, effectiveness may be evidenced by:
--Hyperuricemia (chronic gout secondary to cancer chemotherapy).
 --Improvement of pain caused by a gout attack (e.g., ↓ in joint swelling, redness, and uric acid levels).
Probenecid:
 -↓ in number of gout attacks.
--Prolongs the effects of penicillins and cephalosporins by delaying their elimination.
 -↓ in uric acid levels.