Download Management of Patients With Musculoskeletal Disorders

BY
L-Manal Tharwat Abouzaied
2011-2012
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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.
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 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.
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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.
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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.
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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
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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)
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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).
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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
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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.
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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
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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
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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
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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,
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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
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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
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• 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
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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
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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.
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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.
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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.
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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
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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
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The structures in the upper extremity are
frequently the sites of
painful syndromes. The structures most
frequently affected are
the shoulder, wrist, and hand.
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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.
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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.
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 process may progress to a rotator cuff tear.
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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
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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
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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.
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• 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.
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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
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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
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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
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The goals of the patient may include relief of
pain, improved self care, and absence of
infection.
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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.
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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
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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–
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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.
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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
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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
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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
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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
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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
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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),
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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.
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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.
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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.
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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,
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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.
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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.
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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
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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.
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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.
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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
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The goals for the patient may include
adequate tissue perfusion,
relief of pain, improved mobility, and absence
of infection.
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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.
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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.
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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.
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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
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Teaching Patients Self-Care
The nurse plans patient teaching for home
care, focusing on neurovascular
status, pain management, mobility, and
wound care
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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
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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
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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.
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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,
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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
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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.
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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
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Nutrition
• Low calcium intake
• Low vitamin D intake
• High phosphate
intake (carbonated beverages)
• Inadequate calories
Reduces nutrients
needed for bone
remodeling
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Physical exercise
• Sedentary
• Lack of weight bearing
exercise
• Low weight and
body mass index
Bones need stress
for bone maintenance
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Lifestyle choices
• Caffeine
• Alcohol
• Smoking
• Lack of exposure
to sunlight
Reduces
osteogenesis in
bone remodeling
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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
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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
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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
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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
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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
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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,
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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
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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.
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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
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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.
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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
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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.
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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
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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,
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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.
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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
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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
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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
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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
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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
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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.
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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,
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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
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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.
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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.
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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).
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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.
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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.
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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.
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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.
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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.
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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)
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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.
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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
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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
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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.
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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)
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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.
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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.
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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.
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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.
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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.
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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
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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
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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.
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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.
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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
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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
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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.
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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.
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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
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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

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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.
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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.
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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.
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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.
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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.
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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,
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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
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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,
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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
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COLLABORATIVE PROBLEMS/
POTENTIAL COMPLICATIONS
Potential complications may include the
following:
• Delayed wound healing
• Nutritional deficiency
• Infection
• Hyperkalemia
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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.
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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.
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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.
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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
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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.
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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,
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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
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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.
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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
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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.
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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),
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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.
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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.
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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
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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
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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
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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
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