musculoskeletal system disorders

MUSCULOSKELETAL DISORDERS

JOFRED M. MARTINEZ, RN, MANUniversity of San Agustin Review CenterIloilo City, Philippines

Osteoporosis

Osteoporosis

Nonmodifiable Risk Factors

Older age

A family history of osteoporosis

History of fracture in a first-degree relative

Being female, especially Caucasian or Asian

Being thin and/or having a small frame

Osteoporosis

Modifiable Risk Factors

Low estrogen levels in women (amenorrhea, menopause)

Low testosterone levels in men

Dietary: low lifetime calcium intake, vitamin D deficiency

Medication use: corticosteroids, some anticonvulsants

Lifestyle: inactivity, cigarette smoking, excess alcohol use

Osteoporosis

Osteoporosis

Manifestations

loss of height

curvature of the spine

low back pain

fractures of the forearm, spine, or hip

Dowagers hump

Osteoporosis

Osteoporosis

Complications

Fractures

Osteoporosis

Diagnosis

Bone mineral density (BMD) tests

Dual-energy x-ray absorptiometry (DXA)

Ultrasound

CT scanning of the spine, hip, forearm, or tibia

Complete blood count (CBC), serum and urine calcium, and liver and renal function studies Serum 25(OH)D

Biochemical markers of bone turnover, including serum bone-specific alkaline phosphatase, osteocalcin

Osteoporosis

Medications

BISPHOSPHONATES

Alendronate (Fosamax) Etidronate (Didronel) Ibandronate (Boniva) Pamidronate (Aredia) Risedronate (Actonel) Tiludronate (Skelid) Zoledronate (Zometa)

CALCITONIN

Calcitonin-salmon injection, synthetic Calcimar Miacalcin (injection or nasal spray)

Osteoporosis

Medications

Estrogen replacement therapy in combination with progestin (hormone replacement therapy or HRT)

Selective estrogen receptor modulators (SERMs) - Raloxifene(Evista) and tamoxifen (Nolvadex, Tamofen)

Nursing Management

Health Promotion

Adequate intake of calcium and vitamin D

AGES ELEMENTALCALCIUM (mg)

VITAMIN D(UNITS)

19 to 50 years 1000 200

51 to 70 years 1200 400

> 70 years 1200 600

National Institutes of Health (NIH) recommendations

Nursing Management

Nursing Management

Dietary sources of calcium

milk and milk products

sardines, clams, oysters, and salmon

dark green, leafy vegetables such as broccoli, collard greens, bok choy, and spinach

Nursing Management

Health Promotion

physical activity and weight bearing exercises

regular exercise such as walking, stair climbing, or tai chi

avoiding smoking, avoiding excessive alcohol intake, and limiting caffeine intake to two or three cups of coffee each day

Nursing Management

Assessment

Health history: Age, risk factors, history of fractures, smoking history, alcohol intake, medications, usual diet, menstrual history including menopause, usual exercise/activity level, low back pain.

Physical examination: Height, spinal curves.

Nursing Diagnosis and Interventions

Readiness for Enhanced Self Health Management

Assess the patients health habits, including diet, exercise, smoking, and alcohol use.

Teach women and men of all ages the importance of maintaining an adequate calcium intake.

Discuss the importance of maintaining a regular schedule of weight-bearing exercise, either through an exercise program or regular physical activity.



Refer patients to smoking-cessation programs and alcohol treatment programs as appropriate.

Refer patients with significant risk factors for osteoporosis to primary care providers or clinics for bone-density evaluation.


Risk for Injury

Maintain the bed in low position; use side rails if indicated; provide nighttime lighting to toilet facilities.

Avoid using restraints if at all possible.

Teach patients to participate in weight-bearing exercises to perform exercises at least three times a week for a sustained period of 30 to 40 minutes.


Risk for Injury

Encourage older adults to use assistive devices to maintain independence in ADLs.

Teach older patients about safety and fall precautions.


Readiness for Enhanced Nutrition

Teach adolescents, pregnant or lactating women, and adults through age 50 to eat foods high in calcium and to maintain a daily calcium intake of 1000 mg.

Encourage older adults and postmenopausal women to maintain a calcium intake of 1200 mg daily, either through diet or a calcium supplement.

Teach patients taking calcium supplements the importance of taking the medication at the proper time and the side effects.


Acute Pain

Suggest anti-inflammatory pain medications for treatment of both acute and chronic phases of pain.

Suggest the application of heat to relieve pain.

