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Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 18: Care of Patients with Arthritis
and Other Connective Tissue Diseases; Key Points
Priority concepts applied in this chapter are PAIN, MOBILITY, INFECTION, IMMUNITY, and
INFLAMMATION.
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Connective tissue disease (CTD) is the major focus of rheumatology, the study of rheumatic
disease.
A rheumatic disease is any disease or condition involving the musculoskeletal system.
Most connective tissues diseases are classified as autoimmune disorders.
In autoimmune disease, the immune system does not recognize body cells as self and therefore
triggers an immune response; antibodies attack healthy normal cells and tissues.
Most autoimmune diseases are characterized by chronic PAIN and joint deterioration, which results in
decreased function and impaired MOBILITY.
The usual protective nature of the immune system does not function properly in patients with
autoimmune connective tissue disorders.
Be aware that most of the CTDs and arthritic disorders have a genetic basis as part of their etiology;
most are also classified as autoimmune diseases and have remissions and exacerbations.
OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS
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Osteoarthritis is primarily a noninflammatory degenerative joint disease, whereas rheumatoid
arthritis (RA) is an inflammatory systemic disease.
Older patients have osteoarthritis more than younger patients.
Younger patients have rheumatoid arthritis more than older adults.
IMMUNITY and INFLAMMATION factors cause cartilage damage in patients with RA.
Assess for visual complaints, indicating possible giant cell arteritis, in patients with polymyalgia
rheumatica and report changes immediately to the health care provider.
Be aware that arthritis often accompanies other diseases, such as psoriasis, Crohn’s disease, and
hemophilia.
Assess patients with rheumatoid arthritis for early or late clinical manifestations.
The presence of INFLAMMATION in patients with osteoarthritis indicates a secondary synovitis.
About half of patients with osteoarthritis who have hand involvement have Heberden’s nodes and
Bouchard’s nodes.
Collaborate with the health care team to manage chronic PAIN and increase MOBILITY for patients
with arthritis and other CTDs.
The purpose of drug therapy is to reduce PAIN and secondary joint INFLAMMATION.
Teach patients who have osteoarthritis or are prone to the disease to eat a well-balanced diet, follow
a weight reduction program if obese, avoid trauma, and limit strenuous weight-bearing activities.
Teach arthritic patients about the benefits of exercise, joint protection techniques, and energy
conservation guidelines.
Instruct patients with arthritic PAIN to use multiple modalities for pain relief, including ice/heat, rest,
positioning, complementary and alternative therapies, and medications as prescribed.
Assess for therapeutic effects of drugs used for arthritis and CTDs. Teach patients to monitor and
report side and adverse effects.
Implement interventions to prevent venous thromboembolic complications, for example,
anticoagulants, exercises, and sequential compression devices.
Observe the patient for bleeding when he or she is taking anticoagulants.
Teach patients who are taking hydroxychloroquine (Plaquenil) to have frequent (every 6 months)
eye examinations to monitor for retinal changes.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Administer biological response modifiers (BRMs) and other disease-modifying agents with
caution.
 Be aware that disease-modifying antirheumatic drugs (DMARDs) and BRMs slow the
progression of CTDs, especially RA and systemic lupus erythematosus (SLE).
 Recognize that patients with rheumatoid arthritis may have body image disturbance as a result of
potentially deforming joint involvement and nodules.
 Remind patients to avoid crowds and other possible sources of infection when they are taking
immunosuppressant drugs.
 Implement interventions for patients having total joint arthroplasty (TJA) to prevent venous
thromboembolic complications (e.g., anticoagulants, exercises, sequential compression devices);
observe the patient for bleeding when he or she is taking anticoagulants, and have all necessary
dental procedures done prior to surgery to avoid INFECTION.
 Be careful when positioning a patient after a total hip arthroplasty to prevent partial dislocation
(subluxation) or total dislocation; do not hyperflex the hips or adduct the legs. An abduction pillow
is placed between the patient’s legs to prevent adduction.
 Monitor for signs of INFECTION post surgery, such as elevated temperature and foul-smelling
draining. Exercise caution with older adults who may not have a fever but may experience an
altered mental state. Obtain a sample of drainage for culture and sensitivity to determine causative
organism.
 Frequent neurovascular checks are indicated for any surgical total joint arthroplasty.
 Encourage patients with arthritis and connective tissue diseases to discuss their chronic illness and
PAIN and identify coping strategies that have previously been successful.
 The goal for patients with osteoarthritis A is to maintain or improve a level of MOBILITY and activity
that allows functioning as independently as possible.
 Provide information about community resources for patients, especially professional organizations
such as the Arthritis Foundation.
LUPUS ERYTHEMATOSUS-FOR FUTRE BLOCKS
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The two main classifications of lupus are discoid lupus erythematosus and systemic lupus
erythematosus (SLE).
Thought to be an autoimmune disorder, SLE is a chronic, progressive, inflammatory CTD that can
cause major body organs and systems to fail. It is characterized by spontaneous remissions and
exacerbations (“flare-ups”), and the onset may be acute or insidious (slow).
Prioritize care for patients with SLE by monitoring for life-threatening complications, such as renal
failure and pericarditis.
Differentiate clinical manifestations and prognosis for patients with SLE versus systemic sclerosis.
Manifestations of SLE can include a dry, scaly “butterfly” rash on the face, discoid lesions,
alopecia, polyarthritis, and joint changes. Osteonecrosis, most often affecting the hip, results in PAIN
and decreased MOBILITY.
Teach patients with lupus to avoid sunlight since exacerbations of the disease may be triggered.
Psychosocial implications are significant appearance of the butterfly rash or the consequences of
chronic steroid use. Chronic fatigue and weakness can impact social interaction, and the
unpredictability can cause fear and anxiety.
SYSTEMIC SCLEROSIS-FOR FUTRE BLOCKS
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Differentiate clinical manifestations and prognosis for patients with systemic sclerosis (SSc) versus
SLE.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Prioritize care by assessing for swallowing ability in patients who have systemic sclerosis and
collaborate with the nutritionist for food modifications if needed.
GOUT
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Monitor for acute joint inflammation in patients with a history of gout; the great toe and other small
joints are most typically affected.
Joint INFLAMMATION is the most common finding in gout.
Remind patients with gout to avoid factors that trigger an attack, such as aspirin, organ meats, and
alcohol.
OTHER CONNECTIVE TISSUE DISEASES - FOR FUTURE BLOCKS
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Recognize that patients with fibromyalgia syndrome (FMS) have a chronic PAIN syndrome and are
often frustrated because they have not been diagnosed or have been misdiagnosed.
Teach patients with fibromyalgia and chronic fatigue syndrome that antidepressant drugs can
promote sleep and decrease pain as well as prevent or treat the depression that is common with these
illnesses.
Teach people ways to prevent or detect early Lyme disease.
Ankylosing spondylitis is also known as Marie-Strümpell disease or rheumatoid spondylitis.
The disease affects the vertebral column and causes spinal deformities. Other features include iritis,
arthritis or arthralgia, and nonspecific systemic manifestations such as malaise and weight loss.
Remind patients to avoid crowds and other possible sources of infection when they are taking
immunosuppressant drugs.
Monitor and interpret laboratory test results for patients with autoimmune CTDs.
In summary:
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Collaborate with the health care team to manage chronic PAIN and increase MOBILITY for patients
with arthritis and other CTDs.
Reinforce the importance of good health practices, such as adequate sleep, proper nutrition, regular
exercise, and stress-management techniques for patients with arthritis and other CTDs.
