Got me Working Working Day and
Night!........
•Common Disorders!! You got me
working working day and
night………………!!
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Musculoskeletal
•
Uses the nursing process as a framework for care and teaching of the patient with a cast.(1, 2, 4 and 5)
•
2. Compare the nursing needs of the patient undergoing total hip replacement with those of the patient undergoing total knee
replacement (1, 2 4 and 5)
•
3. Use the nursing process as a framework for care of the patient undergoing orthopedic surgery ( 1, 2 4 5).
•
4. Use the nursing process as a framework for care of the patient with low back pain, osteoporosis, and
Osteomyelitis ( 1, 2 5and 6)
•
Describe the rehabilitation and health education needs of the patient with low back pain ( 1, 2 5 and 6)
•
6. Describe common conditions of the upper extremities and nursing care of the patient undergoing surgery of the hand,wris
or foot ( 1 2 5 and6).
•
7. Explain pathophysiology, pathogenesis, prevention, and management of osteoporosis, osteomalacia, osteomyelitis, and
Paget’s disease( 1, 2 and 5)
•
8.Differentiate between contusion, strains, sprains, and dislocations (1, 2 5 and 6).
•
9.Discuss sport and occupational injuries and injury-prevention strategies ( 1, 2 and 5).
•
10. Describe management and care for the patient with fractures 1, 2 5 and 6)
•
8.Differentiate between contusion, strains, sprains, and dislocations 1, 2 5 and 6).
•
9.Discuss sport and
•
occupational injuries and injury-prevention strategies ( 1, 2 and 5).
•
10. Describe management and care for the patient with fractures 1, 2 5 and 6).
•
11. Describe the preventions and management ond immediate and delayed complications of fractures (1, 2 5, and 6)
•
12. Describe the rehabilitation needs of patients with fractures.
•
13. Use the nursing process as a framework for care of the elderly patient with a hip fracture and surgical Repair ( 1, 2 5 and
6)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Super Massive Black Hole?
•Super Massive Med Surg!!!!
•Where am I?
Med Surg!
Super Massive
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Common Disorders is running through my
head all day………Got me singing Hey!!!
Common Disorders has my
iPod stuck on replay!!
Everyday; talking all day
long!! Reading all
long!!Running through my
mind all day!!!
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Common is on stuck on my iPod..Replay!!
•Common Got me Singing
•Na Na Na Na Na Na
•Everyday got my iPod stuck
on replay……….Replay
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Welcome Back: I couldn’t wait
to see you again!!!
Did You Miss
MedSurg?
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
I got my sights set on you (Common)
• I Can’t wait to see you !
• I just can’t put you down!!
• I can’t wait to study you again!!!1
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
29 Ways to make it to an A!!! In
Common!!
•I can find 2-3 more!!
•Keep up with the readings
•29 ways to stay engaged!
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Common is a Highway!!!!!!
• I want to study it all night long!!
• If you are going my way ( to get an
A!!!!)
• I want to drive it all night long!!!
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 68
•
Management of Patients With Musculoskeletal Disorders
• Dianne McAdams-Jones Ed.D, RN GNE
• Assistant Professor Department of Nursing
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
What findings can be identified with the use of a x ray of
the spine?
A. Fracture, dislocation, infection, osteoarthritis, or
scoliosis
B. Infections, tumors, and bone marrow abnormalities
C. Soft tissue lesions adjacent to the vertebral column
D. Spinal nerve root disorders
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
A
X-ray of the spine may demonstrate a fracture, dislocation,
infection, osteoarthritis, or scoliosis. Bone scan and
blood studies may disclose infections, tumors, and bone
marrow abnormalities. Computed tomography is useful
in identifying soft tissue lesions adjacent to the
vertebral column. An electromyogram is used to
evaluate spinal nerve root disorders.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Low Back Pain—Assessment
• Detailed description of the pain including severity, duration,
characteristics, radiation, associated symptoms such as leg
weakness, description of how the pain occurred, and how
the pain has been managed by the patient
• Work and recreational activities
• Effect of pain and/or movement limitation on lifestyle and
ADLs
• Assess posture, position changes, and gait
• Physical exam: spinal curvature, back and limb symmetry,
movement ability, DTRs, sensation, and muscle strength
• If obese, complete a nutritional assessment
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Low Back Pain—Diagnoses
• Acute pain
• Impaired physical mobility
• Risk for situational low self-esteem
• Imbalanced nutrition
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Low Back Pain—Planning
• Major goals may include relief of pain, improved physical
mobility, use of back conservation techniques and proper
body mechanics, improved self-esteem, and weight
reduction.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Pain management
• Exercise
• Body mechanics
• Work modifications
• Stress reduction
• Health promotion; activities to promote a healthy back
• Dietary plan and encouragement of weight reduction
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Positioning to Promote Lumbar Flexion
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
Proper standing posture occurs when the abdominal
muscles contract, giving a feeling of upward pull, and the
gluteal muscles contract, giving a downward pull.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
True
Proper standing posture occurs when the abdominal
muscles contract, giving a feeling of upward pull, and the
gluteal muscles contract, giving a downward pull.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Proper and Improper Standing Postures
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Proper and Improper Lifting Techniques
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
What is bursitis?
