Chapter 68 & 69
Ch 68
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Management of Patients With Musculoskeletal
Disorders
Nursing Process—Assessment of the Patient with
Low Back Pain
• 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: assess spinal curvature, back and limb symmetry, movement
ability, DTRs, sensation, and muscle strength
• If patient is obese, complete a nutritional assessment
Nursing Process—Diagnosis of the Patient With
Low Back Pain
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Acute pain
Impaired physical mobility
Risk for situational low self-esteem
Imbalanced nutrition
Nursing Process—Planning the Care of the Patient
With Low Back Pain
• Major goals include relief of pain, improved physical mobility, use of back
conservation techniques and proper body mechanics, improved self-esteem,
and weight reduction
Interventions
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Pain management
Exercise
Body mechanics
Work modifications
Stress reduction
Health promotion; see Chart 68-3 (Activities to Promote a Healthy Back)
Dietary plan and encouragement of weight reduction
See Chart 68-2
Positioning to Promote
Lumbar Flexion
Proper and Improper
Standing Postures
Proper and Improper
Lifting Techniques
Common Conditions of the Upper Extremities
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Bursitis and tendonitis
Loose bodies
Impingement syndrome
Carpal tunnel syndrome
Ganglion
Dupuytren’s contracture
Tinel’s Sign—Assessment of
Carpal Tunnel Syndrome
Dupuytren’s Contracture
Tinel’s sign may be used to help identify carpal tunnel syndrome.
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 about signs and symptoms to assess
and report
• Pain control measures: medication, elevation, and intermittent ice or cold
• Prevention of infection: keep dressing clean and dry, provide wound care,
and assess for signs and symptoms of infection
• Assist with ADLs and measures to promote independence
Common Foot Problems
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Plantar fasciitis
Corn, Callus
Ingrown toenail, Hammer toe
Hallux valgus
Claw foot: pes cavus
Morton’s neuroma
Flatfoot: Pes planus
Nursing Process—Assessment of the
Patient Undergoing Foot Surgery
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Surgery is usually performed as an outpatient procedure
Perform routine outpatient preoperative assessment
Determine patient knowledge
Perform neurovascular assessment of the foot
Assess ambulation and balance
Explore the need for home assistance and the structural characteristics of the
home, eg, distances required to walk and the presence of stairs or steps
Nursing Process—Diagnosis of the Patient Undergoing
Foot Surgery
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Risk for ineffective peripheral tissue perfusion
Acute pain
Impaired physical mobility
Risk for infection
Nursing Process—Planning the Care of the Patient
Undergoing Foot Surgery
• Major goals include adequate tissue perfusion, relief of pain, improved
mobility, and absence of complications
Interventions
• Neurovascular assessment is vital
– Assess swelling and neurovascular status every 1 to 2 hours for the first
24 hours
– Instruct patient about signs and symptoms to assess and report
• Relive pain
– Elevate foot
– Use ice intermittently
– Administer medications and oral analgesics
• Improve mobility
– Instruct on weight-bearing restrictions as prescribed
– Use assistive devices (crutches or walker)
– Implement measures to ensure patient safety
• Implement measures to prevent infection
– Provide wound or pin care
– Keep dressing clean and dry
– Assess for signs and symptoms of infections
• Patient teaching: see Chart 68-6
Osteoporosis
• Affects approximately 40 million people over the age of 50 in the U.S.
• 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 breaks easily under stress
• Frequently results in compression fractures of the spine, fractures of the neck or
intertrochanteric region of the femur, and Colles’ fractures of the wrist
• Risk factors: see Chart 68-7
Typical Loss of Height
Associated w Osteoporosis
and Aging
Pathophysiology of Osteoporosis: Prevention
• Follow a balanced diet high in calcium and vitamin D throughout life
• Use calcium supplements to ensure adequate calcium intake: take in divided
doses with vitamin D
• Regular weight bearing exercises: walking
• Weight training stimulates bone mineral density (BMD)
• See Chart 68-8
The prevalence of osteoporosis in women aged more than 80 years is 50%.
Pharmacologic Therapy
• Biphosphonates
– Alendronate: Fosamax
– Risendronate: Actonel
– Ibandronate: Boniva
• Selective estrogen receptor modulators (SERMs): Evista
• Calcitonin
• Teriparatide: Forteo
• Need adequate amounts of calcium and vitamin D
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
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
Question
The primary defect in osteomalacia is a deficiency in activated vitamin D, which
promotes calcium absorption from the GI tract and facilitates mineralization of
bone.