Encourage patients with arthritis and CTDs to discuss their chronic illness and identify coping
strategies that have previously been successful.
Be aware that chronic, painful diseases affect the patient’s quality of life and role performance.
Provide information about community resources for patients, especially professional organizations
such as the Arthritis Foundation and Lupus Foundation.
Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 49: Assessment of the
Musculoskeletal System; Key Points
Priority concepts applied in this chapter are MOBILITY, PAIN, and SENSORY PERCEPTION.
ANATOMY AND PHYSIOLOGY REVIEW
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The musculoskeletal system is the second largest body system and includes the bones, joints, and
skeletal muscles, as well as the supporting structures.
MOBILITY is a basic human need that is essential for performing activities of daily living (ADLs).
Disease, surgery, and trauma can affect one or more parts of the musculoskeletal system, often
leading to decreased mobility.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 When a patient suffers from obesity or other physical limitations and cannot move to perform ADLs
or other daily routines, self-esteem and a sense of self-worth can be diminished.
 When MOBILITY is impaired for a long time, other body systems can be affected, leading to skin
breakdown, constipation, and thrombus formation.
 If nerves are damaged by trauma or disease, patients may also have problems with SENSORY
PERCEPTION (sensation).
 The skeletal system consists of 206 bones and multiple joints.
 Bone can be classified in two ways, by shape and by structure.
o Long bones, such as the femur, are cylindrical with rounded ends and often bear weight.
o Short bones, such as the phalanges, are small and bear little or no weight.
o Flat bones, such as the scapula, protect vital organs and often contain blood-forming cells.
o Bones that have unique shapes are known as irregular bones.
 Bones are also classified by structure or composition.
o The outer layer of bone, or cortex, is composed of dense, compact bone tissue.
o The inner layer, in the medulla, contains spongy, cancellous tissue.
o The softer, cancellous tissue contains large spaces or trabeculae, which are filled with red and
yellow marrow.
o Hematopoiesis occurs in the red marrow.
o The yellow marrow contains fat cells, which can be dislodged and enter the bloodstream to
cause fat embolism syndrome, a life-threatening complication.
o Bone also contains a matrix called osteoid, consisting chiefly of collagen,
mucopolysaccharides, and lipids.
 The skeletal system provides a framework for the body and allows the body to be weight bearing
(upright), supports the surrounding tissues, assists in movement, protects vital organs, manufactures
blood cells, and provides storage for mineral salts.
 Numerous minerals and hormones affect bone growth and metabolism.
 A joint is a space in which two or more bones come together, called articulation of the joint.
 The major function of a joint is to provide movement and flexibility in the body.
 There are three types of joints in the body:
o The first type is synarthrodial, which are completely immovable joints such as the cranium.
o The second type is amphiarthrodial. They are slightly movable joints, such as the pelvis.
o The third is diarthrodial or synovial, which are freely movable, such as the knee.
 There are three types of muscles in the body: smooth muscle, cardiac muscle, and skeletal muscle.
o Smooth, or non-striated, involuntary muscle is responsible for contractions of organs and
blood vessels and is controlled by the autonomic nervous system.
o Cardiac muscle, or striated, involuntary muscle, is also controlled by the autonomic nervous
system.
o Voluntary muscle is controlled by the central and peripheral nervous systems.
o Skeletal muscle enables the body and its parts to move.
 When bones, joints, and supporting structures are adversely affected by injury or disease, the adjacent
muscle and surrounding soft tissue is often involved, limiting mobility.
 Supporting structures for the muscular system include tendons and ligaments. Tendons attach
muscles to bones and ligaments attach bones to other bones at joints.
MUSCULOSKELETAL CHANGES ASSOCIATED WITH AGING
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Osteopenia, or decreased bone density, is most common in older adults, especially thin white
women. Severe osteopenia is also called osteoporosis.
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Key Points
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 Synovial joint cartilage can become less elastic and compressible as a person ages, leading to
osteoarthritis.
 The most common joints affected are the weight-bearing joints of the hip, knee, and cervical and
lumbar spine.
 Joints in the shoulder, arms, feet, and hands can be affected.
 As one ages, muscle tissue atrophy occurs.
ASSESSMENT METHODS
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Review previous or current illness or disease and medications, including long-term steroids, that
may affect musculoskeletal status.
Remember to inquire about the patient's ability to perform ADLs independently or if assistiveadaptive devices are used.
Determine if the current lifestyle is contributing to musculoskeletal health.
Weight-bearing activities such as walking for 30 minutes daily can reduce risk factors for
osteoporosis and maintain muscle strength.
Ask about allergies, particularly allergy to dairy products, and previous and current use of
medications.
Assess the patient’s support systems and coping mechanisms when musculoskeletal trauma or
disease affects his or her body image.
Ask about the patient’s occupation, because heavy manual labor may cause back injury and other
musculoskeletal trauma.
A brief review of the patient’s nutritional history helps determine any risks of inadequate nutrient
intake.
Obtaining a family history assists in identifying disorders that have a familial or genetic tendency.
o Osteoporosis and gout, for instance, often occur in several generations of a family.
The most common complaints of persons with a musculoskeletal problem are pain and weakness,
either of which can impair MOBILITY.
Data that are relevant to the patient’s presenting health problem include date and time of onset,
factors that cause or exacerbate the problem, intermittent or continuous nature, clinical symptoms
(including the pattern of their occurrence), measures that improve symptoms, and nature of pain.
Assess the patient’s PAIN intensity, quality, duration, and location.
Inquire what pain control measures, if any, are being utilized and ask if the measures control or
relieve the PAIN.
Assess the patient’s mobility, including gait, posture, and muscle strength.
Weakness may be related to individual muscles or muscle groups and may occur in proximal or
distal muscles or muscle groups.
o Proximal weakness may indicate myopathy (a problem in muscle tissue).
o Distal weakness may indicate neuropathy (a problem in nerve tissue).
Collaborate with the physical and/or occupational therapist to perform a complete musculoskeletal
assessment if indicated.
PAIN and deformity may limit physical MOBILITY and function.
For physical assessment of the musculoskeletal system, use inspection, palpation, and range of
motion to evaluate joint MOBILITY.
o During the skeletal assessment, notice the size, shape, tone, and strength of major skeletal
muscles.
o For each anatomic location, observe the skin for color, elasticity, and lesions that may relate
to musculoskeletal dysfunction.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
6-6
 Redness or warmth may indicate an inflammatory process and/or pressure injury to
skin.
o For an injury, perform a complete neurovascular assessment. If pulses are not palpable, use
a Doppler device to find pulses in the extremities.
 Since psychosocial issues of anxiety and depression are common with chronic pain and obesity, help
the patient to verbalize feelings related to loss and change in body image and assist in finding support
systems for psychosocial well-being.
Diagnostic Assessment – NICE TO KNOW
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Diagnostic testing assists with determination of the type and extent of the problem.
Laboratory tests can help identify bone and parathyroid gland function.
o Alkaline phosphatase (ALP) increases with bone or liver damage.
 The level of ALP is normally slightly increased in older adults.
o As a result of damage, the muscle tissue releases additional amounts of the following
enzymes, which increases serum levels:
 Creatine kinase, muscle type (CK-MM)
 Aspartate aminotransferase (AST)
 Aldolase (ALD)
 Lactate dehydrogenase (LDH)
Radiography (standard x-rays) is used to identify bone density, alignment, swelling, and intactness
of bones and joints. Soft-tissue involvement may be evident but not clearly differentiated.
o Consider the comfort of the client, especially the older adult, while in radiology, where the
temperature is cold and the surface when taking x-rays is hard.