A. Inflammation of a fluid-filled sac in the joint.
B. New bone growth around a sequestrum.
C. Disease of a nerve root.
D. Inflammation of muscle tendons.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
A
Bursitis is inflammation of a fluid-filled sac in the joint.
Involucrum is new bone growth around a sequestrum.
Radiculopathy is disease of a nerve root. Tendinitis is
inflammation of muscle tendons.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Common Conditions of the Upper
Extremities
• Bursitis and tendonitis
• Loose bodies
• Impingement syndrome
• Carpal tunnel syndrome
• Ganglion
• Dupuytren’s contracture
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Tinel’s Sign: Assessment of Carpal Tunnel
Syndrome
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
How to test for it and what the test means
• Tinel's sign is a way to detect irritated nerves. It is
performed by lightly tapping (percussing) over the nerve
to elicit a sensation of tingling or "pins and needles" in
the distribution of the nerve.It takes its name from
French neurologist Jules Tinel (1879-1952).[1][2][3]
• For example, in carpal tunnel syndrome where the
median nerve is compressed at the wrist, Tinel's sign is
often "positive" causing tingling in the thumb, index, and
middle finger. Tinel's sign is sometimes referred to as
"distal tingling on percussion" or DTP. This distal sign of
regeneration can be expected during different stage of
somatosensory recovery.[4
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Dupuytren’s Contracture
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Dupuytren’s Contracture: Dupuytren's contracture is
caused by underlying contractures of the palmar
aponeurosis (or palmar fascia)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Care of the Patient Undergoing
Surgery of the Hand or Wrist
• Surgery is usually an outpatient procedure
• Patient teaching is a major nursing need for a patient undergoing
outpatient surgery
• Neurovascular assessment is vital—every hour for the first 24
hours—assess motor function only as prescribed, instruct patient
in signs and symptoms to assess and report
• Pain control measures—medication, elevation, intermittent ice or
cold
• Prevention of infection—keep dressing clean and dry, wound care,
signs and symptoms of infection
• Assistance with ADLs and measures to promote independence
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
What is pes cavus?
A. Flexion deformity of the interphalangeal joint that may
involve several toes.
B. Deformity in which the great toe deviates laterally.
C. Common disorder in which the longitudinal arch of the
foot is diminished.
D. Foot with an abnormally high arch and a fixed equinus
deformity of the forefoot.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
D
Hammer toe is flexion deformity of the interphalangeal
joint that may involve several toes. Hallux valgus is a
deformity in which the great toe deviates laterally. Pes
planus is a common disorder in which the longitudinal
arch of the foot is diminished. Pes cavus is a foot with
an abnormally high arch and a fixed equinus deformity
of the forefoot.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Common Foot Problems
• Plantar fasciitis
• Corn
• Callus
• Ingrown toenail
• Hammer toe
• Hallux valgus
• Clawfoot: Pes cavus
• Morton’s neuroma
• Flatfoot: Pes planus
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Common Foot Deformities
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
Undergoing Foot Surgery—Assessment
• Surgery is usually performed as an outpatient procedure
• Routine outpatient preoperative assessment
• Patient knowledge
• Neurovascular assessment of the foot
• Ambulation and balance
• Explore the need for home assistance and the structural
characteristics of the home—for example, distances
required to walk and presence of stairs or steps
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
Undergoing Foot Surgery—Diagnoses
• Risk for ineffective peripheral tissue perfusion
• Acute pain
• Impaired physical mobility
• Risk for infection
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
Undergoing Foot Surgery—Planning
• Major goals may include adequate tissue perfusion, relief
of pain, improved mobility, and absence of complications.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Neurovascular assessment is vital
– Assess swelling and neurovascular status every 1–2
hours for the first 24 hours
– Instruct patient in signs and symptoms to assess and
report
• Reliving pain
– Elevate foot
– Use of intermittent ice
– Medications; oral analgesics
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Improving mobility
– Instruction in weight-bearing restrictions as
prescribed
– Use of assistive devices (crutches or walker)
– Measures to assure patient safety
• Measures to prevent infection
– Wound or pin care
– Keep dressing clean and dry
– Signs and symptoms of infections
• Patient teaching
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Osteoporosis
• Affects approximately 40 million people over the age of
50 in the United States.