Pagets Disease

Pagets Disease

Etiology

family history

viral infection

Pagets Disease

Manifestations

MUSCULOSKELETAL EFFECTS

Pain, headache (with skull involvement) Deformity (enlargement of skull, bowing of lower extremities,

and deformity of elbows and knees) Pathologic fractures (upper femur, pelvis) Compression fractures Collapse of the vertebrae, kyphosis and loss of height Muscle weakness

Pagets Disease

Pagets Disease

Manifestations

NEUROLOGIC EFFECTS Hearing loss Spinal cord injuries Dementia Pain from spinal stenosis Bladder and/or bowel dysfunction

Pagets Disease

Manifestations

CARDIOVASCULAR EFFECTS Heart failure

METABOLIC EFFECTS Symptoms of hypercalcemia in

immobilized patients

Hypercalciuria and renal calculi

Increased skin temperature over affected bone

Pagets Disease

Complications

Nerve palsy syndromes

Pathologic fractures

Neurologic complications

Compression of the spinal cord from affected cervical vertebrae causing quadriplegia

Pagets Disease

Complications

Cardiovascular disease, including high-output heart failure

Osteogenic sarcoma, seen in 5% to 10% of people

Pagets Disease

Diagnosis

x-rays and bone scans

computed tomography scans

magnetic resonance imaging

serum alkaline phosphatase (30 to 115 international units/L)

urinary collagen pyridinoline test

Pagets Disease

Medications

NSAIDs, such as ibuprofen (Motrin) and indomethacin (Indocin)

Bisphosphonates such as alendronate (Fosamax), pamidronate(Aredia), and tiludronate (Skelid)

Calcium and vitamin D supplements

Salmon calcitonin (Calcimar) and human calcitonin (Cibacalcin)

Pagets Disease

Surgery

repairing a complete fracture through pagetic bone

realigning a knee through tibial osteotomy to decrease pain

replacing a hip and/or knee for osteoarthritis


Chronic Pain

Assess the location and extent of the pain to determine the bone areas involved.

Teach the patient to take NSAIDs on a regular basis as prescribed.

Ensure correct placement of prescribed brace or corset.

Suggest referral for heat therapy and massage.


Impaired Physical Mobility

Provide an assistive device for use when ambulating.

Teach good body mechanics.

Reinforce information about exercise protocols and activity regimens.

Gout

Risk Factors for Gout

Male gender

Age

Diet: higher consumption of meat and seafood

Alcohol intake

Sugar- or fructose-sweetened soft drinks

Obesity

Medications: diuretics, aspirin

Gout Manifestations

STAGE MANIFESTATIONS

Asymptomatic Hyperuricemia serum levels averaging 9 to 10 mg/dL

Acute Gouty Arthritis Usually monoarticular, affecting metatarsophalangeal joint of great toe, instep, ankle, knee, wrist, or elbow

Acute pain Red, hot, swollen, and tender joint Fever, chills, malaise Elevated WBC and sedimentation rate

Gout Manifestations

STAGE MANIFESTATIONS

Advanced Gout Tophi evident on joints, bursae, tendon sheaths, pressure points, helix of ear

Joint stiffness, limited ROM, and deformity Ulceration of tophi with chalky discharge

Complications

Kidney disease (acute renal failure)

Gout Manifestations

Gout

Diagnosis

X-rays show a punched-out look when urate acids replace bony structures

serum uric acid (usually above 7.5 mg/dL)

WBC count shows significant elevation

eosinophil sedimentation rate is elevated

serum creatinine

24-hour urine specimen

analysis of fluid from the acutely inflamed joint

Medications for Gout

Acute Attack

NSAIDs

indomethacin (Indocin)

ibuprofen (Motrin)

naproxen (Naprosyn, Anaprox)

tolmetin sodium (Tolectin)

piroxicam (Feldene)

sulindac (Clinoril)

Prophylactic Therapy

Colchicine

Allopurinol (Zyloprim)

Uricosuric Drugs Probenecid (Benemid) Sulfinpyrazone (Anturane)

Treatment for Gout

Complimentary Medicine

Vitamin E and selenium may decrease tissue inflammation.

Amino acids (alanine, aspartic acid, glutamic acid, and glycine) increase the ability of the kidneys to excrete uric acid.

Dark reddish-blue berries

Acupuncture can provide pain relief.

Treatment for Gout

Nutrition

low-purine diet is recommended

obese patient is advised to lose weight

alcohol intake and foods that tend to precipitate attacks are avoided

liberal fluid intake to maintain a daily urinary output of 2000mLor more is recommended

urinary alkalinizing agents, such as sodium bicarbonate or potassium citrate

Treatment for Gout

REST

During an acute attack of gouty arthritis, rest of the involved joint(s) is prescribed.

The affected joint may be elevated and ice packs applied for comfort.

Nursing Diagnoses and Interventions

Acute Pain

Position the affected joint for comfort. Elevate the joint or extremity (usually the foot) on a pillow, maintaining alignment.

Protect the affected joint from pressure, placing a foot cradle on the bed to keep bed covers off the foot.

Take anti-inflammatory and anti-gout medications as prescribed.

Take analgesics as prescribed. Avoid aspirin.

Maintain joint rest.

Osteomalacia

Osteomalacia

Etiology

Vitamin D Deficiency

Inadequate dietary intake

Lack of sun exposure

Malabsorption: gastric bypass, small-bowel disorders, gallbladder disease, chronic pancreatic insufficiency

Renal or liver disorders

Drug effects: isoniazid, rifampin, anticonvulsants

Osteomalacia

Etiology

Phosphate Depletion Inadequate intake Impaired absorption due to chronic antacid use Impaired renal tubular reabsorption due to either acquired or

genetic disorders

Systemic Acidosis Renal tubular acidosis Fanconis syndrome

Osteomalacia

Etiology

Bone Mineralization Inhibitors Hypophosphatasia Sodium fluoride or disodium etidronate (Didronel) Aluminum intoxication

Chronic Renal Failure

Calcium Malabsorption

Osteomalacia

Manifestations

Bone pain

Muscle weakness - early sign of vitamin D deficiency

Difficulty changing from lying to sitting position and sitting to standing position

Osteomalacia

Manifestations

Waddling gait: due to pain and muscle weakness

Dorsal kyphosis

Pathologic fractures

Osteomalacia

Medications

calcium and vitamin D (800 IU daily) supplements

phosphate supplements

Nursing Care

Teach the importance of maintaining an adequate intake of milk and other dairy products that are not only rich in calcium and phosphorus, but also are fortified with vitamin D.

Teach patients to use assistive devices such as walkers, canes, or crutches when ambulating. Teach about safety measures to prevent falls.

Encourage patients to participate in a supervised exercise program such as water aerobics or tai chi.

Osteoarthritis

Osteoarthritis

Etiology

older age

genetics

excessive weight

sedentary lifestyle

repetitive joint use (strenuous, repetitive exercise)

Manifestations of Osteoarthritis

AFFECTED SITE MANIFESTATIONS

Interphalangeal joints Heberdens nodesbony enlargements of distal interphalangeal (DIP) joints

Bouchards nodesbony enlargement of proximal interphalangeal (PIP) joints

First carpometacarpal Swelling, tenderness at base of thumb Crepitus with movement Squared appearance of joint



Spine Localized pain and stiffness Muscle spasm Limited range of motion Nerve root compression with radicular pain and

motor weakness

Hips Pain referred to inguinal area, buttock, thigh, or knee Loss of internal rotation Limited extension, adduction, and flexion



Knees Pain and bony enlargement Effusions Crepitus Instability and deformity with advanced disease Flexion contracture may develop

Osteoarthritis

Medications

ANALGESICS

acetaminophen (Tylenol)

NSAIDs

ibuprofen (Motrin) naproxen (Aleve) ketoprofen (Orudis KT)SELECTIVE COX-2 INHIBITOR celecoxib or Celebrex

TOPICAL NSAIDs

diclofenac topical gel (Pennsaid)

CAPSAICIN capzasin Zostrix

INTRA-ARTICULAR HYALURONIC ACID (HA)

Osteoarthritis

Treatment

ROM exercises, muscle strengthening exercises, aerobic exercises.

Heat and ice.

A balance between exercise and rest.

Use of a cane, crutches, or a walker as needed.

Weight loss, if indicated.

Surgical Treatment for Osteoarthritis

Arthroscopy


Osteotomy


Joint Arthroplasty


Total Hip Replacement

Treatment for Osteoarthritis

Total Knee Replacement

patient must follow a regimen of exercise, rest, and medication

Complementary and Alternative Therapies

Biomagnetic therapy Acupuncture Eliminating nightshade foods such as potatoes, tomatoes,

peppers, eggplant, tobacco. Taking nutritional supplements, such as glucosamine,

chondroitin, boron, zinc, copper, selenium, manganese, flavonoids, and/or SAM-e.

Treatment for Osteoarthritis

Complementary and Alternative Therapies

Herbal therapy Massage therapy Osteopathic manipulation Vitamin therapy Yoga

Nursing Management for Osteoarthritis

Health Promotion

Maintaining a normal weight and having a program of regular, moderate exercise.

Glucosamine and chondroitin are nutritional supplements found to be of benefit in reducing manifestations.

Nursing Management for Osteoarthritis

HEALTH HISTORY Family history of OA, occupation, recreational activities, joint

pain and stiffness, ability to carry out ADLs and self-care activities.

PHYSICAL ASSESSMENT Height/weight; gait; joints: symmetry, size, shape, color,

appearance, temperature, pain, crepitus, range of motion, Heberdens nodes, Bouchards nodes.


Chronic Pain Monitor the level of pain, including intensity, location, quality,

and aggravating and relieving factors.

Teach patients to take prescribed analgesic or anti-inflammatory medication as directed.

Encourage rest of painful joints.

Suggest applying heat to painful joints using the shower, a tub or sitz bath, warm packs, hot wax baths, heated gloves, or diathermy.


Chronic Pain Emphasize the importance of proper posture and good body

mechanics for walking, sitting, lifting, and moving.

Encourage the overweight patient to reduce weight.

Encourage the use of nonpharmacologic pain relief measures such as progressive relaxation, meditation, visualization, and distraction.



Assess the ROM of affected joints.

Perform a functional mobility assessment, evaluating gait, ability to sit and rise from sitting position, ability to step into and out of the tub or shower, and negotiation of stairs.

Teach active and passive ROM exercises as well as isometric, progressive resistance, and low-impact aerobic exercises.


Readiness for Enhanced Self-Care

Perform a functional assessment of the upper and lower extremities.

Assess the home setting to determine the need for assistive devices such as handrails, grab bars, walk-in shower stall, or shower chair and handheld showerhead.

Assist in obtaining other assistive devices such as long-handled shoehorns, zipper grabbers, long-handled tongs, jar openers, and special eating utensils.

Muscular Dystrophy

Muscular Dystrophy

TYPE ONSET MANIFESTATION PROGRESS

Duchenne Males Ages 3 to 5

Weakness of pelvic and shoulder girdles

Waddling gait Toe walking Lordosis Cardiac abnormalities Low IQ in 50% of cases

Rapid; patient usually confined towheelchair by age 15; death occurs by age 20

Muscular Dystrophy

Muscular Dystrophy


Myotonic Males and females

Any age

Weakness and atrophy of facial muscles

Muscle weakness of distal extremities

Cardiac abnormalities Endocrine

abnormalities Mental retardation

(common)

Slow; death usually occurs inearly 50s

Muscular Dystrophy


Becker Males Ages 5 to 20

Weakness of pelvic and shoulder girdles

Cardiac involvement, possible heart failure

Slow; patient usually confined to wheelchair at 25 years after onset; life span into 30s to 50s

Muscular Dystrophy


Facioscapulohumeral

Males and females

Ages 10 to 20

Weakness of face and shoulder girdlesEventual involvement of abdominal, feet,and pelvic musclesure

Slow; normal life span

Muscular Dystrophy


Limb-girdle Males and females

Ages 15 to 40

Weakness of shoulder and pelvic girdles

Extremely variable; usually slow

Muscular Dystrophy

Treatment for Muscular Dystrophy

Diagnosis

creatine kinase - elevated

muscle biopsy

electromyogram (EMG) - decrease in amplitude

Nursing Management for Muscular Dystrophy

Promoting independence and mobility and providing psychologic support for both the patient and family.

Holistic approach is essential in planning and implementing care.


Provide patients and family with supportive care during the progress of the disease.

Promote independence. Encourage tasks that can be accomplished rather than letting the patient struggle with tasks that may prove frustrating.

Rheumatoid Arthritis


genetic factors in combination with environmental factors infectious agent, such as mycoplasma, Epstein-Barr virus, or

another virus heavy smokers


Joint Manifestations

joint swelling with associated stiffness, warmth, tenderness, and pain

fatigue, anorexia, weight loss, and nonspecific aching

Swollen, inflamed joints feel boggy or sponge-like on palpation

ROM is limited in affected joints, and weakness

Swan-neck deformity

Boutonnire deformity


Joint Manifestations

deformities of the feet and toes include subluxation, hallux valgus, lateral deviation of the toes, and cock-up toes


Extra-Articular Manifestations

Fatigue, weakness, anorexia, weight loss, and low-grade fever

Anemia resistant to iron therapy

Skeletal muscle atrophy

Pleural effusion, vasculitis, pericarditis, and splenomegaly


FEATURE RHEUMATOID ARTHRITIS OSTEOARTHRITIS

Onset Usually insidious, may be abrupt

Insidious

Course Generally progressive, characterized by remissionsand exacerbations

Slowly progressive

Pain and stiffness Predominant on arising, lasting > 1 hour; also occurs after prolonged inactivity

Pain with activity; stiffness following periods ofimmobility generally relieved within minutes



Affected joints Appear red, hot, swollen; boggy and tender to palpation; decreased ROM, weakness

Multiple joints affected in symmetric pattern; PIP, MCP, wrists, knees, ankles, and toes often involved

Affected joints may appear swollen; cool and bony hard on palpation; decreased ROM

One or several joints affected including hips, knees, lumbar and cervical spine, PIP and DIP, and 1st MTP joint



Systemicmanifestations

Fatigue, weakness, anorexia, weight loss, fever; rheumatoid nodules; anemia

Fatigue


Diagnostic Criteria for Rheumatoid Arthritis

Morning stiffness lasting for at least 1 hour and persisting for at least 6 weeks

Arthritis with swelling or effusion of three or more joints persisting for at least 6 weeks

Arthritis of wrist, MCP, or PIP joints persisting for at least 6 weeks

Symmetric arthritis with simultaneous involvement of corresponding joints on both sides of the body


Diagnostic Criteria for Rheumatoid Arthritis

Rheumatoid nodules

Positive serum rheumatoid factor

Characteristic radiologic changes of rheumatoid arthritis


Medications

NSAIDs and mild analgesics

low-dose oral corticosteroids

disease-modifying antirheumatic drugs (DMARDs)

NSAIDs Used to Treat Rheumatoid Arthritis

DRUG NURSING PRECAUTIONS

Aspirin Least expensive NSAID; associated with risk of GI ulceration, bleeding, and possible hemorrhage; may cause hepatotoxicity

Diclofenac (Voltaren) Expensive; risk of hepatotoxicity

Ibuprofen (Motrin, Advil, others)

Available in prescription and OTC forms; less gastric distress reported than with aspirin or indomethacin;discontinue if visual disturbances develop

NSAIDs Used to Treat Rheumatoid Arthritis

DRUG NURSING PRECAUTIONS

Indomethacin (Indocin)

A potent NSAID used for moderate to severe RA and acute episodes of chronic disease; higher incidence of adverse GI effects and CNS effects such as headache, dizziness, and depression

Naproxen (Aleve,Anaprox, Naprosyn)

Available in prescription and OTC preparations

Disease-Modifying Drugs Used to Treat Rheumatoid Arthritis

DRUG ADVERSE EFFECTS NURSING PRECAUTIONS

Abatacept(Orencia)

HeadacheNauseaUpper respiratorytract infection

Screen for tuberculosis prior to initiating treatment

Stop infusion and notify physician if hypotension, urticaria, or dyspnea develop

Instruct to promptly report signs of allergic response or infection

Advise to avoid live-virus vaccines while taking abatacept and for 3 months after discontinuing the drug

Disease-Modifying Drugs Used to Treat Rheumatoid Arthritis

DRUG ADVERSE EFFECTS NURSING PRECAUTIONS

Methotrexate Stomatitis, gastric distress

Blood dyscrasias Liver toxicity,

cirrhosis Interstitial

pneumonitis,pulmonary fibrosis

Maintain high fluid intake Inspect mouth daily; report ulcerations,

necrotic areas, bleeding or discomfort Monitor liver and kidney function tests,

CBC, chest x-rays, reporting abnormal or unexpected results

Instruct to avoid alcohol and exposure to sunlight or ultraviolet light

Instruct to practice effective contraception during treatment

Treatment for Rheumatoid Arthritis

REST AND EXERCISE

short period of bed rest may be prescribed during an acute exacerbation of the disease

splinting of inflamed joints

orthotic devices to reduce joint strain and help maintain function

ROM exercises

isometric exercises and isotonic exercises

low impact aerobic exercises


PHYSICAL AND OCCUPATIONAL THERAPY

Physical and occupational therapists design and monitor individualized activity and rest programs.

HEAT AND COLD

Heat and cold are used for their analgesic and muscle-relaxing effects


ASSISTIVE DEVICES AND SPLINTS

cane, walker, or raised toilet seat, are most useful for patients with significant hip or knee arthritis

splints provide joint rest and prevent contractures

NUTRITION

ordinary, well-balanced diet is recommended

dietary fat with omega-3 fatty acids found in certain fish oils


OTHER THERAPIES

plasmapheresis

total lymphoid irradiation

SURGERY

synovectomy

arthrodesis

arthroplasty

total joint replacement

Nursing Management for Rheumatoid Arthritis

Assessment

Health history: Pain; stiffness; fatigue; joint problems: location, duration, onset, effect on function; fever; sleep patterns; past illnesses or surgery; ability to carry out ADLs and self-care activities.

Physical assessment: Height/weight; gait; joints: symmetry, size, shape, color, appearance, temperature, range of motion, pain; skin: nodules, purpura; respiratory: cough, crackles; cardiovascular: pericardial friction rub, apical bradycardia, S3.


Chronic Pain

Monitor the level of pain and duration of morning stiffness.

Teach the importance of joint and whole-body rest in relieving pain.

Teach the use of heat and cold applications to provide pain relief.

Teach about the use of prescribed anti-inflammatory medication and the relationship of pain and inflammation.

Encourage using other nonpharmacologic pain relief measures such as visualization, distraction, meditation, and progressive relaxation techniques.


Fatigue

Encourage a balance of periods of activity with periods of rest.

Stress the importance of planned rest periods during the day.

Help in prioritizing activities, performing the most important ones early in the day.

Encourage regular physical activity in addition to prescribed ROM exercises.

Refer to counseling or support groups.


Ineffective Role Performance

Discuss the effects of the disease on the patients career and other life roles.

Encourage the patient and family to discuss their feelings about role changes and grieve lost roles or abilities.

Listen actively to concerns expressed by the patient and family members; acknowledge the validity of concerns about the disease, prescribed treatment, and the prognosis.


Ineffective Role Performance

Help the patient and family identify strengths they can use to cope with role changes.

Encourage the patient to make decisions and assume personal responsibility for disease management.


Disturbed Body Image

Demonstrate a caring, accepting attitude toward the patient.

Encourage the patient to talk about the effects of the disease, both physical effects and effects on life roles.

Encourage the patient to maintain self-care and usual roles to the extent possible. Provide positive feedback for self-care activities and adaptive strategies.

Refer to self-help groups, support groups, and other agencies that provide assistive devices and literature.

Ankylosing Spondylitis


Etiology

men have more severe disease

genetic component (HLA-B27 antigen)

enteric bacteria


Manifestations

persistent or intermittent bouts of low back pain that may radiate to the buttocks, hips, or down the legs

morning stiffness that is relieved by activity

peripheral arthritis, primarily affecting the hip, shoulders, and knee joints

anorexia, weight loss, fever, and fatigue

inflammatory bowel disease, psoriasis, and, uncommonly, pulmonary or cardiac dysfunction

Management for Ankylosing Spondylitis

Diagnosis

elevated ESR during periods of active disease

positive HLA-B27 antigen

x-ray examination of the sacroiliac joints and spine (confirm)

magnetic resonance imaging

Management for Ankylosing Spondylitis

Treatment

physical therapy and daily exercises

NSAIDs

DMARD that targets tumor necrosis factor-alpha e.g. infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira)

Nursing Management for Ankylosing Spondylitis

Teach the patient to take NSAIDs at regular intervals throughout the day with food, milk, or antacid.

Encourage the patient to maintain a fluid intake of 2500 mL or more per day.

Suggest that the patient perform exercises in the shower because warm, moist heat prompts mobility.

Stress the importance of following the prescribed physical therapy and exercise program to maintain mobility.

Nursing Management for Ankylosing Spondylitis

Teach the patient that proper positioning and posture are important.

Teach the patient to losing weight if applicable, avoiding smoking, and using muscle-strengthening exercises.

Suggest occupational counseling if pain and deformity are severe enough to cause work-related problems.

Reactive Arthritis

Reactive Arthritis

Etiology

Chlamydia or Salmonella, Shigella, Yersinia, or Campylobacter

inherited HLA-B27 antigen

HIV infection

Reactive Arthritis

Manifestations

nonbacterial urethritis in men.

urethritis and cervicitis in women may be asymptomatic

fatigue, malaise, fever, and weight loss

conjunctivitis and acute inflammatory arthritis

tendinitis, fasciitis, and back pain

mouth ulcers, inflammation of the glans penis, and skin lesions

heart and aorta may also be affected

Reactive Arthritis

Treatment

diagnosis is based on the patients history and presenting symptoms

NSAIDs

DMARD such as sulfasalazine immunosuppressive agent such as azathioprine (Imuran)

Nursing Management for Reactive Arthritis

Teach the patient about the association of the arthritis with the precipitating infection (if identified).

Provide information about sexually transmitted infections and protective measures to prevent their transmission.

Discuss the usual self-limited nature of reactive arthritis, the appropriate use of prescribed NSAID preparations, and symptomatic relief measures such as application of heat and rest.

Systemic Lupus Erythematosus


Etiology

human leukocyte antigen (HLA) genes

viruses (e.g., Epstein-Barr virus), bacterial antigens, chemicals, drugs, or ultraviolet light

imbalance of sex hormones


Manifestations

Painful or swollen joints and muscle pain

Unexplained fever Red rash, especially on the face Alopecia Pale, cyanotic fingers or toes Sensitivity to the sun

Edema in legs and around eyes Ulcers in the mouth Enlarged glands Extreme fatigue


Butterfly Rash


Warning Signs of a Flare

Increased fatigue

Pain, abdominal discomfort

Rash

Headache

Fever

Dizziness


Diagnosis

ANA testing is positive in more than 95% of patients with SLE.

ESR is typically elevated, occasionally to > 100 mm/h.

Serum complement levels are usually decreased

CBC abnormalities include moderate to severe anemia, leukopenia and lymphocytopenia, and possible thrombocytopenia.


Diagnosis

Urinalysis shows mild proteinuria, hematuria, and blood cell casts during exacerbations of the disease when the kidneys are involved.

Renal function tests including serum creatinine, blood urea nitrogen (BUN), and GFR to evaluate the extent of renal disease.

Kidney biopsy to assess the severity of renal lesions and guide therapy


Medications

Arthralgias, arthritis, fever, and fatigue can often be managed with aspirin or other NSAIDs.

Skin and arthritic manifestations may be treated with antimalarial drugs such as hydroxychloroquine (Plaquenil).

Patients with severe and life-threatening manifestations (such as nephritis, hemolytic anemia, myocarditis, pericarditis, or CNS lupus) require corticosteroid therapy in high doses


Medications

Immunosuppressive agents such as cyclophosphamide or azathioprine may be used, alone or in combination with corticosteroids


Treatment

Patients should use sunscreens with a sun protection factor (SPF) rating of 15 or higher when out of doors.

Topical corticosteroids to treat skin lesions.

Avoiding the use of oral contraceptives because estrogen can trigger an acute episode.

End stage renal disease are treated with dialysis (hemodialysis or peritoneal dialysis) and kidney transplantation

Nursing Management for Systemic Lupus Erythematosus

Impaired Skin Integrity

Assess knowledge of SLE and its possible effects on the skin.

Discuss the relationship between sun exposure and disease activity, both dermatologic and systemic.

Keep skin clean and dry; apply therapeutic creams or ointments to lesions as prescribed.


Impaired Skin Integrity

Suggest the following strategies to limit sun exposure:

Avoid being out of doors during hours of greatest sun intensity. Use sunscreen with an SPF of 15 or higher when sun exposure

cannot be avoided. Apply it 30 minutes before going out into the sun.

Reapply sunscreen after swimming, exercising, or bathing. Wear loose clothing with long sleeves and wide-brimmed hats

when out of doors.


Ineffective Protection

Wash hands before and after providing direct care.

Use strict aseptic technique in caring for intravenous lines and indwelling urinary catheters or performing any wound care.

Assess frequently for infection. Monitor temperature and vital signs every 4 hours. Assess for signs of cellulitis, including tenderness, redness, swelling, and warmth. Report signs of infection to the physician promptly.



Monitor laboratory values, including CBC and tests of organ function; report changes to the physician.

Initiate reverse or protective isolation procedures as indicated by the patients immune status.

Ensure an adequate nutrient intake, offering supplementary feedings as indicated or maintaining parenteral nutrition if necessary.



Teach the patient the importance of good hand hygiene after using the bathroom and before eating.

Monitor for potential adverse effects of medications including thrombocytopenia and possible bleeding, fluid retention with edema and possible hypertension, loss of bone density, osteoporosis, and possible pathologic fractures, renal or hepatic toxicity, and cardiac effects, particularly in the patient with fluid retention and hypervolemia.



Assess the ability to maintain optimal health, identifying physical and psychosocial factors that may affect health maintenance.

Provide care and teaching in a nonjudgmental manner.

Encourage the patient and family members to discuss the effect of the disease on their lives.

Initiate an interdisciplinary care conference with the patient and family.



Refer the patient and family to counseling as needed.

Refer the patient and family to community and social service agencies, and local support groups.