Myelography involves the injection of contrast medium into the subarachnoid space of the spine to
view the vertebral column, intervertebral disks, spinal nerve roots, and blood vessels.
An arthrogram is an x-ray study of a joint after contrast medium (air or solution) has been injected
to enhance its visualization.
The bone scan is a radionuclide test (nuclear scan) in which radioactive material is injected for
viewing the entire skeleton. Not used as frequently today, it may be helpful in detecting hairline
fractures.
o The gallium and thallium scans are similar to the bone scan but are more specific and
sensitive in detecting bone problems.
Most joints are now studied by magnetic resonance imaging (MRI) and magnetic resonance
arthrography.
o Magnetic resonance arthrography combines arthrography and MRI. It is particularly useful
for diagnosing problems of the shoulder.
Computed tomography (CT) detects musculoskeletal problems, particularly those of the vertebral
column and joints.
Muscle biopsy is done for the diagnosis of atrophy, as in muscular dystrophy, and inflammation, as
in polymyositis.
Electromyography is used to evaluate diffuse or localized muscle weakness and often is
accompanied by nerve conduction studies for determining the electrical potential generated in an
individual muscle.
o Electromyography helps in the diagnosis of neuromuscular, lower motor neuron, and
peripheral nerve disorders.
o It is contraindicated for patients undergoing anticoagulant therapy.
o Teach the patient that mild discomfort can be expected during electromyography.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
6-7
 Arthroscopy may be used as a diagnostic test or a surgical procedure and consists of a fiberoptic
tube (arthroscope) inserted into a joint for direct visualization of the ligaments, menisci, and articular
surfaces of the joint.
o Although complications are not common, monitor and teach the patient to observe for
swelling, increased joint pain, thrombophlebitis, and infection.
o Evaluate the neurovascular status of the patient’s affected extremity after an arthroscopic
procedure as the priority for care.
 Monitor and document distal pulses, warmth, color, capillary refill, PAIN, movement,
and sensation of the affected extremity.
 Ask the patient questions to ensure safety before an MRI.
 Ask the patient about allergy to contrast media before diagnostic testing such as CT scans.
Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 50: Care of Patients with
Musculoskeletal Problems; Key Points
Priority concepts applied in this chapter are PAIN, MOBILITY, INFLAMMATION, and INFECTION.
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Musculoskeletal disorders include metabolic bone diseases, bone tumors and lesions, and a variety
of deformities and syndromes.
Almost all musculoskeletal health problems can cause the patient to have difficulty meeting the
human need of MOBILITY.
METABOLIC BONE DISEASES
Osteoporosis
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A major health problem, osteoporosis is a chronic metabolic disease in which bone loss causes
decreased density and increases the risk of fracture.
Often referred to as a silent thief, the first indication of osteoporosis in most people occurs as a
fracture, often of the hip, spine, or wrist.
Osteoporosis and osteopenia (low bone mass) occur when bone resorption activity is greater than
bone-building activity.
Primary osteoporosis is caused by a combination of genetic, lifestyle, and environmental factors.
Bone mineral density (BMD) determines bone strength.
Before and during the peak years, which are 25 to 30 years of age, osteoclastic activity and
osteoblastic activity work at the same rate.
After the peak years, bone resorption activity exceeds bone-building activity, and BMD decreases.
Density decreases rapidly in postmenopausal women as serum estrogen levels diminish.
Osteoporosis may result from changes in hormones or other diseases.
The focus of prevention is to decrease modifiable risk factors such as inadequate calcium and
vitamin D intake, smoking, alcohol intake, and sedentary lifestyles.
People who drink large amounts of carbonated beverages each day (over 40 ounces) are at high risk
for calcium loss and subsequent osteoporosis, regardless of age or gender.
Most patients are unaware that they have osteoporosis until they experience a fracture, the most
common complication of the disease.
Inspection and palpation of the vertebral column usually reveal the classic dowager’s hump or
kyphosis of the dorsal spine.
Back pain accompanied by tenderness and voluntary restriction of spinal movement suggests one or
more compression vertebral fractures, the most common type of osteoporotic fracture.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
6-8
 Standards for the diagnosis of osteoporosis are based on BMD testing that provides a T-score for the
patient. A T-score represents the number of standard deviations above or below the average BMD
for young, healthy adults.
 Dual x-ray absorptiometry is the most commonly used screening and diagnostic tool for measuring
bone mineral density.
 Vertebroplasty and kyphoplasty are minimally invasive procedures used to treat vertebral body
compression and fracture found in persons with osteoporosis.
 People with osteoporosis are at an increased risk for fracture if a fall occurs and can develop a fear
of falling (fallophobia), which prevents them from socializing or going outside their homes.
 Coordinate with health care team members when assessing patients with osteoporosis for risk for
falls.
 In coordination with physical and occupational therapists, educate the patient and family on home
safety when the patient has a metabolic bone disease, such as osteoporosis.
 Teach patients at risk for osteoporosis to minimize risk factors, such as stopping smoking,
decreasing alcohol intake, exercising regularly, and increasing dietary calcium.
 Remind patients at risk for osteoporosis to have regular screening tests, such as the dual x-ray
absorptiometry (DXA or DEXA) scan.
o The spine and hip are most often assessed when a central DXA (cDXA) scan is done.
o Used for community screening purposes, a peripheral DXA (pDXA) scan assesses BMD of
the heel, forearm, or finger.
 Instruct older adults to have at least 5 to 10 minutes of sun per week and to eat vitamin D–fortified
foods to prevent osteomalacia.
 Refer patients with genetic-associated diseases for genetic testing and counseling.
 Bisphosphonates (BPs) slow bone resorption by binding with crystal elements in bone, especially
spongy, trabecular bone tissue.
o BPs are the most common drugs used for the prevention and treatment of osteoporosis, but
some are also approved for Paget’s disease and hypercalcemia related to cancer.
o Three FDA-approved BPs—alendronate (Fosamax), ibandronate (Boniva), and risedronate
(Actonel)—are commonly used for the prevention and treatment of osteoporosis.
o The most recent additions to the BPs are IV zoledronic acid (Reclast) and IV pamidronate
(Aredia).
 Reclast is needed only once a year and Aredia is given every 3 to 6 months. Both
drugs have been linked to jaw osteonecrosis.
 Teach patients to have an oral assessment and preventive dentistry before beginning any BP therapy.
 Remind patients taking BPs to take them early in the morning, at least 30 to 60 minutes before
breakfast, with a full glass of water and to remain sitting upright during that time to prevent
esophagitis, a common complication of BP therapy.
 Raloxifene (Evista) is currently the only approved drug in the estrogen agonist/antagonists class and
increases BMD, reduces bone resorption, and reduces the incidence of osteoporotic vertebral
fractures.
o The drug should not be given to women who have a history of thromboembolism.
 A newer type of drug is denosumab (Prolia, Xgeva), a monoclonal antibody that has been approved
for treatment of osteoporosis when other drugs are not effective. Patients who already have a low
calcium level should not take the drug and, like other drugs used for osteoporosis, denosumab can
cause fractures.
 Refer patients with musculoskeletal problems to appropriate community resources, such as the Paget
Foundation and the National Osteoporosis Foundation.
