Chapter 68
Management of Patients With
Musculoskeletal Disorders
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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
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Nursing Process—Assessment of the
Patient With Low Back Pain (cont.)
• 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
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Nursing Process—Diagnosis of the
Patient With Low Back Pain
• Acute pain
• Impaired physical mobility
• Risk for situational low self-esteem
• Imbalanced nutrition
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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
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Interventions
• 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
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Positioning to Promote Lumbar Flexion
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Proper and Improper Standing Postures
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Proper and Improper Lifting Techniques
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Common Conditions of the
Upper Extremities
• Bursitis and tendonitis
• Loose bodies
• Impingement syndrome
• Carpal tunnel syndrome
• Ganglion
• Dupuytren’s contracture
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Tinel’s Sign—Assessment of
Carpal Tunnel Syndrome
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Dupuytren’s Contracture
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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
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Nursing Care of the Patient Undergoing
Surgery of the Hand or Wrist (cont.)
• 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
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Common Foot Problems
• Plantar fasciitis
• Corn
• Callus
• Ingrown toenail
• Hammer toe
• Hallux valgus
• Claw foot: pes cavus
• Morton’s neuroma
• Flatfoot: Pes planus
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Common Foot Deformities
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Nursing Process—Assessment of the
Patient Undergoing Foot Surgery
• 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
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Nursing Process—Diagnosis of the Patient
Undergoing Foot Surgery
• Risk for ineffective peripheral tissue perfusion
• Acute pain
• Impaired physical mobility
• Risk for infection
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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
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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
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Interventions (cont.)
• 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
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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
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Progressive Osteoporosis Bone Loss and
Compression Fractures
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Typical Loss of Height Associated With
Osteoporosis and Aging
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Pathophysiology of Osteoporosis
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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
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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
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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
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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
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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
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Paget’s Disease (cont.)
• 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
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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
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Osteomyelitis (cont.)
• Prevention of osteomyelitis is the goal
• Early detection and prompt treatment of
osteomyelitis are required to reduce potential
for chronic infection and disability
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Nursing Process—Assessment of the
Patient With 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
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Nursing Process—Diagnosis of the
Patient With Osteomyelitis
• Acute pain
• Impaired physical mobility
• Risk for extension of infection: bone abscess
formation
• Deficient knowledge
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Nursing Process—Planning the Care of the
Patient With Osteomyelitis
• Major goals include relief of pain, improved
physical mobility within therapeutic limitations,
control and eradication of infection, and
knowledge of therapeutic regimen
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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
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Interventions (cont.)
• 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
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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
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Nursing Process—Assessment of the
Patient With a Bone Tumor
• 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
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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
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Nursing Process—Diagnosis of the
Patient With a Bone Tumor
• Deficient knowledge
• Acute and chronic pain
• Risk for injury
• Ineffective coping
• Risk for situational low self-esteem
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Collaborative Problems/Potential
Complications
• Delayed wound healing
• Nutritional deficiency
• Infection
• Hypercalcemia
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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
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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
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Interventions (cont.)
• Promote proper nutrition
– Administer antiemetics as prescribed
– Implement relaxation techniques
– Provide oral care
– Administer nutritional supplements
• Provide adequate hydration
• Use strict aseptic technique
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