Paget’s Disease
• Also called osteitis deformans, Paget’s disease is a disorder of localized bone
turnover
• Incidence: 2% to 3% of the population over 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, and highly vascular
• Patients are at risk for fractures, arthritis, and hearing loss
• 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 although most patients do not have symptoms
• Pharmacologic management
– NSAIDs for pain
– Calcitonin
– Biphosphonates (etidronate: Didronel)
– Plicamycin (Mithracin): a cytotoxic antibiotic that may be used for severe disease
resistant to other therapy
Osteomyelitis
• Infection of the bone occurs due to:
– Extension of soft-tissue infection
– Direct bone contamination
– Bloodborne spread from another site of infection
 This typically occurs in an area of bone that has been traumatized or has
lowered resistance
• Causative organisms
– Staphylococcus aureus (70% to 80%)
– Other: Proteus, Pseudomonas, and E. coli
• Prevention of osteomyelitis is the goal
• Early detection and prompt treatment of osteomyelitis are required to reduce
potential for chronic infection and disability
Nursing Process—Assessment of the Patient w Osteomyelitis
• Risk factors
• Signs and symptoms of infection, localized pain, edema, erythema, fever, and
drainage
– With chronic osteomyelitis, fever may be low grade and occur in the afternoon or
evening
• Signs and symptoms of adverse reactions and complications of antibiotic therapy
include signs and symptoms of superinfections
• Ability to adhere to prescribed therapeutic regimen: antibiotic therapy
Nursing Process—Diagnosis of the Patient w Osteomyelitis
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Acute pain
Impaired physical mobility
Risk for extension of infection: bone abscess formation
Deficient knowledge
Major goals include relief of pain, improved physical mobility within
therapeutic limitations, control and eradication of infection, and knowledge of
therapeutic regimen
Interventions
• Relieve pain
– Immobilization
– Elevation
– Handle with great care and gentleness
– Administer prescribed analgesics
• Improve physical mobility
– Activity is restricted
– Perform gentle ROM to joints above and below the affected part
– Participate in ADLs within limitations
• Promote good nutrition including 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
Bone Tumors
• Primary tumors
– Benign tumors are more common, generally 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
Nursing Process—Assessment of the Patient w a Bone Tumor
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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
Nursing Process—Postoperative Assessment of the Patient
With a Bone Tumor
• Postoperative assessment resembles that for a patient who has had orthopedic
surgery
• Motif VS, LOC, neurovascular status, and pain
• Assess for signs and symptoms of complications
• Monitor laboratory results: WBC and serum calcium level
• Assess for signs and symptoms of hypercalcemia
Nursing Process—Diagnosis of the Patient w a Bone Tumor
• Deficient knowledge
• Acute and chronic pain
• Risk for injury
• Ineffective coping
• Risk for situational low self-esteem
Collaborative Problems/Potential Complications
• Delayed wound healing
• Nutritional deficiency
• Infection
• Hypercalcemia
Nursing Process—Planning the Care of the Patient
With a Bone Tumor
• Major goals include knowledge of disease process and treatment regimen,
control of pain, absence of pathologic fractures, effective coping patterns,
improved self-esteem, and absence of complications
Interventions
• Care is similar to that of other patients who have undergone orthopedic surgery
• Provide patient and family teaching regarding diagnosis, disease process, and
treatment
• Prevent 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 assistive devices
• Promote proper nutrition
– Administer antiemetics as prescribed
– Implement relaxation techniques
– Provide oral care
– Administer nutritional supplements
• Provide adequate hydration
• Use strict aseptic technique
Chapter 69
Ch 69
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Management of Patients With Musculoskeletal
Trauma
Injuries of the Musculoskeletal System
• Contusion: soft tissue injury produced by blunt force
– Pain, swelling, and discoloration: ecchymosis
• Strain: pulled muscle-injury to the musculocutaneous unit
– Pain, edema, muscle spasm, ecchymosis, and loss of function are on a
continuum graded 1st , 2nd, and 3rd degree
• Sprain: injury to ligaments and supporting muscle fiber around a joint
– Joint is tender and movement is painful; edema, disability, and pain
increase during the first 2 to 3 hours
• Dislocation: articular surfaces of the joint are not in contact
– A traumatic dislocation is an emergency with pain change in contour,
axis, and length of the limb and loss of mobility
Common Sports-Related Injuries
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Contusions, strains, sprains, and dislocations
Tendonitis: inflammation of a tendon by overuse
Meniscal injuries of the knee occur with excessive rotational stress
Traumatic fractures
Stress fractures
Prevention of Sports-Related Injuries
• Use of proper equipment: running shoes for runners, wrist guards for skaters, etc.