Osteomalacia - FOR FUTURE BLOCKS
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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Osteomalacia is loss of bone related to a vitamin D deficiency caused by inadequate deposits of
calcium and phosphorus in the bone matrix.
It is the adult equivalent of rickets, or vitamin D deficiency, in children.
Normal remodeling and calcification of the bone is disrupted.
Osteomalacia can be caused by liver and pancreatic disorders, chronic kidney disease, and bone
tumors.
The major treatment for osteomalacia is vitamin D through dietary intake, sun exposure, and drug
supplements such as ergocalciferol.
Paget’s Disease of the Bone - FOR FUTURE BLOCKS
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Paget’s disease or osteitis deformans is a chronic metabolic disorder in which bone is excessively
broken down and reformed.
Bone matrix is structurally disorganized, resulting in bone weakness with increased risk of bowing
of long bones and fractures.
Two types of Paget’s disease can occur—familial and sporadic.
Teach patients the importance of genetics in familial Paget’s disease and refer them to the
appropriate genetic counseling resources.
Paget’s disease is second only to osteoporosis as one of the most common bone diseases in the
United States, affecting about 1 million people.
Eighty percent of patients with Paget’s disease are asymptomatic and discovered during a routine
laboratory or x-ray examination, with deformity confined to one bone.
In more severe cases, the manifestations are potentially fatal.
Bone PAIN and pathologic fractures may be the presenting clinical manifestation.
Increases in serum alkaline phosphatase and urinary hydroxyproline levels are the primary
laboratory findings indicating possible Paget’s disease.
X-rays reveal the presence of osteolytic lesions and enlarged bones with a radiolucent, or “punched
out,” appearance.
Radionuclide bone scan may be the most sensitive test. A radiolabeled BP is injected IV and shows
pagetic bone in areas of high bone turnover activity.
Computed tomography and magnetic resonance imaging are useful in the detection of cancerous
tumors, changes in the skull, and spinal cord or nerve compression.
OSTEOMYELITIS – FOR FUTRUE BLOCKS
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Bacteria, viruses, or fungi can cause bone INFECTION, known as acute or chronic osteomyelitis,
which can be a severe and difficult problem to treat.
Invasion by one or more pathogenic microorganisms stimulates the inflammatory response in bone,
producing vascular leak and edema.
Osteomyelitis is categorized as exogenous, in which infectious organisms enter from outside the
body, as in an open fracture; endogenous, in which organisms are carried in the bloodstream from
other areas of the body; or contiguous, when bone infection results from skin infection of adjacent
tissues.
o Bone INFECTION can result in chronic recurrence of infection, loss of function, amputation,
and even death.
o Bacterial invasion stimulates the inflammatory response in bone tissue and causes
INFLAMMATION.
o If bacteremia is present, septic shock may result and the patient may die.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Treatment of infection may be complicated further by the presence of methicillin-resistant
Staphylococcus aureus or other multidrug-resistant organisms.
 To prevent the transmission of infection, follow Contact Precautions when caring for patients with
an open wound associated with osteomyelitis.
 Teach family members or other caregivers in the home setting how to administer antimicrobials if
they are continued after hospital discharge or are used only at home.
BENIGN BONE TUMORS Nice to know
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Benign bone tumors are often asymptomatic and may be discovered on routine x-ray examination or
as the cause of pathologic fractures.
Tumors may arise from several types of tissues, including chondrogenic tumors from cartilage,
osteogenic tumors from bone, and fibrogenic tumors from fibrous tissue.
The most common benign bone tumor is the osteochondroma.
In addition to prescribing analgesics to reduce pain, nonsteroidal anti-inflammatory drugs are given
to inhibit prostaglandin synthesis that increases PAIN and INFLAMMATION.
BONE CANCER – FOR FUTURE BLOCKS
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Cancerous bone tumors may be primary or secondary.
Primary tumors occur most often in people between 10 and 30 years of age and make up a small
percentage of bone cancers.
Metastatic lesions most often occur in the older age group and account for most bone cancers.
Previous radiation therapy in the area is an increased risk factor.
Osteosarcoma, or osteogenic sarcoma, is a large tumor causing acute pain and swelling, and is the
most common primary malignant bone tumor.
Chondrosarcoma occurs most often in middle-aged and older people and has a better prognosis than
osteogenic sarcoma.
o In contrast to osteosarcoma, the patient with chondrosarcoma experiences dull PAIN and
swelling for a long period.
Fibrosarcomas can be divided into subtypes, of which malignant fibrous histiocytoma is the most
worrisome.
Primary tumors of the prostate, breast, kidney, thyroid, and lung are called bone-seeking cancers
because they spread to the bone more often than other primary tumors.
The major complications of reconstructive surgery, such as a joint replacement, are superficial and
deep wound INFECTION, dislocation or loosening of the implants, and rapid neurovascular
compromise.
For patients who have surgery for bone cancer, report postoperative manifestations of INFECTION,
dislocation, or neurovascular compromise to the surgeon promptly.
In addition to analgesics for local PAIN relief, chemotherapeutic agents and radiation therapy are
often administered to shrink the tumor.
A diagnosis of bone cancer is a major stressor that causes the patient and family or significant others
to grieve. Help identify available support systems as soon as possible.
Remember that managing the severe chronic pain is a priority for patients with metastatic bone
disease.
DISORDERS OF THE HAND Nice to know
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
6-11
 Dupuytren’s contracture, or deformity, is a slowly progressive thickening of the palmar fascia,
resulting in flexion contracture of the fourth and fifth fingers.
o This common problem usually occurs in older Euro-American men, in families, and can be
bilateral.
 A ganglion is a round, benign cyst, often found on a wrist or foot joint or tendon.
o Synovium degenerates, allowing the tendon sheath tissue to become weak and distended, and
pain often occurs.
o If surgery is warranted, patients should avoid strenuous activity for 48 hours after surgery
and report any signs of INFLAMMATION.
DISORDERS OF THE FOOT Nice to know
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The hallux valgus deformity is a common foot problem in which the great toe deviates laterally at
the first metatarsophalangeal joint, resulting in a bunion.
o This occurs as a result of poorly fitted shoes, osteoarthritis, rheumatoid arthritis, and family
history.
o Women are affected more often than men.
In Morton’s neuroma, or plantar digital neuritis, a small tumor grows in a digital nerve of the foot,
causing an acute, burning PAIN sensation in the web space.
Plantar fasciitis is an INFLAMMATION of the plantar fascia in the area of the arch of the foot, often
occurring in middle-aged and older adults, as well as in athletes.
Be aware that even minor hand and foot problems can be very painful.
SCOLIOSIS FOR FUTURE BLOCKS
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Scoliosis occurs when the vertebrae rotate and begin to compress, and the spinal column moves into
a lateral curve, most commonly in the right lateral thoracic area.
o Congenital scoliosis occurs during embryonic development.
o Neuromuscular scoliosis can result from a neuromuscular condition in childhood or
adulthood, such as cerebral palsy or spinal cord tumors.
o Idiopathic scoliosis is the most common form.
Complete a thorough pain assessment for patients reporting back PAIN.
Either an anterior or posterior thoracic or abdominal approach may be used for surgical repair.
o Recognize that the patient having spinal reconstructive surgery will have a high level of
anxiety and pain.
o Be sure to remind the patient how to use the IV patient-controlled analgesia.
o Assist him or her when sitting up, standing, and walking for the first time.
o Collaborate with the physical therapist to improve mobility and ambulation.