• Normal homeostatic bone turnover is altered and the rate
of bone resorption is greater than the rate of bone
formation, resulting in loss of total bone mass.
• Bone becomes porous, brittle, and fragile, and break
easily under stress
• Frequently result in compression fractures of the spine,
fractures of the neck or intertrochanteric region of the
femur, and Colles’ fractures of the wrist
• Risk factors.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Progressive Osteoporosis Bone Loss and
Compression Fractures
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Typical Loss of Height Associated with
Osteoporosis and Aging
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Prevention
• Balanced diet high calcium and vitamin D throughout life
• Use of calcium supplements to ensure adequate calcium
intake—take in divided doses with vitamin C
• Regular weight-bearing exercises—walking
• Weight training stimulates bone mineral density (BMD)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pharmacologic Therapy
• Biphosphonates
– Alendronate: Fosamax
– Risedronate: Actonel
– Ibandronate: Boniva
• Selective estrogen modulators (SERMs): Evista
• Cacitonin
• Teriparatide: Forteo
• Also need adequate amounts of calcium and vitamin D
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
How long does a patient taking biphosphonates need to
stay upright after administration?
A. 10 minutes
B. 20 minutes
C. 30 minutes
D. 120 minutes
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
C
Biphosphonates are administered on arising in the morning
with a full glass of water on an empty stomach and the
patient must stay upright for 30–60 minutes.
• Preventing throat ulcers caused by Fosamax
• Patients who are taking Fosamax® (alendronate) for prevention of
osteoporosis know that they are supposed to take it with a full glass of water
and remain upright for 30 minutes after taking it. Fosamax can cause ulcers in
the esophagus if patients do not follow those two instructions. However,
recently, a woman taking Fosamax was admitted to the hospital. While she
was there, the nurses did not give her a glass of water, and they did not allow
her to sit upright in bed after taking Fosamax. As a result, she developed an
esophageal ulcer while in the hospital. If you take Fosamax and must be
admitted to the hospital, remember to take it correctly, even if your nurses
forget. If you cannot sit up, ask your doctor if you have to take Fosamax while
you there--perhaps not taking it for a few days until you get home would be
the safest idea, especially if you are not able to sit up.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Osteoporosis—Assessment
• Occurrence of osteopenia and osteoporosis
• Family history
• Previous fractures
• Dietary consumption of calcium
• Exercise patterns
• Onset of menopause
• Use of corticosteroids as well as alcohol, smoking, and
caffeine intake
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Osteoporosis—Diagnoses
• Deficient knowledge about the osteoporotic process and
treatment regimen
• Acute pain related to fracture and muscle spasm
• Risk for constipation related to immobility or
development of ileus (intestinal obstruction)
• Risk for injury: additional fractures related to
osteoporosis
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Osteoporosis—Planning
• The major goals for the patient may include knowledge
about osteoporosis and the treatment regimen, relief of
pain, improved bowel elimination, and absence of
additional fractures.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Promoting understanding of osteoporosis and the
treatment regimen
• Relieving pain
• Improving bowel elimination
• Preventing injury
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Osteomalacia
• A metabolic bone disease characterized by inadequate
bone mineralization
• Softening and weakening of the long bones causes pain,
tenderness, and deformities caused by the bowing of
bones and pathologic fractures
• Deficiency of activated vitamin D causes lack of bone
mineralization and low extracellular calcium and
phosphate
• Causes include gastrointestinal disorders, severe renal
insufficiency, hyperparathyroidism, and dietary deficiency
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Treatment of Osteomalacia
• Correct underlying cause
• Increased doses of vitamin D and calcium are usually
recommended
• Handle patient gently; patient is at high risk for fractures
• Address pain and discomfort
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Paget’s Disease
• AKA osteitis deformans
• Disorder of localized bone turnover
• Incidence: 2–3% of the population older than age 50
• More common in men and risk increases with aging;
familial predisposition has been noted
• Pathophysiology: excessive bone resorption by
osteoclasts is followed by increased osteoblastic activity.