• Effective training and conditioning specific for the person and the sport
• Stretching prior to engaging in a sport or exercise has been recommended but may
not prevent injury
• Changes in activity and stresses should occur gradually
• Time to “cool down”
• Tune in to the body; be aware of limits and capabilities
• Modify activities to minimize injury and promote healing
Occupational-Related Injuries
• Common injuries include strains, sprains, contusions, fractures, back injuries,
tendonitis, and amputations
• Prevention measures include personnel training, proper use of equipment,
availability of safety and other types of equipment (patient lifting equipment, back
belts), correct use of body mechanics, and institutional policies
Types of Fractures
• Complete or Incomplete
• Closed or simple
• Open or compound/complex
– Grade I, Grade II. or Grade III
Types of Fractures
Manifestations of Fracture
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Pain
Loss of function
Deformity
Shortening of the extremity
Crepitus
Local swelling and discoloration
Diagnosis by symptoms and x-ray
Patient usually reports an injury to the area
Emergency Management
• Immobilize the body part
• Splinting: joints distal and proximal to the suspected fracture site must be
supported and immobilized
• Assess neurovascular status before and after splinting
• Open fracture: cover with sterile dressing to prevent contamination
• Do not attempt to reduce the fracture
Medical Management
• Reduction
– Closed
– Open
• Immobilization: internal or external fixation
• Open fractures require treatment to prevent infection
– Tetanus prophylaxis, antibiotics, and cleaning and debridement of wound
– Closure of the primary wound may be delayed to permit edema, wound drainage,
further assessment, and debridement if needed
Techniques of
Internal Fixation
Nursing Management of the Patient With a Simple Fracture
• Assessment: include neurovascular assessment, pain, activity limitations, patient
knowledge, and home environment and support
• Goal is to have patient return to usual activities as soon as possible
• Patient teaching is a primary intervention as the patient will usually be cared for in
the home setting
• See Chart 69-2
Complications of Fractures
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Factors that affect fracture healing: see Chart 69-3
Shock
Fat embolism
Compartment syndrome
Delayed union and nonunion
Avascular necrosis
Reaction to internal fixation devices
Complex regional pain syndrome (CRPS)
Heterotrophic ossification
Wick Catheter Used to Monitor
Compartment Pressure
Bone Healing Stimulator
A hallmark sign of acute compartment syndrome is pain that occurs or intensifies with
passive ROM. This pain can be caused by (1) a reduction in the size of the muscle
compartment because the enclosing muscle fascia is too tight or a cast or dressing
is constrictive or (2) an increase in compartment contents because of edema or
hemorrhage.
Rehabilitation Related to Specific Fractures
• Clavicle
– Use of claviclar strap (“figure 8”) or sling
– Exercises
– Limitation of activities
– Do not elevate arm above shoulder for approximately 6 weeks
• Humeral neck and shaft fractures
– Slings and bracing
– Activity limitations and pendulum exercises
Fracture of Clavicle and
Immobilization Device
Immobilizers for Proximal
Humeral Fractures
Prescribed Shoulder Exercises
(Clavicle Fractures)
Functional Humeral Brace
Rehabilitation Related to Specific Fractures
• Elbow fractures
– Monitor regularly for neurovascular compromise and signs of compartment
syndrome
– Consider potential for Volkmann's contracture: see Chart 69-4
– Encourage active exercises and ROM to prevent limitation of joint movement
after immobilization and healing (4 to 6 weeks for nondisplaced, casted) or after
internal fixation (about 1 week)
• Colles’ fracture
– Early functional rehabilitation exercises
– Active motion exercises of fingers and shoulder
• Pelvic fractures
– Management depends upon type and extent of fracture and associated injuries
– Stable fractures are treated with a few days’ bed rest and symptom management
– Early mobilization reduces problems related to immobility
• Hip fracture
– Surgery is usually done to reduce and fixate the fracture
– Care is similar to that of a patient undergoing other orthopedic surgery or
hip replacement surgery
Stable Pelvic Fractures
Unstable Pelvic Fractures
Regions of the
Proximal Femur
Examples of Internal Fixation
for Hip Fractures
Rehabilitation Related to Specific Fractures
• Femoral shaft fractures
– Lower leg, foot, and hip exercises to preserve muscle function and
improve circulation
– Early ambulation stimulates healing
– Physical therapy, ambulation, and weight bearing are prescribed
– Active and passive knee exercises are begun as soon as possible to
prevent restriction of knee movement
• Uncomplicated rib fractures
– Chest strapping is not used
– Encouraged to cough and deep breathe
• Thoracolumbar spine fractures
– Usually treated conservatively with limited bed rest
– Avoid sitting
– Progressive ambulation
– Emphasize good posture and body mechanics
- Implement back strengthening exercises
Femoral Fractures
Stretch Spica Wrap
Nursing Process—Assessment of the Patient With Fracture
of the Hip
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Health history and presence of concomitant problems