PROGRESSIVE MUSCULAR DYSTROPHIES FOR FUTURE BLOCKS
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Muscular dystrophy (MD) can be categorized as slowly progressive or rapidly progressive, with
slowly progressive being more common in adults.
Assess the genetic risk for patients who have parents with MD. Recognize that most major types of
MD are genetic and manifest usually in childhood.
o The most common forms are Duchenne muscular dystrophy (DMD) and Becker muscular
dystrophy (BMD).
o Both are X-linked recessive disorders.
The primary problem is progressive muscle weakness. Respiratory and cardiac failure eventually
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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occur.
 Care is supportive.
 With the exception of steroids, no drug has been found to slow the progression of the disorder.
 In collaboration with the health care team, provide supportive care for the patient with MD.
Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 51: Care of Patients with
Musculoskeletal Trauma; Key Points
Priority concepts applied in this chapter are MOBILITY, SENSORY PERCEPTION, PAIN, PERFUSION,
and INFECTION.
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Musculoskeletal trauma is one of the primary causes of disability, ranging from simple muscle strain
to multiple bone fractures with severe soft-tissue damage.
Fractures and other musculoskeletal trauma impair a patient’s MOBILITY in varying degrees,
depending on the severity and extent of the injury.
These injuries also affect SENSORY PERCEPTION and PAIN because of pressure on nerve endings from
edema. In some cases, peripheral nerves are directly damaged as a result of musculoskeletal injury.
Injury is a definable, correctable event with specific identifiable risks.
An important role in nursing is educating the public about how to prevent musculoskeletal trauma
and other types of injuries.
FRACTURES
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A fracture is a break or disruption in the continuity of a bone that often affects MOBILITY and
SENSORY PERCEPTION.
The primary cause of a fracture is trauma from a motor vehicle accident or fall, especially in older
adults.
The trauma experienced may be a direct blow to the bone or an indirect force from muscle
contractions or pulling forces on the bone.
Sports, vigorous exercise, and malnutrition are contributing factors.
Bone diseases, such as osteoporosis, increase the risk of a fracture in older adults.
A fracture is classified by the extent of the break as complete or incomplete.
A fracture is described by the extent of associated soft-tissue damage as open (or compound) or
closed (or simple).
In young, healthy adult bone, healing takes about 4 to 6 weeks.
In the older person who has reduced bone mass and density, healing time is lengthened; complete
healing often takes 3 to 6 months.
Factors that affect healing include the severity of the trauma, the type of bone injured, type of
management, infections, and ischemic or avascular necrosis.
Hip fractures include those involving the upper third of the femur and are classified as
intracapsular (within the joint capsule) or extracapsular (outside the joint capsule). These types
are further divided according to fracture location.
After a hip repair, older adults frequently experience acute confusion, or delirium.
The primary nursing concern is assessment and prevention of neurovascular dysfunction or
compromise. Marked neurovascular compromise will significantly decrease arterial PERFUSION.
o Perform a thorough neurovascular assessment, evaluating circulation, movement, and
sensation (SENSORY PERCEPTION).
o Assess skin color and temperature, sensation, MOBILITY, PAIN, and pulses distal to the
fracture site.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Careful monitoring and assessment can often prevent the serious complications of acute
compartment syndrome, crush syndrome, hypovolemic shock, fat embolism syndrome, venous
thromboembolism, and INFECTION.
 Acute compartment syndrome causes decreased PERFUSION and further ischemia results.
o SENSORY PERCEPTION deficits or paresthesia usually appear first.
o The most common sites are the compartments in the lower leg and forearm.
o Identify the patient at risk, and loosen bandages or request that the patient’s cast be cut if
neurovascular compromise is noted.
 In fat embolism syndrome, more common in those with a fractured hip or fractured pelvis, fat
globules are released into the bloodstream and clog small vessels, often in the lungs, and impair
PERFUSION, resulting in respiratory failure or death.
o When the lungs are affected, the complication may be misdiagnosed as a pulmonary
embolism from a blood clot.
 Because some fractures (pelvic fractures) cause internal organ damage resulting in hemorrhage,
assess vital signs, skin color, and level of consciousness for indications of possible hypovolemic
shock. Bladder injury can be evidenced by hematuria.
 Chronic complications include ischemic necrosis and delayed union.
 When inspecting the site of a possible fracture, look for a change in bone alignment.
 Standard x-rays confirm a diagnosis of fracture, revealing the bone disruption, malalignment, or
deformity.
 Computed tomography (CT) scanning is useful for fractures of complex structures, such as the hip
and pelvis, and in identifying compression fractures of the spine.
 Magnetic resonance imaging (MRI) is useful in determining the amount of soft-tissue damage that
may have occurred with the fracture and in visualizing avascular necrosis.
 Provide appropriate cast care, depending on the type of cast (plaster or synthetic). Check for
pressure necrosis under the cast by feeling for heat, assessing the patient’s PAIN level, and smelling
the cast for an unpleasant odor.
 Venous thromboembolism includes deep vein thrombosis and its major complication, pulmonary
embolism. It is the most common complication of lower extremity surgery or trauma and the most
often fatal complication of musculoskeletal surgery.
 Wound INFECTIONS are the most common type of INFECTION resulting from orthopedic trauma.
o Bone INFECTION, or osteomyelitis, is most common with open fractures after surgical repair
of a fracture.
o The risk for hospital-acquired infections is increased, with many from multidrug-resistant
organisms, such as methicillin-resistant Staphylococcus aureus (MRSA).
o Reducing MRSA infections is a primary desired outcome for all health care agencies.
 Potential complications related to severe impairment in MOBILITY include skin breakdown,
respiratory dysfunction (such as pneumonia and atelectasis), constipation, joint contractures, and cast
syndrome.
 Emergency care of traumatic fractures often begins in the field with a primary survey, including
calling 911 and starting an assessment of airway, breathing, and circulation (ABCs).
o Cardiopulmonary resuscitation is provided before focusing on a fracture.
o Remove any clothing from the fracture site, and jewelry from the affected extremity.
o Control bleeding and prevent shock.
o In the emergency department, fracture management begins with reduction and
immobilization of the fracture, while attending to continued pain assessment and
management of the patient’s injury.
 Traction is the application of a pulling force to a part of the body to provide reduction, alignment,
and rest or to decrease muscle spasm and prevent or correct deformity and tissue damage.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Although not used as often today, the two most common types of traction are skin and skeletal
traction.
o The primary purpose of skin traction is to decrease painful muscle spasms that accompany
hip fractures, which involves the use of a Velcro boot (Buck’s traction) secured around the
affected leg.
 A weight is used as a pulling force, which is limited to 5 to 10 pounds to prevent
injury to the skin.
 Weights should be freely hanging at all times and are usually not removed without a
prescription.
o Skeletal pins or wires can be inserted through the skin and into bone (e.g., halo traction) for
the purpose of skeletal traction or external fixation.
o Provide pin care for patients with skeletal traction or external fixation; assess for
manifestations of INFECTION at the pin sites.
 Closed reduction and immobilization are the most common nonsurgical methods for managing a
simple fracture. While applying a manual pull on the bone, the health care provider moves the bone
ends so that they realign. An x-ray confirms that the bone ends are approximated before the bone is
immobilized, and a splint is usually applied to keep the bone in alignment.
 Open reduction with internal fixation (ORIF) is one of the most common methods of reducing
and immobilizing a fracture and is often the preferred surgical method for an older adult because it
provides early MOBILITY.
 Based on the knowledge that bone has electrical properties that are used in healing, noninvasive
electrical bone stimulation systems deliver a small continuous electrical charge on the skin or over
a cast to deliver a pulsed magnetic field.
 Bone grafting can be used to treat nonunion, to replace diseased bone, or to increase bone tissue for
joint replacement.
 Bone banking from living donors is becoming increasingly popular. If qualified, patients undergoing
total hip replacement may donate their femoral heads to the bank for later use as bone grafts for
others.
 Low-intensity pulsed ultrasound can be used for slow-healing fractures or for new fractures as an
alternative to surgery as ultrasound treatment has had excellent results with no reported
contraindications or adverse effects.
 Musculoskeletal PAIN related to soft-tissue damage, bone disruption, and muscle spasm is one of the
most severe types of pain that can be experienced.
 Commonly, opioid and non-opioid analgesics, anti-inflammatory drugs, and muscle relaxants are
prescribed.
 Assess the effectiveness of the analgesic and its side effects. Constipation is a common side effect of
opioid therapy, especially for older adults.
 Be aware that open fractures cause a higher risk for INFECTION than do closed fractures.
 Use strict aseptic technique when caring for wounds in patients with compound fractures to help
prevent INFECTION; give antibiotic therapy as prescribed.
 As a priority, assess PERFUSION with neurovascular checks frequently in patients with
musculoskeletal injury, traction, or cast.
 Assess the risk for and implement interventions to prevent complications of immobility in patients
having musculoskeletal injury or surgery, such as pressure ulcers or venous thromboembolism.
 Teach patients and their family members and significant others how to care for casts or traction at
home.
 Reinforce teaching for ambulating with crutches, walkers, or canes.
 Teach the patient to elevate the affected arm or leg and apply ice for the first 24 to 36 hours.
o Circulation impairment causing decreased PERFUSION and peripheral nerve damage can result
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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from tightness of the cast.
o Teach the patient to assess for circulation at least daily, including the ability to move the area
distal to the extremity, numbness, and increased PAIN.
o You should be able to insert a finger between the cast and the skin.
SELECTED FRACTURES OF SPECIFIC SITES
Fractures of the Hip
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Hip fracture is the most common injury in older adults and has a high mortality rate as a result of
multiple complications related to surgery, depression, and prolonged immobility.
Teach older adults about the risk factors for hip fracture, including physiologic aging changes,
disease processes, drug therapy, and environmental hazards.
The treatment of choice is surgical repair by ORIF. Skin (Buck’s) traction may be applied before
surgery to help decrease pain associated with muscle spasm.
Because of the postoperative complications of acute confusion or delirium in the older adult, monitor
patients carefully to prevent falls. Keep in mind that the patient can have a silent delirium.
To prevent hip dislocation or subluxation in the patient who has an ORIF, prevent hip adduction and
rotation with pillows or abduction devices to keep the operative leg in proper alignment.
Provide special care for older adults with hip fractures, including preventing heel pressure ulcers and
promoting early ambulation to prevent complications of immobility.
Compression Fractures of the Spine
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Compression fractures of the spine are associated with osteoporosis, metastatic bone lesions, and
multiple myeloma. Compression fractures are produced by a loading force applied to the long axis of
cancellous bone.
Minimally invasive surgeries can be done to manage the fractures.
With long-term, severe PAIN, the patient cannot depend solely on drugs for relief.
o Recommend temporary pain relief measures, such as ice or heat, depending on the cause of
the pain.
o If swelling causes pressure on the affected area, ice and elevation of the affected body part
may be appropriate.
o Teach the patient to plan activities that allow for rest and quiet periods.
o Muscle spasms are best relieved by application of heat and massage.
o Other physical measures include a warm, soothing bath; a back rub; and the use of
therapeutic touch.
o If these measures are not effective in reducing pain, distraction, imagery, or music therapy
may be used as an alternative.
AMPUTATIONS
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An amputation is the removal of a part of the body.
A traumatic amputation requires rapid emergency care to possibly save the severed body part for
reattachment and prevent hemorrhage.
Advances in microvascular surgical procedures and antibiotic therapy, and improved surgical
techniques for trauma and bone neoplasm, help to reduce the incidence of amputation.
The psychosocial aspects of the procedure are often more devastating than the physical impairments
that result since the loss is complete and permanent.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Collaborate with members of the health care team, including prosthetists, rehabilitation therapists,
psychologists, case managers, and physiatrists, when providing care to the patient who has an
amputation. Collaborate with the rehabilitation therapist to improve ambulation and/or enable the
patient to be independent in activities of daily living.
 The most common complications of elective or traumatic amputations are hemorrhage, infection,
phantom limb pain, neuroma, and flexion contractures.
 Phantom limb pain (PLP) is a frequent complication of amputation wherein sensation is felt in the
amputated part after surgery. It is more common in patients who had chronic limb pain before
surgery and rare in those who have traumatic amputations.
 Observe for hemorrhage and infection in the patient having an amputation.
 Postoperatively, assess for and promptly manage phantom limb pain in the patient who has an
amputation; collaborate with specialists to incorporate complementary and alternative therapies into
the patient’s plan of care.
 Teach exercises to patients with leg amputation to prevent hip flexion contractures.
 Several community organizations, such as the Amputee Coalition of America, are available to help
patients and their families cope with the loss of a body part.
 Recognize that the patient having an amputation may need to adjust to an altered lifestyle; however,
new custom prosthetics improve mobility.
 Help the patient with an amputation or other musculoskeletal trauma and the family to set realistic
outcomes and take one day at a time.
 Assess the patient’s feelings and coping abilities. Patients with severe musculoskeletal trauma may
have a prolonged hospitalization and recovery period, and the disruption in lifestyle can create a
significant degree of stress.
COMPLEX REGIONAL PAIN SYNDROME
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Complex regional pain syndrome (CRPS), formerly called reflex sympathetic dystrophy (RSD),
is a poorly understood dysfunction of the central and peripheral nervous systems that leads to severe,
chronic PAIN.
Often resulting from traumatic musculoskeletal injury, it commonly occurs in the feet and hands.
A triad of clinical manifestations is present, including abnormalities of the autonomic nervous
system (changes in color, temperature, and sensitivity of skin over the affected area; excessive
sweating; edema), motor symptoms (paresis, muscle spasms, loss of function), and sensory
symptoms (intense burning pain that becomes intractable [unrelenting]).
The first priority of management is PAIN relief, which includes drug therapy and a variety of
nonpharmacologic modalities.
Minimally invasive surgical sympathectomy, or cutting of the sympathetic nerve branches via
endoscopy through a small axillary incision, may be required.
Peripheral or spinal cord neurostimulation using an external or internal implanted device delivers
electrical pulses to block pain from getting to the brain, where pain is perceived.
o The external or acupuncture method requires weekly sessions or a short-term continuous trial
before the device is surgically implanted.
o Complications of implantable neurostimulators include spinal cord damage from hematoma
or edema formation or other neurologic dysfunction.
KNEE INJURIES Nice to know
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Patellofemoral pain syndrome (PFPS) is the most common diagnosis in patients who have knee
PAIN.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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o Sometimes referred to as “runner’s knee,” PFPS occurs most often in people who are runners
or who overuse their knee joints.
o Patients with this problem describe pain as being behind or around their patella (knee cap) in
one or both knees. Swelling is not common, although stiffness may be present, especially
when the knee is flexed.
o Management usually involves rest, physical therapy, bracing or splinting, and mild
analgesics.
 Torn meniscus is usually a result of twisting the leg when the knee is flexed and the foot is placed
firmly on the ground.
o The medial meniscus is much more likely to tear than the lateral meniscus because it is less
mobile.
o Internal rotation causes a tear in the medial meniscus, while external rotation causes a tear in
the lateral meniscus.
o Surgery is often required for this type of injury. Most surgeons prefer to remove only the
affected portion during a closed meniscectomy, which can be done through an arthroscope as
a same-day surgical procedure.
 The cruciate and collateral ligaments in the knee are predisposed to injury, often from sports or
vehicular crashes.
o The anterior cruciate ligament (ACL) is the most commonly torn ligament in the knee.
o Athletes often get these injuries during skiing, skating, or gymnastics.
o Women have ACL tears more often than men, possibly related to hormonal influences,
biomechanical factors, and anatomic differences.
o Treatment may be nonsurgical or surgical, depending on the severity of the injury and the
activity of the patient.
o Exercises, bracing, and limits on activities while the ligament heals may be sufficient.
o If medical management is not effective or the tear is severe, surgery may be needed.
CARPAL TUNNEL SYNDROME Nice to know
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Carpal tunnel syndrome (CTS) is a common condition in which the median nerve in the wrist
becomes compressed, causing PAIN and numbness.
CTS is the most common type of repetitive stress injury (RSI).
A medical diagnosis is often made on the basis of the patient’s history and report of hand pain and
numbness and without further assessment.
Phalen’s wrist test, sometimes called Phalen’s maneuver, produces paresthesia in the median
nerve distribution (palmar side of the thumb, index, and middle finger, and half of the ring finger)
within 60 seconds due to increased internal carpal pressure.
o The patient is asked to relax the wrist into flexion or to place the back of the hands together
and flex both wrists at the same time.
o The Phalen’s test is positive in most patients with CTS.
The same sensation can be created by tapping lightly over the area of the median nerve in the wrist
(Tinel’s sign).
Surgical treatment seems to be more effective than conservative measures over the long term.
There is no evidence that one type of procedure, open or endoscopic, is more effective.
TENDINOPATHY AND JOINT DISLOCATION Nice to know
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Other injuries can affect any synovial joint, including Achilles tendon–related injuries
(tendinopathy).
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Rupture of the Achilles tendon is common in adults who participate in strenuous sports or in women
who wear high heels regularly.
 It can also occur after taking fluoroquinolone antibiotics.
 In the older adult, quadriceps tendon rupture may occur from a fall down several steps.
 Most cases of Achilles tendinopathy can be treated with RICE:
o Rest
o Ice
o Compression
o Elevation
 Dislocation of a joint occurs when the ends of two or more bones are moved away from each other.
 The joint can also be partially dislocated, or subluxed, most commonly occurring in the shoulder,
hip, knee, and fingers.
 Usually due to trauma, dislocation can also be congenital or pathologic and can result from joint
disease, such as arthritis.
 The typical manifestations of dislocation are:
o PAIN
o Decreased MOBILITY
o Alteration in contour of the joint
o Deviation in length of the extremity
o Rotation of the extremity
 The joint can be surgically reduced (closed reduction) and immobilized until healing occurs.
 For recurrent dislocations, commonly in the knee and shoulder, the joint may be fixed with wires or
other device to prevent further displacement, then immobilized for 3 to 6 weeks.
STRAINS AND SPRAINS
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A strain is excessive stretching of a muscle or tendon when it is weak or unstable.
A first-degree mild strain usually causes mild inflammation, swelling, ecchymosis, and tenderness.
A second-degree or moderate strain involves tearing of the muscle or tendon fibers without complete
disruption, but that may impair muscle function.
A third-degree or severe strain involves a ruptured muscle or tendon with separation of muscle from
muscle, tendon from muscle, or tendon from bone, causing severe pain and disability. This causes
marked instability of the joint.
Mild sprains are treated with rest, use of ice for 24 to 48 hours, application of a compression
bandage for a few days, and elevation.
Second-degree sprains require immobilization, such as an elastic bandage and an air stirrup ankle
brace or splint, and partial weight bearing while the tear heals.
For severe ligament damage, immobilization for 4 to 6 weeks is necessary.
ROTATOR CUFF INJURIES Nice to know
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The patient with a torn rotator cuff has shoulder PAIN and cannot easily abduct the arm at the
shoulder.
Young adults usually sustain a tear of the cuff by substantial trauma, such as may occur during a fall,
while throwing a ball, or with heavy lifting.
Older adults tend to have small tears related to aging, repetitive motions, or falls, and the tears are
usually painless.
Muscle atrophy is commonly seen, and MOBILITY is reduced.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Diagnosis is confirmed with x-rays, MRI, ultrasonography, and/or CT scans.
 The patient with a partial-thickness tear is treated with nonsteroidal anti-inflammatory drugs,
intermittent steroid injections, physical therapy, and activity limitations while the tear heals.
o Surgical repair is done for those who do not respond to conservative treatment or have a
complete tear.
o After surgery, the affected arm is usually immobilized for several weeks.
o Teach patients that they may not have full function for several months.
Muscle mass and strength decrease with age and inactivity which leads to calcium lose in bones. It is
normal to lose 2-10% in height with age due to normal vertebral collapse.
For every day an older adult with chronic disease is on bedrest, it takes an average of 4 days to regain
strength. Deconditioning and functional decline will result starting on the second day of bedrest.
The number one fear of people over age 65 is the fear of falling and getting injured.
Ergonomic testing should be performed on patients. This involves the Egress Test (Get Up and Go).
Have the patient go from sitting to standing three times, then take three steps in place. The majority of
falls are predictable using the valid screening tools – we just don’t do that work enough!
Risk for falls with significant injury – think ABCS. Age/frailty, bone loss history, coagulation therapy,
and surgery recently.
90% of falls are not witnessed. 40% of these have injuries and 5% of those injuries are life threatening.
Osteoarthritis is not a normal part of aging. It is a result of repetitive stress injuries from chronic joint
tissue regrowth. It is also thought to be autoimmune in nature.
American College of Rheumatology also follows the Exercise is Medicine model.
Never lift anyone who weighs 10% or more of your own weight, even if they can assist you to the best
of their abilities. Always use safe patient handling and movement guidelines-use lifts!
Tumeric, ginger, and glucosamine may help with pain and inflammation associated with osteoarthritis.
But they must be used consistently for 60 days before any change is seen. And then a schedule must be
maintained. There is no evidence that magnets are helpful.
Hemiarthroplasty replaces only the ball of the femur.
For joint replacement, non-cement instrumentation is still preferred.
Total ankle joint replacements are becoming more popular. The joint is fitted into the tibia and the foot.
It has a plastic ball bearing that acts as a shock absorber and allows for full range of motion. The
incision is anterior to the ankle. After surgery, the ankle is splinted and a bone stimulator may or may
not be used. After a week in the splint, the joint is casted for 8 weeks. Then a boot is placed when the
cast is removed and physical therapy begins. The patients may need to be in a leg brace permanently.
Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 06: Rehabilitation Concepts for
Chronic and Disabling Health Problems; Key Points
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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Priority concepts applied in this chapter include NUTRITION, MOBILITY, ELIMINATION, COGNITION,
and TISSUE INTEGRITY.
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Rehabilitation is the process of learning to live with chronic and disabling conditions.