Bone structure disorganized, weak an highly vascular
• Patients are at risk for fractures, arthritis, and hearing
loss
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Paget’s Disease
• Manifestations include skeletal deformities, mild to
moderate aching pain, and tenderness and warmth over
bones. Symptoms may be insidious and may be
attributed to old age or arthritis. Most patients do not
have symptoms.
• Pharmacologic management
– NSAIDs for pain
– Calcitonin
– Biphosphonates (etidronate—Didronel)
– Plicamycin (Mithracin): a cytotoxic antibiotic may be
used for severe disease resistant to other therapy
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Osteomyelitis
• Infection of the bone
• Occurs due to:
– Extension of soft tissue infection
– Direct bone contamination
– Blood-borne spread from another site of infection
• This typically occur in an area of bone that has
been traumatized or has lowered resistance
• Causative organisms
– Staphylococcus aureus (70–80%)
– Other: Proteus and Pseudomonas species, E. coli
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
• Prevention of osteomyelitis is the goal.
• Early detection and prompt treatment
of osteomyelitis is required to reduce
potential for chronic infection and
disability.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Osteomyelitis—Assessment
• Risk factors
• Signs and symptoms of infection localized pain edema,
erythema, fever, drainage
• Note: With chronic osteomyelitis fever may be low grade
and occur in afternoon or evening
• Signs and symptoms of adverse reactions and
complications of antibiotic therapy including signs and
symptoms of superinfections
• Ability to adhere to prescribed therapeutic regimen—
antibiotic therapy
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Osteomyelitis—Diagnoses
• Acute pain
• Impaired physical mobility
• Risk for extension of infection: bone abscess formation
• Deficient knowledge
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Osteomyelitis—Planning
• Major goals may include relief of pain, improved physical
mobility, within therapeutic limitations, control and
eradication of infection, and knowledge of therapeutic
regimen.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Reliving pain
– Immobilization
– Elevation
– 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
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Promote good nutrition: vitamin C and protein
• Encourage adequate hydration
• Administer and monitor antibiotic therapy
• Patient and family teaching
– Long-term antibiotic therapy and management of
home IV administration
– Mobility limitations
– Safety and prevention of injury
– Follow-up care
• Referral for home health care
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Bone Tumors
• Primary tumors
– Benign tumors are more common and generally are
slow growing and present few symptoms
– Malignant
• Prognosis depends upon type and whether the
tumor has metastasized
• Osteogenic sarcoma is the most common, and
most often fatal, primary malignant bone tumor
• Metastatic bone tumors
– More common than primary tumors
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with a Bone Tumor—Assessment
• Onset and course of symptoms
• Knowledge of disease and treatment
• Pain
• Patient coping
• Family support and coping
• Physical examination of area including neurovascular
status and ROM
• Mobility and ADL abilities
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with a Bone Tumor—Postoperative
Assessment
• Postoperative assessment as for a patient who has had
orthopedic surgery
• Motif VS, LOC, neurovascular status, pain
• Signs and symptoms of complications
• Monitor laboratory results: WBC and serum calcium level
• Signs and symptoms of hypercalcemia
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with a Bone Tumor—Diagnoses
• Deficient knowledge
• Acute and chronic pain
• Risk for injury
• Ineffective coping
• Risk for situational low self-esteem
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Collaborative Problems/Potential
Complications
• Delayed wound healing
• Nutritional deficiency
• Infection
• Hypercalcemia
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with a Bone Tumor—Planning
• Major goals include knowledge of disease process and
treatment regimen, control of pain, absence of pathologic
fractures, effective coping patterns, improved selfesteem, and absence of complications.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Care is similar to that of other patients who have
undergone orthopedic surgery.
• Patient and family teaching regarding diagnosis, disease
process, and treatment.
• Prevention of pathologic fractures
– Support affected extremities at all times and handle
gently
– External supports or fixation devices may be required
– Restrict weight-bearing and activity as prescribed
– Use of assistive devices
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Promoting proper nutrition
– Administer antiemetics as prescribed
– Relaxation techniques
– Oral care
– Nutritional supplements
• Provide adequate hydration
• Use strict aseptic technique
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins