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BY L-Manal Tharwat Abouzaied 2011-2012 On completion of this chapter, the learner will be able to: 1. Use the nursing process as a framework for care of the patient with low back pain. 2. Describe the rehabilitation and health education needs of the patient with low back pain. 3. Describe conditions of the upper extremities and nursing care of the patient undergoing surgery of the hand or wrist. 4. Use the nursing process as a framework for care of the patient undergoing foot surgery. 5. Explain the pathophysiology, pathogenesis, prevention, and management of osteoporosis. 6. Identify the causes and related medical management of osteomalacia. 7. Describe the medication therapy program for the patient with Paget’s disease. 8. Use the nursing process as a framework for care of the patient with osteomyelitis. 9. Use the nursing process as a framework for care of the patient with a bone tumor. Musculoskeletal disorders, such as impairment of the back and spine, are leading health problems and causes of disability, particularly in people during their employment years. The limitations imposed on the patient are severe, and the economic cost, ACUTE LOW BACK PAIN The number of medical visits resulting from low back pain is second only to the number of visits for upper respiratory illnesses. Most low back pain is caused by one of many musculoskeletal problems, including acute lumbosacral strain, unstable lumbosacral ligaments and weak muscles, osteoarthritis of the spine, spinal stenosis, intervertebral disk problems, and unequal leg Older patients may experience back pain associated with osteoporotic vertebral fractures or bone metastasis. Other causes include kidney disorders, pelvic problems, retroperitoneal tumors, abdominal aneurysms, and psychosomatic problems. The patient complains of either acute back pain or chronic back pain (lasting more than 3 months without improvement) and fatigue. The patient may report pain radiating down the leg, which is known as radiculopathy or sciatica and which suggests nerve root involvement. The patient’s gait, spinal mobility, reflexes, leg length, leg motor strength, and sensory perception may be altered. Physical examination may disclose paravertebral muscle spasm (greatly increased muscle tone of the back postural muscles) with a loss of the normal lumbar curve and possible spinal deformity. He The initial evaluation of acute low back pain includes a focused history and physical examination, including general observation of the patient, back examination, and neurologic testing (reflexes, sensory impairment, straight-leg raising, muscle strength, and muscle atrophy). The findings suggest either nonspecific back symptoms or potentially serious problems, such as sciatica, spine fracture, cancer, infection, or rapidly progressing neurologic deficit. If the initial examination does not suggest a serious condition, no additional testing is performed during t first 4 weeks of symptoms. Most back pain is self-limited and resolves within 4 weeks with analgesics, rest, stress reduction, and relaxation. Based on initial assessment findings, the patient is reassured that the assessment indicates that the back pain is not due to a serious condition. Management focuses on relief of pain and discomfort, activity modification, and patient education. Nonprescription analgesics (acetaminophen, ibuprofen) are usually effective in achieving pain relief. At times, a patient may require the addition of muscle relaxants or opioids. Heat or cold therapy frequently provides temporary relief of symptoms. In the absence of symptoms of disease (radiculopathy of the roots of spinal nerves), manipulation may be helpful. Glossary bursitis: inflammation of a fluid-filled sac in a joint contracture: abnormal shortening of muscle or fibrosis of joint structures involucrum: new bone growth around a sequestrum radiculopathy: disease of a nerve root sciatica: sciatic nerve pain; pain travels down back of thigh into foot sequestrum: dead bone in abscess cavity tendinitis: inflammation of muscle tendons X-ray of the spine—may demonstrate a fracture, dislocation, infection, osteoarthritis, or scoliosis Bone scan and blood studies—may disclose infections, tumors, and bone marrow abnormalities Computed tomography (CT scan)—useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral disks Magnetic resonance imaging (MRI)—permits visualization of the nature and location of spinal pathology Electromyogram (EMG) and nerve conduction studies—used to evaluate spinal nerve root disorders (radiculopathies) Assessment The nurse encourages the patient with low back pain to describe the discomfort (e.g., location, severity, duration, characteristics, radiation, associated weakness in the legs). If back pain is a recurrent problem, information about previous successful pain control methods helps in planning current management. The nurse also asks how the back pain affects the patient’s lifestyle. the nurse assesses the effect of chronic pain on the emotional wellbeing of the patient. Referral to a psychiatric nurse clinician for assessment and management of stressors contributing to the low back pain and related depression During the interview, the nurse observes the patient’s posture, position changes, and gait. Often, the patient’s movements are guarded, with the back kept as still as possible. The patient often selects a chair of standard seat height with arms for support. The patient may sit and stand in an unusual position, leaning away from the most painful side, and may ask for assistance when undressing for the physical examination. Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Acute pain related to musculoskeletal problems • Impaired physical mobility related to pain, muscle spasms, and decreased flexibility • Deficient knowledge related to backconserving techniques of body mechanics • Risk for situational low self-esteem related to impaired mobility, chronic pain, and altered role performance • Imbalanced nutrition: more than body requirements related to obesity The major goals for the patient may include relief of pain, improved physical mobility, use of backconserving techniques of body mechanics, improved self-esteem, and weight reduction To relieve pain, the nurse encourages the patient to reduce stress on the back muscles and to change position frequently. Patients are taught to control and modify the perceived pain through behavioral therapies that reduce muscular and psychological tension. Diaphragmatic breathing and relaxation help reduce muscle tension contributing to low back pain. Diverting the patient’s attention from the pain to another activity (eg, reading, conversation, watching television) may be helpful in some instances. Guided imagery, in which the relaxed patient learns to focus on a pleasant event, may be used along with other pain-relief strategies Physical mobility is monitored through continuing assessments. The nurse assesses how the patient moves and stands. As the back pain subsides, self-care activities are resumed with minimal strain on the injured structures. Position changes should be made slowly and carried out with assistance as required. Twisting and jarring motions are avoided. The nurse encourages the patient to alternate lying, sitting, and walking activities frequently and advises the patient to avoid sitting, standing, Discuss the following strategies with the patient: Pain Management • Limit bed rest; keep knees flexed to decrease strain on back • Non pharmacologic approaches: distraction, relaxation, imagery, thermal interventions (eg, ice or heat), stress reduction • Pharmacologic approaches: non steroidal anti-inflammatory drugs, analgesics, muscle relaxants Exercise • Stretch to enhance flexibility, do strengthening exercises • Perform prescribed back exercises to increase function, emphasizing gradual increases in time and repetitions Body Mechanics • Practice good posture • Avoid twisting body • Push objects rather than pull them • Keep load close to body when lifting • Bend knees and tighten abdominal muscles when lifting • Avoid overreaching • Use wide base of support • Use back brace to protect back Work Modifications • Adjust work area to avoid stress on back • Adjust height of chair or work table • Use lumbar support in chair • Avoid prolonged standing and repetitive tasks • Avoid bending, twisting, and lifting heavy objects • Avoid work involving continuous vibrations Stress Reduction • Discuss with patient the interdependence of stress and anxiety on muscle tension and pain • Explore effective coping mechanisms • Teach stress reduction techniques • Refer patient to back clinic Good body mechanics and posture are essential to avoid recurrence of back pain. The patient must be taught how to stand, sit, lie, and lift properly (Figs. 68-2 and 68-3). Providing the patient with a list of suggestions helps in making these long-term changes (Chart 68-3). The patient who wears high heels is encouraged The nurse instructs the patient in the safe and correct way to lift objects—using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles. With feet placed to provide a wide base of support, the patient should bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion, avoiding twisting and jerking. To prevent recurrence of acute low back pain, the nurse may instruct the patient to wear a back support when repeated lifting is required and to avoid lifting more than one third of his or her weight without help. Because of the immobility associated with low back pain, the patient may depend on others to do various tasks. Dependency may continue beyond physiologic needs and become a way to fulfill psychosocial needs. Assisting both the patient and support people to recognize continued dependency helps the patient identify and cope with the underlying reason for the dependency. Obesity contributes to back strain by stressing the relatively weak back muscles. Exercises are less effective and more difficult to perform when the patient is overweight. Weight reduction through diet modification may prevent recurrence of back pain. Weight reduction is based on a sound nutritional plan that includes a change in eating habits to maintain desirable weight. Expected patient outcomes may include the following: 1. Experiences pain relief a. Rests comfortably b. Changes positions comfortably c. Obtains relief through use of physical modalities, psychological techniques, and medications d. Avoids drug dependency 2. Demonstrates resumption of physical mobility a. Resumes activities gradually b. Avoids positions that cause discomfort and muscle spasm c. Plans recumbent rest periods throughout the day 3. Demonstrates back-conserving body mechanics a. Improves posture b. Positions self to minimize stress on the back c. Demonstrates use of good body mechanics d. Participates in exercise program 4. Resumes role-related responsibilities a. Uses coping techniques to deal with stressful situations b. Demonstrates decreased dependence on others for selfcare c. Resumes role responsibilities as low back pain resolves d. Resumes full, productive lifestyle 5. Achieves desired weight a. Identifies need to lose weight if appropriate b. Sets realistic goals c. Participates in development of weight-reduction plan d. Complies with weight-reduction regimen The structures in the upper extremity are frequently the sites of painful syndromes. The structures most frequently affected are the shoulder, wrist, and hand. Bursitis and tendinitis are inflammatory conditions that commonly occur in the shoulder. Bur= sae are fluid-filled sacs that prevent friction between joint structures during joint activity. When inflamed, they are painful. Similarly, muscle tendon sheaths become inflamed with repetitive stretching. The inflammation causes proliferation of synovial membrane and pannus formation, which restricts joint movement. Conservative treatment includes rest of the extremity, intermittent ice and heat to the joint, and nonsteroidal anti-inflammatory drugs Loose bodies may occur in a joint as a result of articular cartilage wear and bone erosion. These fragments interfere with joint movement, locking the joint, and cause painful movement. Loose bodies are removed by arthroscopic surgery. Overuse (micro trauma) may produce an impingement syndrome in the shoulder. The supra spinatus and biceps tendons become irritated and edematous and press against the a acromion process, limiting shoulder motion. The patient experiences pain, shoulder tenderness, limited movement, muscle spasm, and atrophy. The process may progress to a rotator cuff tear. Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass. The syndrome is commonly caused by repetitive hand activities but may be associated with arthritis, hypothyroidism, or pregnancy. The patient experiences pain, numbness, paresthesia, and possibly weakness along the median nerve (thumb and first two fingers). Tinsel's sign may be used to help identify carpal tunnel syndrome (Fig. 68-4). Night pain is common. Treatment is based on cause. Rest splints to prevent hyperextension and prolonged flexion of the wrist, avoidance of repetitive flexion of the wrist (eg, use of ergonomic changes at work to reduce wrist strain), NSAIDs, and carpal canal cortisone injections may relieve the symptoms. Specific yoga postures, relaxation, A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. It most frequently occurs in women younger than 50 years of age. The ganglion is locally tender and may cause an aching pain. When a tendon sheath The nurse provides guidelines for general care and instructs the patient in carrying out measures that will promote shoulder healing. Patient education includes the following points: • During the acute phase, rest the joint in a position that minimizes stress on the joint structures, to prevent further damage and the development of adhesions. • Support the affected arm on pillows while sleeping, to keep from turning onto the shoulder. • For the first 24 to 48 hours of the acute phase, apply cold to reduce swelling and discomfort; then, according to the treatment plan, apply heat intermittently to promote circulation and healing. • Gradually resume motion and use of the joint. Assistance with dressing and other activities of daily living may be needed. • Avoid working and lifting above shoulder level or pushing an object against a “locked” shoulder. • Perform the prescribed daily range-ofmotion and strengthening exercises. Dupuytren’s deformity is a slowly progressive contracture of the palmar fascia, which causes flexion of the fourth and fifth fingers, and frequently the middle finger. This renders the fingers more or less useless (Fig. 68-5). It is caused by an inherited autosomal dominant trait and occurs most frequently in men who are older than 50 years of age and who are of Scandinavian or Celtic origin. It is also associated with arthritis, diabetes, gout, and alcoholism. It starts as a nodule of the palmar fascia. The nodule may not change, or it may progress so that the fibrous thickening extends to involve the skin in the distal palm and produces a contracture of the fingers. The patient may experience dull aching discomfort, morning numbness, cramping, and stiffness in the affected fingers. This condition starts in one hand, but eventually both hands are affected symmetrically. Initially, finger stretching Assessment Surgery of the hand or wrist, unless related to major trauma, is generally an ambulatory surgery procedure. Before surgery, the nurse assesses the patient’s level and type of discomfort and limitations in function caused by the ganglion, carpal tunnel syndrome, Dupuytren’s contracture, or other condition of the hand Based on the assessment data, the nursing diagnoses for the patient undergoing surgery of the hand or wrist may include the following: • Risk for peripheral neurovascular dysfunction related to surgical procedure • Acute pain related to inflammation and swelling • Self-care deficit: bathing/hygiene, dressing/grooming, feeding,and/or toileting related to bandaged hands • Risk for infection related to surgical procedure The goals of the patient may include relief of pain, improved self care, and absence of infection. PROMOTING NEUROVASCULAR FUNCTION Neurovascular assessment of the exposed fingers every hour for the first 24 hours is essential for monitoring function of the nerves and perfusion of the hand. The nurse compares the affected hand with the unaffected hand and the postoperative status with the documented preoperative status. The nurse asks the patient to describe the sensations in the hands and to demonstrate finger mobility. With tendon repairs and nerve, vascular, or skin grafts, motor function is tested only if prescribed. Pain may be related to surgery, edema, hematoma formation, or restrictive bandages. To control swelling that may increase the patient’s pain and discomfort, the nurse elevates the hand to heart level with pillows. When higher elevation is prescribed, an elevating sling may be attached to a pole used in intravenous (IV) therapies or to an overhead frame. If the patient is ambulatory, the arm is elevated in a conventional sling with the hand During the first few days after surgery, the patient needs assistance with ADLs because one hand is bandaged and independent self-care is impaired. The patient may need to arrange for assistance with feeding, bathing and hygiene, dressing, grooming, and toileting. Within a few days, the patient develops skills in one handed ADLs and is usually able to function with minimal assistance and use of assistive devices. The nurse encourages use of the involved hand, unless contraindicated, within the limits of discomfort. As rehabilitation progresses, the patient resumes use of the injured hand. Physical or occupational therapy– As with all surgery, there is a risk for infection. The nurse teaches the patient to monitor temperature and signs and symptoms that suggest an infection. It also is important to instruct the patient to keep the dressing clean and dry and to report any drainage, foul odor, or increased pain and swelling. Patient education includes aseptic wound care as well as education related to prescribed prophylactic antibiotics. Teaching Patients Self-Care After the patient has undergone hand surgery, the nurse teaches the patient how to monitor neurovascular status and the signs of complications that need to be reported to the surgeon (eg,paresthesia, paralysis, uncontrolled pain, coolness of fingers, extreme swelling, excessive bleeding, purulent drainage, fever). The nurse discusses prescribed medications with the patient. In addition, the nurse teaches the patient to elevate the hand above the elbow and to apply ice (if prescribed) to control swelling. Unless contraindicated, the nurse encourages extension and flexion exercises of the fingers to promote circulation. The use of assistive devices is encouraged if they would be helpful in promoting accomplishment of ADLs. For bathing, the nurse instructs the patient EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Maintins périphérie tissue perfusion a. Demonstrates normal skin temperature and capillary refill b. Exhibits normal sensations c. Exhibits acceptable motor function 2. Achieves pain relief a. Reports increased comfort b. Controls edema through elevation of the hand c. Experiences no discomfort with movement 3. Demonstrates independent self-care a. Secures assistance with ADLs during first few days postoperatively b. Adapts to one-handed ADLs c. Uses injured hand within its functional capability 4. Demonstrates absence of wound infection a. Complies with treatment protocol and prevention strategies b. Reports temperature and pulse within normal limits c. Experiences no purulent wound drainage d. Experiences no wound inflammation Disabilities of the foot are commonly caused by poorly fitting shoes. Fashion, vanity, and eye appeal, rather than function and physiology of the foot, are the determining factors in the design of footwear. Ill-fitting shoes distort normal anatomy while inducing deformity and pain. Several systemic diseases affect the feet. Patients with diabetes are prone to develop corns and peripheral neuropathies with diminishing sensation, leading to ulcers at pressure points of the foot The discomforts of foot strain are treated with rest, elevation, physiotherapy, supportive strappings, and orthotic devices. The patient must inspect the foot and skin under pads and orthotic devices for pressure and skin breakdown daily. If a “window” is cut into shoes to relieve pressure over a bony deformity, the skin must be monitored daily for breakdown from pressure exerted at the “window” area. Active foot exercises promote the circulation and help strengthen the feet. Walking in properly fitting shoes Plantar fasciitis, an inflammation of the footsupporting fascia, presents as an acute onset of heel pain experienced with the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Management includes stretching exercises, wearing shoes with support and cushioning to relieve pain, orthotic devices (eg, heel cups, arch supports), A corn is an area of hyperkeratosis (overgrowth of a horny layer of epidermis) produced by internal pressure (the underlying bone is prominent because of congenital or acquired abnormality, commonly arthritis) or external pressure (ill-fitting shoes). The fifth toe is most frequently involved, but any toe may be involved. Corns are treated by soaking and scraping off the horny layer by a podiatrist, by application of a protective shield or pad, or by surgical modification of the underlying offending osseous structure. Soft corns are located between the toes and are kept soft by moisture. Treatment consists of drying the affected spaces and separating the affected toes with lamb’s wool or gauze. A callus is a discretely thickened area of the skin that has been exposed to persistent pressure or friction. Faulty foot mechanics usually precede the formation of a callus. Treatment consists of eliminating the underlying causes and having the callus treated by a podiatrist if it is painful. A keratolytic ointment may be applied and a thin plastic cup worn over the heel if the callus is on this area. Felt padding with adhesive backing is also used to prevent and relieve pressure. An ingrown toenail (onychocryptosis) is a condition in which the free edge of a nail plate penetrates the surrounding skin, either laterally or interiorly. A secondary infection or granulation tissue may develop. This painful condition is caused by improper self treatment, external pressure (tight shoes or stockings), internal pressure (deformed toes, growth under the nail), trauma, or infection. Trimming the nails properly (clipping them straight across and filing the corners consistent with the contour of the toe) can prevent this problem. Active treatment consists of washing the foot twice a day, followed by the application of a local antibiotic ointment, and relieving the pain by decreasing the pressure of the nail plate on the surrounding soft tissue. Hammer toe is a flexion deformity of the interphalangeal joint, which may involve several toes (Fig. 68-6). The condition is usually an acquired deformity. Tight socks or shoes may push an overlying toe back into the line of the other toes. The toes usually are pulled upward, forcing the metatarsal joints (ball of the foot) downward. Corns develop on top of the toes, and tender calluses develop under the metatarsal area. The treatment consists of conservative measures: wearing open-toed sandals or shoes that conform to the shape of the foot, carrying out manipulative exercises, Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally (see Fig. 68-6). Associated with this is a marked prominence of the medial aspect of the first metatarsal–phalangeal joint. There is also osseous enlargement (exostosis) of the medial side of the first metatarsal head, over which a bursa may form (secondary to pressure and inflammation). Acute bursitis symptoms include a reddened area, edema, and tenderness. Factors contributing to bunion formation include heredity, ill-fitting shoes, and gradual lengthening and widening of the foot associated with aging. Pes cavus (clawfoot) refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot (see Fig. 686). The shortening of the foot and increased pressure produce calluses on the metatarsal area and on the dorsum (bottom) of the foot. Charcot-Marie-Tooth disease (a peripheral neuromuscular disease associated with a familial degenerative disorder), diabetes mellitus, and tertiary syphilis are common causes of pes cavus. Exercises are prescribed to manipulate the forefoot into dorsiflexion and relax the toes. Morton’s neuroma (plantar digital neuroma, neurofibroma) is a swelling of the third (lateral) branch of the median plantar nerve (see Fig. 68-6). The third digital nerve, which is located in the third intermetatarsal (web) space, is most commonly involved. Microscopically, digital artery changes cause an ischemia of the nerve. The result is a throbbing, burning pain in the foot that is usually relieved when the patient rests. Conservative treatment consists of inserting innersoles and metatarsal pads designed to spread the metatarsal heads and balance the foot posture. Local injections of hydrocortisone and a local anesthetic may provide relief. If these fail, surgical excision of the neuroma is necessary Flatfoot (pes planus) is a common disorder in which the longitudinal arch of the foot is diminished. It may be caused by congenital abnormalities or associated with bone or ligament injury, muscle and posture imbalances, excessive weight, muscle fatigue, poorly fitting shoes, or arthritis. Symptoms include a burning sensation, fatigue, clumsy gait, edema, and pain. Exercises to strengthen the muscles and to improve posture and walking habits are helpful. A number of foot orthoses are available to give the foot additional support. Assessment Surgery of the foot may be necessary because of various conditions, including neuromas and foot deformities (bunion, hammer toe, clawfoot). Generally, foot surgery is performed on an outpatient basis. Before surgery, the nurse assesses the patient’s ambulatory ability and balance and the neurovascular status of the foot. Additionally, the nurse considers the availability of assistance at home and the structural characteristics of the home in planning for care during the first few days after surgery. The nurse uses these data, in addition to knowledge of the usual medical management of the condition, to formulate appropriate nursing diagnoses. Based on the assessment data, the nursing diagnoses for the patient undergoing foot surgery may include the following: • Risk for ineffective peripheral tissue perfusion: related to swelling • Acute pain related to surgery, inflammation, and swelling • Impaired physical mobility related to the footimmobilizing device • Risk for infection related to the surgical procedure/surgical incision The goals for the patient may include adequate tissue perfusion, relief of pain, improved mobility, and absence of infection. PROMOTING TISSUE PERFUSION Neurovascular assessment of the exposed toes every 1 to 2 hours for the first 24 hours is essential to monitor the function of the nerves and the perfusion of the tissues. If the patient is discharged within several hours after the surgery, the nurse teaches the patient and family how to assess for swelling and neurovascular status (circulation, motion, sensation). Compromised neurovascular function can increase the patient’s pain. Pain experienced by patients who undergo foot surgery is related to inflammation and edema. Formation of a hematoma may contribute to the discomfort. To control the swelling, the foot should be elevated on several pillows when the patient is sitting or lying. Intermittent ice packs applied to the surgical area during the first 24 to 48 hours may be prescribed to control swelling and provide some pain relief. As activity increases, the patient may find that dependent positioning of the foot is uncomfortable. After surgery, the patient will have a bulky dressing on the foot, protected by a light cast or a special protective boot. Limits forweight bearing on the foot will be prescribed by the surgeon. Some patients are allowed to walk on the heel and progress to weight-bearing as tolerated; other patients are restricted to non– weight-bearing activities. Assistive devices (eg, crutches, walker) may be needed. The choice of the devices depends on the patient’s general condition and balance and on the weight-bearing prescription. Safe use of the assistive devices must be ensured through adequate patient education and practice before discharge. Any surgery carries a risk for infection. In addition, percutaneous pins may be used to hold bones in position, and these pins serve as potential sites for infection. Because the foot is on or near the floor, care must be taken to protect it from dirt and moisture. When bathing, the patient can secure a plastic bag over the dressing to prevent it from getting wet. Patient instruction concerning aseptic wound care and pin care may be necessary. The nurse teaches the patient to monitor for temperature and infection. Drainage on the dressing, foul odor, or increased pain and swelling could indicate infection Teaching Patients Self-Care The nurse plans patient teaching for home care, focusing on neurovascular status, pain management, mobility, and wound care EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Maintains peripheral tissue perfusion a. Demonstrates normal skin temperature and capillary refill b. Exhibits normal sensations c. Exhibits acceptable motor function 2. Obtains pain relief a. Elevates foot to control edema b. Applies ice to foot as prescribed c. Uses oral analgesics as needed and prescribed d. Reports decreased pain and increased comfort 3. Demonstrates increased mobility a. Uses assistive devices safely b. Resumes weight-bearing gradually as prescribed c. Exhibits diminished disability associated with preoperative condition 4. Develops no infection a. Reports temperature and pulse within normal limits b. Reports no purulent drainage or signs of wound inflammation c. Maintains clean and dry dressing d. Takes prophylactic antibiotics as prescribed OSTEOPOROSIS Osteoporosis is a disease that threatens more than 28 million Americans Characteristics of osteoporosis include a reduction of bone density and a change in bone structure, both of which increase susceptibility to fracture. The normal homeostatic bone turnover is altered: the rate of bone resorption is greater than the rate of bone formation, resulting in a reduced total bone mass. Suboptimal bone mass development in children and teens contributes to the development of osteoporosis. Primary osteoporosis occurs in women after menopause and later in life in men, but it is not merely a consequence of aging. Failure to develop optimal peak bone mass during childhood, adolescence, and young adulthood contributes to the development of osteoporosis without resultant bone loss. Early identification of at-risk teenagers and young adults, increased calcium intake, participation in regular weight-bearing exercise, and modification of lifestyle (eg, reduced use of caffeine, cigarettes, and alcohol) are interventions that decrease the risk for development of osteoporosis, fractures, Normal bone remodeling in the adult results in gradually increased bone mass until the early 30s. Gender, race, genetics, aging, low body weight and body mass index, nutrition, lifestyle choices (eg, smoking, caffeine and alcohol consumption), and physical activity influence peak bone mass and the development of osteoporosis Loss of bone mass is a universal phenomenon associated with aging. Age-related loss begins soon after the peak bone mass is achieved (ie, in the fourth decade). Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased. Estrogen, which inhibits bone breakdown, decreases with aging. On the other hand, parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time. Genetics • Caucasian or Asian • Female • Family history • Small frame Predisposes to low bone mass Age • Post-menopause • Advanced age • Low testosterone in men • Decreased calcitonin Hormones (estrogen, calcitonin, and testosterone) inhibit bone loss Nutrition • Low calcium intake • Low vitamin D intake • High phosphate intake (carbonated beverages) • Inadequate calories Reduces nutrients needed for bone remodeling Physical exercise • Sedentary • Lack of weight bearing exercise • Low weight and body mass index Bones need stress for bone maintenance Lifestyle choices • Caffeine • Alcohol • Smoking • Lack of exposure to sunlight Reduces osteogenesis in bone remodeling Medications e.g., corticosteroids, ant seizure medications, heparin, thyroid hormone Co-morbidity e.g., anorexia nervosa, hyperthyroidism, malabsorption syndrome, renal failure Affects calcium absorption and metabolism Individual Risk Factors • Female, Caucasian, non-Hispanic or Asian • Increased age • Low weight and body mass index • Estrogen deficiency or menopause • Family history • Low initial bone mass • Contributing, coexisting medical conditions (eg, celiac disease) and medications (eg, corticosteroids, antiseizure medications) Lifestyle Risk Factors • Diets low in calcium and vitamin D • Cigarette smoking Use of alcohol and/or caffeine • Lack of weight-bearing exercise • Lack of exposure to sunshine Risk-Lowering Strategies • Increased dietary calcium and vitamin D intake • Smoking cessation • Alcohol and caffeine consumption in moderation • Regular weight-bearing exercise regimen • Walk or exercise out of doors Osteoporosis may be identified on routine xrays when there has been 25% to 40% demineralization. There is radiolucency to the bones. When the vertebrae collapse, the thoracic vertebrae become An adequate, balanced diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence, young adulthood, and the middle years, protects against skeletal demineralization. Such a diet would include three glasses of skim or whole vitamin D–enriched milk or other foods high in calcium (eg, cheese and other dairy products, steamed broccoli, canned salmon with bones), daily. To ensure adequate calcium intake, a calcium supplement Regular weight-bearing exercise promotes bone formation. From 20 to 30 minutes of aerobic exercise (eg, walking), 3 days or more a week, is recommended. Weight training stimulates an increase in BMD. In addition, exercise improves balance, At natural or surgical menopause, hormone replacement therapy (HRT) with estrogen and progesterone has been the mainstay of therapy to retard bone loss and prevent occurrence of fractures. Estrogen replacement decreases bone resorption and increases bone mass, reducing the incidence of osteoporotic fractures. However, recent studies have demonstrated greater risks than previously recognized Fractures of the hip are managed surgically by joint replacement or by closed or open reduction with internal fixation (eg, hip pinning). Surgery, early ambulation, intensive physical therapy, and adequate nutrition result in decreased morbidity and improved outcomes. In addition, patients need to be evaluated for osteoporosis and treated, if indicated. Osteoporotic compression fractures of the vertebra are managed conservatively. Additional vertebral fractures and progressive kyphosis are common. Pharmacologic and dietary treatment are aimed at increasing vertebral bone density. A new procedure, percutaneous vertebroplasty/kyphoplasty Assessment Health promotion, identification of people at risk for osteoporosis, and recognition of problems associated with osteoporosis form the basis for nursing assessment. The health history includes questions concerning the occurrence of osteopenia and osteoporosis and focuses on family history, previous fractures, dietary consumption of calcium, exercise patterns, onset of menopause, and use of corticosteroids as well as alcohol, smoking, and caffeine intake. Any symptoms the patient is experiencing, such as back pain, constipation, or altered body image, are explored. Based on the assessment data, the major nursing diagnoses for the patient who experiences a spontaneous vertebral fracture related to osteoporosis may include the following: • Deficient knowledge about the osteoporotic process and treatment regimen • Acute pain related to fracture and muscle spasm • Risk for constipation related to immobility or development of ileus (intestinal obstruction) • Risk for injury: additional fractures related to osteoporosis The major goals for the patient may include knowledge about osteoporosis and the treatment regimen, relief of pain, improved bowel elimination, and absence of additional fractures. PROMOTING UNDERSTANDING OF OSTEOPOROSIS AND THE TREATMENT REGIMEN Patient teaching focuses on factors influencing the development of osteoporosis, interventions to arrest or slow the process, and measures to relieve symptoms. Adequate dietary or supplemental calcium and vitamin D, regular weight-bearing exercise, and modification of lifestyle, if necessary (eg, cessation of smoking, reduced use of caffeine and alcohol), help to maintain bone mass. Diet, exercise, and physical activity are the primary keys to developing high-density bones that are resistant to osteoporosis. It is emphasized that all people continue to need sufficient calcium, vitamin D, sunshine, and weight-bearing exercise to slow the progression Relief of back pain resulting from compression fracture may be accomplished by resting in bed in a supine or side-lying position several times a day. The mattress should be firm and nonsagging. Knee flexion increases comfort by relaxing back muscles. Intermittent local heat and back rubs promote muscle relaxation. The nurse instructs the patient to move the trunk as a unit and to avoid twisting. The nurse encourages good posture and teaches body mechanics. When the patient is assisted out of bed, Constipation is a problem related to immobility and medications. Early institution of a high-fiber diet, increased fluids, and the use of prescribed stool softeners help to prevent or minimize constipation. If the vertebral collapse involves the T10–L2 vertebrae, the patient may develop an ileus. The nurse therefore monitors the patient’s intake, bowel sounds, and bowel activity. Physical activity is essential to strengthen muscles, improve balance, prevent disuse atrophy, and retard progressive bone demineralization. Isometric exercises can strengthen trunk muscles. The nurse encourages walking, good body mechanics, and good posture. Daily weight-bearing activity, preferably outdoors in the sunshine to enhance the body’s ability to produce vitamin D, is encouraged. Sudden bending, jarring, and strenuous are avoidedlifting EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Acquires knowledge about osteoporosis and the treatment regimen a. States relationship of calcium and vitamin D intake and exercise to bone mass b. Consumes adequate dietary calcium and vitamin D c. Increases level of exercise d. Takes prescribed hormonal or nonhormonal therapy e. Complies with prescribed screening and monitoring procedures 2. Achieves pain relief a. Experiences pain relief at rest b. Experiences minimal discomfort during ADLs c. Demonstrates diminished tenderness at fracture site 3. Demonstrates normal bowel elimination a. Has active bowel sounds b. Reports regular bowel movements 4. Experiences no new fractures a. Maintains good posture b. Uses good body mechanics c. Consumes a diet high in calcium and vitamin D d. Engages in weight-bearing exercises (walks daily) e. Rests by lying down several times a day f. Participates in outdoor activities g. Creates a safe home environment h. Accepts assistance and supervision as needed Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. As a result of faulty mineralization, there is softening and weakening of the skeleton, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures. On physical examination, skeletal deformities (spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling The primary defect in osteomalacia is a deficiency of activated vitamin D (calcitriol), which promotes calcium absorption from the gastrointestinal tract and facilitates mineralization of bone. The supply of calcium and phosphate in the extracellular fluid is low. Without adequate vitamin D, calcium and phosphate are not moved to calcification sites in bones. Osteomalacia may result from failed calcium absorption (eg, malabsorption syndrome) or from excessive loss of calcium from the body. Gastrointestinal disorders (eg, celiac disease, chronic biliary tract obstruction, chronic pancreatitis, small bowel resection) in which fats are inadequately absorbed are likely to produce osteomalacia through loss of vitamin D (along with other fatsoluble vitamins) and calcium, On x-ray, generalized demineralization of bone is evident. Studies of the vertebrae may show a compression fracture with indistinct vertebral end-plates. Laboratory studies show low serum calcium The underlying cause of osteomalacia is corrected if possible. If osteomalacia is caused by malabsorption, increased doses of vitaminD, along with supplemental calcium, are usually prescribed. Exposure to sunlight for ultraviolet radiation to transform a cholesterol substance (7-dehydrocholesterol) present in the skin into vitamin D may be recommended. Physical, psychological, and pharmaceutical measures are used to reduce the patient’s discomfort and pain. When assisting the patient to change positions, the nurse handles the patient gently, and pillows are used to support the body. As the patient responds to therapy, the skeletal discomforts diminish. Frequently, skeletal problems associated with osteomalacia resolve themselves when the underlying nutritional deficiency or pathologic process is adequately treated. Long-term monitoring of the patient is appropriate to ensure stabilization or reversal of osteomalacia. Some persistent orthopedic deformities may need to be treated with braces or surgery (eg, osteotomy may be performed to correct long bone deformity). Paget’s disease (osteitis deformans) is a disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae. There is a primary proliferation of osteoclasts, which produces bone resorption. This is followed by a compensatory increase in osteoblastic activity that replaces the bone. As bone turnover continues, a classic mosaic (disorganized) pattern of bone develops. Because the diseased bone in Paget’s disease is highly vascularized and structurally weak, pathologic fractures occur. Paget’s disease is insidious; most patients never know they have it. Some patients do not experience symptoms but have skeletal deformity. A few patients have symptomatic deformity and pain. The condition is most frequently identified on x-ray during a routine physical examination or in the course of a workup for another problem. Sclerotic changes, skeletal deformities (eg, bowing of femur and tibia, enlargement of the skull, deformity of pelvic bones), and cortical thickening of the long bones occur. Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reflect increased osteoblastic activity. Higher values suggest more active disease. Patients with Paget’s disease have normal blood calcium levels. X-rays confirm the diagnosis of Paget’s disease. Local areas of demineralization and bone overgrowth produce characteristic mosaic patterns and irregularities. Bone scans demonstrate the extent of the disease. Bone biopsy may aid in the differential diagnosis. Pain usually responds to administration of NSAIDs. Gait problems from bowing of the legs are managed with walking aids, shoe lifts, and physical therapy. Weight is controlled to reduce stress on weakened bones and malaligned joints. Asymptomatic patients may be managed with diets adequate in calcium and vitamin D and periodic monitoring. Fractures, arthritis, and hearing loss are complications of Paget’s disease. Fractures are managed according to location. Healing occurs if fracture reduction, immobilization, and stability are adequate. Severe degenerative arthritis may require total joint replacement. Patients with moderate to severe disease may benefit from specific antiosteoclastic therapy. Several medications reduce bone turnover, reverse the course of the disease, relieve pain, and improve mobility. Calcitonin, a polypeptide hormone, retards bone resorption by decreasing the number and availability of osteoclasts. Calcitonin therapy facilitates remodeling of abnormal bone into normal lamellar bone, relieves bone pain, and helps alleviate neurologic and biochemical signs and symptoms. Calcitonin is administered subcutaneously or by nasal inhalation. Side effects include flushing of the face and nausea. OSTEOMYELITIS Osteomyelitis is an infection of the bone. The bone becomes infected by one of three modes: • Extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional infection) • Direct bone contamination from bone surgery, open fracture, or traumatic injury (eg, gunshot wound) Hematogenous (bloodborne) spread from other sites of infection (eg, infected tonsils, boils, infected teeth, upper respiratory infections). Osteomyelitis resulting from hematogenous spread typically occurs in a bone area of trauma or lowered resistance, possibly from subclinical (nonapparent) trauma. Postoperative surgical wound infections occur within 30 days after surgery. They are classified as incisional (superficial, located above the deep fascia layer) or deep (involving tissue beneath the deep fascia). If an implant has been used, deep postoperative infections may occur within a year. Deep sepsis after arthroplasty may be classified as follows: Stage 1, acute fulminating: occurring during the first 3 months after orthopedic surgery; frequently associated with hematoma, drainage, or superficial infection Stage 2, delayed onset: occurring between 4 and 24 months after surgery Stage 3, late onset: occurring 2 or more years after surgery, usually as a result of hematogenous spread Staphylococcus aureus causes 70% to 80% of bone infections. Other pathogenic organisms frequently found in osteomyelitis include Proteus and Pseudomonas species and Escherichia coli. The incidence of penicillin-resistant, nosocomial, gramnegative, and anaerobic infections is increasing. The initial response to infection is inflammation, increased vascularity, and edema. After 2 or 3 days, thrombosis of the blood vessels occurs in the area, resulting in ischemia with bone necrosis. The infection extends into the medullary cavity and under the periosteum and may spread into adjacent soft tissues and joints. Unless the infective process is treated promptly, a bone abscess forms. The resulting abscess cavity contains dead bone tissue When the infection is blood borne, the onset is usually sudden, occurring often with the clinical manifestations of septicemia (e.g., chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteal and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting pus. In acute osteomyelitis, early x-ray findings demonstrate soft tissue swelling. In about 2 weeks, areas of irregular decalcification, bone necrosis, periosteal elevation, and new bone formation are evident. Radioisotope bone scans, particularly the isotopelabeled white blood cell (WBC) With chronic osteomyelitis, large, irregular cavities, raised periosteum, sequestra, or dense bone formations are seen on x-ray. Bone scans may be performed to identify areas of infection. The sedimentation rate and the WBC count are usually normal. Anemia, associated with chronic infection, may be evident. Prevention of osteomyelitis is the goal. Elective orthopedic surgery should be postponed if the patient has a current infection (eg, urinary tract infection, sore throat) or a recent history of infection. During orthopedic surgery, careful attention is paid to the surgical environment and to techniques to decrease direct bone contamination. Prophylactic antibiotics, administered to achieve adequate tissue levels at the time of surgery and for 24 hours after surgery, are helpful. Urinary catheters and drains are removed as soon as possible to decrease the incidence of hematogenousspread of infection. The initial goal of therapy is to control and halt the infective process. Antibiotic therapy depends on the results of blood and wound cultures. Frequently, the infection is caused by more than one pathogen. General supportive measures (eg, hydration, diet high in vitamins and protein, correction of anemia) should be instituted. The area affected with osteomyelitis is immobilized to decrease discomfort and to prevent pathologic fracture of the weakened bone. Warm wet soaks for 20 minutes several times a day may be prescribed to increase circulation. As soon as the culture specimens are obtained, IV antibiotic therapy begins, based on the assumption that infection results from a staphylococcal organism that is sensitive to a semisynthetic penicillin or cephalosporin. The aim is to control the infection before the blood supply to the area diminishes as a result of thrombosis. Around-the-clock dosing is necessary to achieve a sustained high therapeutic blood level of the antibiotic. An antibiotic to which the causative organism is sensitive is prescribed after results of the culture and sensitivity studies are known. If the patient does not respond to antibiotic therapy, the infected bone is surgically exposed, the purulent and necrotic material is removed, and the area is irrigated with sterile saline solution. Antibiotic-impregnated beads may be placed in the wound for direct application of antibiotics for 2 to 4 weeks. IV antibiotic therapy is continued. In chronic osteomyelitis, antibiotics are adjunctive therapy to surgical débridement. A sequestrectomy (removal of enough involucrum to enable the surgeon to remove the sequestrum) is performed. In many cases, sufficient bone is removed to convert a deep cavity into a shallow saucer Based on the nursing assessment data, nursing diagnoses for the patient with osteomyelitis may include the following: • Acute pain related to inflammation and swelling • Impaired physical mobility related to pain, use of immobilization devices, and weight-bearing limitations • Risk for extension of infection: bone abscess formation • Deficient knowledge related to the treatment regimen The patient’s goals may include relief of pain, improved physical mobility within therapeutic limitations, control and eradication of infection, and knowledge of treatment regimen. RELIEVING PAIN The affected part may be immobilized with a splint to decrease pain and muscle spasm. The nurse monitors the neurovascular status of the affected extremity. The wounds are frequently very painful, and the extremity must be handled with great care and gentleness. Elevation reduces swelling and associated discomfort. Treatment regimens restrict activity. The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone. The patient must understand the rationale for the activity restrictions. The joints above and below the affected part should be gently placed through their range of motion. The nurse encourages full participation in ADLs within the physical limitations to promote general well being The nurse monitors the patient’s response to antibiotic therapy and observes the IV access site for evidence of phlebitis, infection, or infiltration. With long-term, intensive antibiotic therapy, the nurse monitors the patient for signs of super infection (e.g., oral or vaginal candidiasis, loose or foul-smelling stools). If surgery was necessary, the nurse takes measures to ensure adequate circulation (wound suction to prevent fluid accumulation ,elevation of the area to promote venous drainage, avoidance of pressure on grafted area), to maintain needed immobility, and to comply with weight-bearing restrictions. The nurse changes dressings using aseptic technique to promote healing The patient and family must learn and recognize the importance of strictly adhering to the therapeutic regimen of antibiotics and preventing falls or other injuries that could result in bone fracture. The patient needs to know how to maintain and manage the IV access and IV administration equipment in the home. Medication education includes medication name, dosage, frequency, administration rate, safe storage and handling, adverse reactions, and necessary laboratory monitoring. Management of osteomyelitis, including wound care and IV antibiotic therapy, is usually performed at home. The patient must be medically stable, physically able, and motivated to adhere strictly to the therapeutic regimen of antibiotic therapy. The home care environment needs to be conducive to promotion of health and to the requirements of the therapeutic regimen. EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Experiences pain relief a. Reports decreased pain b. Experiences no tenderness at site of previous infection c. Experiences no discomfort with movement 2. Increases physical mobility a. Participates in self-care activities b. Maintains full function of unimpaired extremities c. Demonstrates safe use of immobilizing and assistive devices d. Modifies environment to promote safety and to avoid falls 3. Shows absence of infection a. Takes antibiotic as prescribed b. Reports normal temperature c. Exhibits no swelling d. Reports absence of drainage e. Laboratory results indicate normal white blood cell count and sedimentation rate f. Wound cultures are negative 4. Complies with therapeutic plan a. Takes medications as prescribed b. Protects weakened bones c. Demonstrates proper wound care d. Reports signs and symptoms of complications promptly e. Eats a diet that is high in protein and vitamin C f. Keeps follow-up health appointments g. Reports increased strength h. Reports no elevation of temperature or recurrence of pain, swelling, or other symptoms at the site Joints can become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation. Previous trauma to joints, joint replacement, coexisting arthritis, and diminished host resistance contribute to the development of an infected joint. The patient with acute septic arthritis usually presents with a warm, painful, swollen joint with decreased range of motion. Systemic chills, fever, and leukocytosis are present. Risk factors include advanced age, diabetes mellitus, rheumatoid arthritis, and preexisting joint disease or joint replacement. An assessment for the source and cause of infection is performed. Diagnostic studies include aspiration, examination, and culture of the synovial fluid. Computed tomography and MRI may disclose damage to the joint lining. Radioisotope scanning may be useful in localizing the infectious process. Prompt treatment is essential and may save a joint prosthesis for patients who have one. Broad-spectrum IV antibiotics are started promptly and then changed to organismspecific antibiotics after culture results are available. The IV antibiotics are continued until symptoms disappear. The synovial fluid is monitored for sterility and decrease in WBCs. The inflamed joint is supported and immobilized in a functional position by a splint that increases the patient’s comfort. Analgesics, such as codeine, may be prescribed to control pain. After the infection has responded to antibiotic therapy, NSAIDs may be prescribed to limit joint damage. The nurse describes the septic arthritis process to the patient and teaches the patient how to relieve pain using pharmacologic and nonpharmacologic interventions. The nurse also explains the importance of supporting the affected joint, adhering to the prescribed antibiotic regimen, The nurse teaches the patient strategies to promote healing through aseptic dressing changes and proper wound care. The patient is then encouraged to perform range-ofmotion exercises after the infection subsides. Neoplasms of the musculoskeletal system are of various types, including osteogenic, chondrogenic, fibrogenic, muscle (rhabdomyogenic), and marrow (reticulum) cell tumors as well as nerve, vascular, and fatty cell tumors. They may be primary tumors or metastatic tumors from primary cancers elsewhere in the body (eg, breast, lung, prostate, kidney). Metastatic bone tumors are more common than primary bone tumors. Benign tumors of the bone and soft tissue are more common than malignant primary bone tumors. Benign bone tumors generally are slow growing and well circumscribed, present few symptoms, and are not a cause of death. Osteochondroma is the most common benign bone tumor. It usually occurs as a large projection of bone at the end of long bones (at the knee or shoulder). It develops during growth and then becomes a static bony mass. Enchondroma is a common tumor of the hyaline cartilage that develops in the hand, femur, tibia, or humerus. Usually, the only symptom is a mild ache. Pathologic fractures may occur. Primary malignant musculoskeletal tumors are relatively rare and arise from connective and supportive tissue cells (sarcomas) or bone marrow elements (multiple myeloma; see Chap. 33). Malignant primary musculoskeletal tumors include osteosarcoma, chondrosarcoma, Ewing’s sarcoma, and fibrosarcoma. Osteogenic sarcoma (osteosarcoma) is the most common and most often fatal primary malignant bone tumor. Prognosis depends on whether the tumor has metastasized to the lungs at the time the patient seeks health care. Metastatic bone disease (secondary bone tumor) is more common than any primary bone tumor. Tumors arising from tissues elsewhere in the body may invade the bone and produce localized bone destruction (lytic lesions) or bone overgrowth (blastic lesions). The most common primary sites of tumors that metastasize to bone are the kidney, prostate, lung, breast, ovary, and thyroid. Metastatic tumors most frequently attack the skull, spine, pelvis, femur, and humerus A tumor in the bone causes the normal bone tissue to react by osteolytic response (bone destruction) or osteoblastic response (bone formation). Primary tumors cause bone destruction, which weakens the bone, resulting in bone fractures. Adjacent normal bone responds to the tumor by altering its normal pattern of remodeling. The bone’s surface changes, and the contours enlarge in the tumor area. Patients with metastatic bone tumor may have a wide range of associated clinical manifestations. They may be symptom free or have pain (mild and occasional to constant and severe), varying degrees of disability and, at times, obvious bone growth. Weight loss, malaise, and fever may be present. The tumor may be diagnosed only after pathologic fracture has occurred. The differential diagnosis is based on the history, physical examination, and diagnostic studies, including computed tomography, bone scans, myelography, arteriography, MRI, biopsy, and biochemical assays of the blood and urine. Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma. With metastatic carcinoma of the prostate, serum acid phosphatase levels are elevated. Chest x-rays are performed to determine the presence of lung metastasis. Surgical staging of musculoskeletal tumors is based on tumor grade and site (intracompartmental or extracompartmental), as well as on metastasis. The goal of primary bone tumor treatment is to destroy or remove the tumor. This may be accomplished by surgical excision (ranging from local excision to amputation and disarticulation), radiation therapy if the tumor is radiosensitive, and chemotherapy (preoperative, intraoperative [neoadjuvant], postoperative, and adjunctive for possible micro metastases). Major gains are being made in the use of wide bloc excision with restorative grafting technique. The treatment of metastatic bone cancer is palliative. The therapeutic goal is to relieve the patient’s pain and discomfort while promoting quality of life. If metastatic disease weakens the bone, structural support and stabilization are needed to prevent pathologic fracture. At times, large bones with metastatic lesions are strengthened by prophylactic internal fixation. Assessment The nurse asks the patient about the onset and course of symptoms. During the interview, the nurse notes the patient’s understanding of the disease process, how the patient and the family have been coping, and how the patient has managed the pain. On physical examination, the nurse gently palpates the mass and notes its size and associated soft tissue swelling, pain, Based on the nursing assessment data, the major nursing diagnoses for the patient with a bone tumor may include the following: • Deficient knowledge related to the disease process and the therapeutic regimen • Acute and chronic pain related to pathologic process and surgery • Risk for injury: pathologic fracture related to tumor and metastasis • Ineffective coping related to fear of the unknown, perception of disease process, and inadequate support system • Risk for situational low self-esteem related to loss of body part or alteration in role performance COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Potential complications may include the following: • Delayed wound healing • Nutritional deficiency • Infection • Hyperkalemia The major goals for the patient include knowledge of the disease process and treatment regimen, control of pain, absence of pathologic fractures, effective patterns of coping, improved self-esteem, and absence of complications. The nursing care of a patient who has undergone excision of a bone tumor is similar in many respects to that of other patients who have had skeletal surgery. Vital signs are monitored; blood loss is assessed; and observations are made to assess for the development of complications such as deep vein thrombosis, pulmonary emboli, infection, contracture, and disuse atrophy. Patient and family teaching about the disease process and diagnostic and management regimens is essential. Explanation of diagnostic tests, treatments (eg, wound care), and expected results(eg, decreased range of motion, numbness, change of body contours) helps the patient deal with the procedures and changes. Cooperation and adherence to the therapeutic regimen are enhanced through understanding. Accurate pain assessment is the foundation for pain management. Pharmacologic and non pharmacologic pain management techniques are used to relieve pain and increase the patient’s comfort level. The nurse works with the patient in designing the most effective pain management regimen, thereby increasing the patient’s control over the pain. The nurse prepares the patient and gives support during painful procedures. Prescribed IV or epidural analgesics are used during the early postoperative period. Later, oral or transdermal opioid Bone tumors weaken the bone to a point at which normal activities or even position changes can result in fracture. During nursing care, the affected extremities must be supported and handled gently. External supports (eg, splints) may be used for additional protection. At times, the patient may elect to have surgery (eg,open reduction with internal fixation, joint replacement) in an attempt to prevent pathologic fracture. The nurse encourages the patient and family to verbalize their fears, concerns, and feelings. They need to be supported as they deal with the impact of the malignant bone tumor. Feelings of shock, despair, and grief are expected. Referral to a psychiatric nurse liaison, psychologist, counselor, Independence versus dependence is an issue for the patient who has a malignancy. Lifestyle is dramatically changed, at least temporarily. It is important to support the family in working through the adjustments that must be made. The nurse assists the patient in dealing with changes in body image due to surgery and possible amputation. It is helpful to provide realistic reassurance about the future Delayed Wound Healing Wound healing may be delayed because of tissue trauma from surgery, previous radiation therapy, inadequate nutrition, or infection. The nurse minimizes pressure on the wound site to promote circulation to the tissues. An aseptic, non traumatic wound dressing promotes healing. Monitoring and reporting of laboratory findings facilitate initiation of interventions to promote homeostasis and wound healing. Because loss of appetite, nausea, and vomiting are frequent side effects of chemotherapy and radiation therapy, it is necessary to provide adequate nutrition for healing and health promotion. Antiemetic's and relaxation techniques reduce the gastrointestinal reaction. Stomatitis is controlled with anesthetic or antifungal mouthwash Prophylactic antibiotics and strict aseptic dressing techniques are used to diminish the occurrence of osteomyelitis and wound infections. During healing, other infections (eg, upper respiratory infections) need to be prevented so that hematogenous spread does not result in osteomyelitis. Hypercalcemia is a dangerous complication of bone cancer. The symptoms must be recognized and treatment initiated promptly. Symptoms include muscular weakness, incoordination, anorexia, nausea and vomiting, constipation, electrocardiographic changes (eg, shortened QT interval and ST segment, bradycardia, heart blocks), Preparation for and coordination of continuing health care are begun early as a multidisciplinary effort. Patient teaching addresses medication, dressing, treatment regimens, and the importance of physical and occupational therapy programs. The nurse teaches weight-bearing limitations and special handling to prevent pathologic fractures. Frequently, arrangements are made with a home health care agency for home care supervision and follow-up. The home care nurse assesses the patient’s and family’s abilities to meet the patient’s needs and determines whether the services of other agencies are needed. The nurse advises the patient to have readily available the telephone numbers of people to contact in case concerns arise. Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Describes disease process and treatment regimen a. Describes pathologic condition b. States goals of the therapeutic regimen c. Seeks clarification of information 2. Achieves control of pain a. Uses multiple pain control techniques, including prescribed medications b. Experiences no pain or decreased pain at rest, during ADLs, or at surgical sites 3. Experiences no pathologic fracture a. Avoids stress to weakened bones b. Uses assistive devices safely and appropriately c. Strengthens uninvolved extremities with exercise 4. Demonstrates effective coping patterns a. Verbalizes feelings b. Identifies strengths and abilities c. Makes decisions d. Requests assistance as needed 5. Demonstrates positive self-concept a. Identifies home and family responsibilities that can be accomplished b. Exhibits confidence in own abilities c. Demonstrates acceptance of altered body image d. Demonstrates independence in ADLs 6. Exhibits absence of complications a. Demonstrates wound healing b. Experiences no skin breakdown c. Maintains or increases body weight d. Experiences no infections e. Does not experience hypercalcemia f. Manages side effects of therapies g. Reports symptoms of medication toxicity or complications 7. Participates in continuing health care at home a. Complies with prescribed regimen (ie, takes prescribed medications, continues physical and occupational therapy programs) b. Acknowledges need for long-term health supervision c. Keeps follow-up health care appointments d. Reports occurrence of symptoms or complications Any questions Thanks