The most common settings for care are freestanding rehabilitation hospitals, rehabilitation units
within hospitals, and skilled nursing facilities.
Rehabilitation patients typically receive care for 1 to 3 weeks.
A chronic health problem is one that has existed for at least 3 months. Especially common chronic
conditions requiring rehabilitation are stroke, coronary artery disease, chronic obstructive pulmonary
disease, asthma, and arthritis.
A disabling health problem is any physical or mental health problem that can cause disability.
Chronic and disabling illnesses affect almost half of the population in the United States.
Complications of chronic disease account for the majority of all deaths, and associated medical costs
account for over two thirds of the nation’s health care cost.
The rate of chronic and disabling conditions is expected to increase as more “baby boomers”
approach late adulthood.
Younger adults are also living longer with potentially disabling congenital or genetic disorders,
which in the past would have shortened life expectancy.
Accidents are a leading cause of death among young and middle-aged adults.
Increasing accident survival rates mean that individuals are often faced with chronic or disabling
conditions, such as traumatic brain injuries and spinal cord injuries.
The main outcome of rehabilitation is that the patient will return to the best possible physical,
mental, social, vocational, and economic capacity.
Patients in a rehabilitation setting are managed by an interdisciplinary team of health care
professionals; the patient and family are also members of the team.
Collaborate with the rehabilitation health care team when planning and providing patient care.
PATIENT-CENTERED COLLABORATIVE CARE
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The focus of the rehabilitation team is to restore and maintain the patient’s function to the extent
possible.
Successful rehabilitation depends on the coordinated effort of a group of health care professionals,
the interdisciplinary rehabilitation team, and the involvement of the patient, family, and other
support systems in planning and implementing care.
In addition to the patient (resident), family, and/or significant others, members of the
interdisciplinary health care team in the rehabilitation setting may include:
o Physicians
o Nurses and nursing assistants
o Physical therapists and assistants
o Occupational therapists and assistants
o Speech-language pathologists and assistants
o Pharmacists
o Rehabilitation assistants/restorative aides
o Recreational or activity therapists
o Cognitive therapists or neuropsychologists
o Social workers or case managers
o Clinical psychologists
o Vocational counselors
o Spiritual care counselors
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
6-21
o Nutritionists (also called registered dietitians [RDs])
 A physician who specializes in rehabilitative medicine is called a physiatrist.
 As the coordinator of the patient’s care, the nurse collaborates with the rehabilitation health team
when planning and providing patient care to restore and maintain the patient’s function.
 Patients may not require the services of all health care team members. Patient assessment is a key
collaborative function.
o Collect the history of the patient’s present condition, any current drug therapy, and any
treatment programs in progress.
o Assess the patient’s usual daily schedule and habits of everyday living, including hygiene
practices, NUTRITION, ELIMINATION, sexual activity, and sleep.
o Collect the physical assessment data systematically according to major body systems, on
admission for baseline and every day.
o Assess associated signs and symptoms of decreased cardiac output or respiratory distress,
such as chest pain, shortness of breath, and fatigue.
o Fear associated with any inability to breathe normally can make a person dependent in many
aspects of life.
o Some disorders of the respiratory system can be resolved or diminished, but some chronic
diseases, such as emphysema, often continue to worsen.
 Determine when the patient experiences these symptoms and what relieves them.
 Determine the level of activity that can be accomplished without experiencing
shortness of breath.
o Monitor the patient’s oral intake and pattern of eating (NUTRITION), checking for the presence
of anorexia or dysphagia.
o The neurologic assessment includes motor function (MOBILITY), sensation, and COGNITION.
o Ask whether the patient can manage bowel function independently. Independence in bowel
elimination requires COGNITION, manual dexterity, sensation, muscle control, and MOBILITY.
o Ask about bowel and bladder function and the normal pattern of ELIMINATION. Constipation
is common problem for rehabilitation patients.
o Ask about the patient’s baseline urinary patterns (ELIMINATION), including the number of
times the patient usually voids. Determine whether he or she routinely awakens during the
night to empty the bladder or has uninterrupted sleep and other sleep habits, patterns, and
sleep aids.
o Neurologic assessment includes motor function, sensation, and COGNITION.
o Assess the patient’s pre-existing problems, general physical condition, cultural background,
and communication abilities (COGNITION).
o Evaluate COGNITION using a common tool such as the Brief Interview for Mental Status
(BIMS) or Confusion Assessment Method (CAM).
o Assess patients in rehabilitation for risk factors that make them likely to develop skin
breakdown. Identify actual or potential interruptions in TISSUE INTEGRITY. To maintain
healthy skin, the body must have adequate food (NUTRITION), water, and oxygen intake;
intact waste-removal mechanisms; sensation; and functional MOBILITY.
 Assess the patient’s psychosocial needs adequately through verbal indicators and descriptions of
self-care.
o Chronic or disabling health problems may cause changes in the patient’s self-esteem and
body image.
o Assess the patient’s self-esteem and changes in body image caused by chronic or disabling
health problems.
o Assess the patient’s and family’s response to chronic and disabling conditions, including
feelings of loss and grief, coping, and the availability of support systems.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Key Points
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 Functional ability refers to the ability to perform activities of daily living (ADLs), such as bathing,
dressing, feeding, and ambulating.
o Categories for assessment are self-care, sphincter control (ELIMINATION), MOBILITY and
locomotion, communication, and COGNITION.
o Independent living skills include activities such as using the telephone, shopping, preparing
food, and housekeeping.
o These skills are sometimes referred to as instrumental ADLs.
 In coordination with the physical and occupational therapists, the nurses assess the patient’s ability
to perform activities using a functional assessment process.
o Functional assessment tools are used to assess a patient’s abilities.
o The Functional Independence Measure (FIM) system is one assessment tool used to assess
functional ability of the patient in rehabilitation.
o As a basic indicator of the severity of a disability, the FIM attempts to quantify what the
person actually does, whatever the diagnosis or impairment.
o Similar to the FIM form, the Interdisciplinary Minimum Data Set is used to assess patients in
long-term care settings.
o The resident’s motor ability (MOBILITY), sensation, and COGNITION are evaluated, as well as
overall health status.
 Following assessment, the rehabilitation team devises a plan of care and education.
o Use evidence-based Safe Patient Handling practices when assessing and moving patients.
o The members of the interdisciplinary team teach patients transfer, bed MOBILITY, and gait
training techniques. Most problems requiring rehabilitation relate to decreased physical
MOBILITY.
o The patient is taught how to perform ADLs with or without using adaptive devices;
encourage the patient to be as independent as possible.
o Assess patients in rehabilitation for risk factors that make them likely to develop skin
breakdown (TISSUE INTEGRITY); interventions to prevent skin problems include re-positioning
and adequate NUTRITION.
o Prevent complications of immobility for the patient and teach patients and families how to
prevent complications (MOBILITY).
o Patients with neurogenic bladder and bowel problems (ELIMINATION) are managed by
training programs; overactive (spastic or reflex) and underactive (hypotonic or flaccid)
elimination problems are managed differently.
 Encourage the family to allow the patient to perform as many functions as possible independently to
promote feelings of self-worth.
 Evaluate the ability of patients to use assistive or adaptive devices to promote independence.
 After assessing the home environment, the case manager, occupational therapist, and rehabilitation
nurse make recommendations to the patient and family about home modifications.
 Vocational counselors can help the patient find meaningful training, education, or employment after
discharge from the rehabilitation setting.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.