Pain
VS, respiratory status, LOC, and signs and symptoms of shock
Affected extremity including frequent neurovascular assessment
Bowel and bladder elimination, bowel sounds, and I&O
Skin condition
Anxiety and coping
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Acute pain
Impaired physical mobility
Impaired skin integrity
Risk for impaired urinary elimination
Risk for ineffective coping
Risk for disturbed thought processes
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Hemorrhage
Peripheral neurovascular dysfunction
DVT
Pulmonary complications
Pressure ulcers
Nursing Process—Diagnosis of the Patient With Fracture of
the Hip
Collaborative Problems/Potential Complications
Nursing Process—Planning the Care of the Patient With
Fracture of the Hip
• Major goals include pain relief; achievement of a pain-free, functional, and
stable hip; healed wound; maintenance of normal urinary elimination
pattern; use of effective coping mechanisms; an oriented patient who
participates in decision making; and absence of complications
Relief of Pain
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Administer analgesics as prescribed
Use of Buck’s traction as prescribed
Handle extremity gently
Support extremity with pillows and when moving
Position for comfort
Provide frequent position changes
Provide alternative pain relief methods
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Maintain neutral position of hip
Use trochanter rolls
Maintain abduction of hip
Implement isometric, quad-setting, and gluteal- setting exercises
Use trapeze
Use ambulatory aids
Consult with physical therapy
Prompting Physical Mobility
Interventions
• Use aseptic technique with dressing changes
• Avoid/minimize use of indwelling catheters
• Support coping
– Provide and reinforce information
– Encourage the patient to express concerns
– Support coping mechanisms
– Encourage the patient to participate in decision making and planning
– Consult social services or other supportive services
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Orient patient to and stabilize the environment
Provide for patient safety
Encourage participation in self-care
Encourage coughing and deep breathing exercises
Ensure adequate hydration
Apply TED hose or SCDs as prescribed
Encourage ankle exercises
Provide patient and family teaching
Rehabilitation of Patients With Amputation
• Amputation may be congenital, traumatic, or due to conditions such as
progressive peripheral vascular disease, infection, or malignant tumor
• Amputation is used to relieve symptoms, improve function, and save the
person's life
• The health care team needs to communicate a positive attitude to facilitate
acceptance and participation in rehabilitation
Levels of Amputation
Rehabilitation Needs
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Psychological support
Prosthesis fitting and use
Physical therapy
Vocational/occupational training and counseling
Use a multidisciplinary team approach
Patient teaching: see Chart 69-6
Nursing Process—Assessment of the Patient With an
Amputation
• Assess neurovascular status and function of affected extremity or residual
limb and of unaffected extremity
• Assess for signs and symptoms of infection
• Determine nutritional status
• Assess concurrent health problems
• Determine psychological status and coping
Nursing Process—Diagnosis of the Patient With an
Amputation
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Acute pain
Risk for disturbed sensory perception
Disturbed body image
Ineffective coping
Risk for anticipatory or dysfunctional grieving
Self-care deficit
Impaired physical mobility
Collaborative Problems/Potential Complications
• Postoperative hemorrhage
• Infection
• Skin breakdown
Nursing Process—Planning the Care of the Patient With an
Amputation
• Major goals include relief of pain, absence of altered sensory perceptions,
wound healing, acceptance of altered body image, resolution of grieving
processes, restoration of physical mobility, and absence of complications
Interventions
• Relief of pain
– Administer analgesic or other medications as prescribed
– Change position
– Put a light sandbag on residual limb
– Alternative methods of pain relief: distraction; TENS unit
 Pain may be an expression of grief and altered body image
• Promote wound healing
– Handle limb gently
– Provide residual limb shaping
Wrapping of Leg After
Above-the-Knee Amputation
Wrapping of Arm After Above
-the-Elbow Amputation
Resolving Grief and Enhancing Body Image
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Encourage communication and expression of feelings
Create an accepting, supportive atmosphere
Provide support and listen
Encourage the patient to look at, feel, and care for the residual limb
Help the patient set realistic goals
Help the patient resume self-care and independence
Provide referral to counselors and support groups
Achieving Physical Mobility
• Provide proper positioning of limb; avoid abduction, external rotation, and
flexion
• Turn the patient frequently; use prone position if possible
• Use assistive devices
• Implement ROM exercises
• Implement muscle strengthening exercises
• Provide “preprosthetic care”: proper bandaging, massage, and “toughening”
of the residual limb
*** Following an amputation, the residual limb should not be placed on a pill
because a flexion contracture of the hip may result.