Polymyositis

Polymyositis

Manifestations

muscle pain, tenderness, and weakness; rash; arthralgias; fatigue; fever; and weight loss

muscle weakness predominant manifestation

dusky red rash may be present on the face and upper trunk

Raynauds phenomenon, dysphagia, dyspnea, and cough

Polymyositis

Polymyositis

Diagnosis

autoantibodies identified in blood serum

creatine kinase (CK) and aldolase levels is elevated

biopsy of involved muscle shows patchy muscle fiber necrosis and the presence of inflammatory cells

Polymyositis

Treatment

rest and corticosteroid therapy

Immunosuppressive agents such as methotrexate, cyclophosphamide, and azathioprine may be used for patients who do not respond well to treatment with corticosteroids.

Nursing Management for Polymyositis

Provide alternate means of communication as needed, and use patience in listening.

Modify the patients diet as needed to maintain nutrition and safety.

Emphasize the need to balance periods of rest and activity.

Discuss skin care to prevent dryness and infection.

Teach the patient about prescribed medications and their short and long-term side effects.

Lyme Disease

Lyme Disease

Manifestations

erythema migrans - initial manifestation

fatigue, malaise, fever, chills, and myalgias

facial nerve palsy and meningitis

arthritis, arthralgias, myalgias, and tendinitis

Lyme Disease

Erythema migrans

Lyme Disease

Complications

Chronic recurrent arthritis, primarily affecting large joints (especially the knee).

Meningitis, encephalitis, and neuropathies, as well as cardiac complications including myocarditis and heart block.

Lyme Disease

Diagnosis

Enzyme-linked immunosorbent assay (ELISA) or Western blot methods within 2 to 4 weeks of the initial skin lesion

Treatment

Antibiotics including doxycycline (Doxy-Caps, Vibramycin), tetracycline, amoxicillin (Amoxil), cefuroxime axetil (Ceftin), or erythromycin

aspirin or another NSAID may be prescribed for relief of arthritic symptoms

Nursing Management for Lyme Disease

Avoid tick-infested areas, especially in spring and summer, such as woods and rural areas with brush and tall weeds.

Cover exposed skin with long-sleeved shirts and tuck pants into socks. Wearing high rubber boots may provide additional protection.

Use insect repellents that contain DEET on clothing and exposed skin and apply permethrin to clothing prior to exposure.

Remove attached ticks with fine-tipped tweezers.

Osteomyelitis

Osteomyelitis

Etiology

adults over age 50

bacterial, fungi, parasites, and viruses

Types of Osteomyelitis

TYPE PATHOPHYSIOLOGY

HematogenousOsteomyelitis

affects older adults, people with sickle cell anemia, and intravenous drug users

lumbar spine is involved more frequently urinary tract infections, soft tissue infection,

endocarditis, and infected intravenous sites are sources of pathogens

Osteomyelitis from a Contiguous Infection

complication of direct penetrating wounds, joint replacements, decubitus ulcers, and neurosurgery

most common cause of osteomyelitis in adults

Types of Osteomyelitis


Osteomyelitis Associated with Vascular Insufficiency

diabetes and peripheral vascular disease are at risk

Manifestations of Osteomyelitis

LOCAL EFFECTS

Drainage and ulceration at involved site

Swelling, erythema, and warmth at involved site

Localized tenderness

Acute or chronic pain of increasing intensity

Manifestations of Osteomyelitis

SYSTEMIC EFFECTS

Lymph node involvement, especially in the involved extremity

High temperature with chills

Malaise

Tachycardia

Nausea and vomiting

Anorexia

Osteomyelitis

Diagnosis

bone scans and MRI to identify abscesses, sinus tracts, and bone changes

ultrasound to detect subperiosteal fluid collections, abscesses, and periosteal thickening and elevation

ESR and WBC are elevated

blood and tissue cultures to identify the infecting organism and direct antibiotic therapy

Osteomyelitis

Medications

parenteral antibiotic therapy begins as soon as cultures are obtained

penicillinase-resistant semisynthetic penicillin (e.g., nafcillin, oxacillin) may be given until the culture and sensitivity results are known

oral therapy with twice-daily ciprofloxacin for treating adult patients with chronic osteomyelitis

Osteomyelitis

Surgery

surgical debridement is the primary treatment

musculocutaneous (myocutaneous) flap for the treatment of the dead space


Risk for Infection

Maintain strict hand hygiene practices.

Administer antimicrobial therapy at specified time intervals.

Maintain the patients optimal dietary kilocalorie and protein intake.


Hyperthermia

Monitor temperature every 4 hours and when patient reports chills and/or fever.

Blood cultures are frequently ordered when an acute elevation of temperature occurs.

Maintain a cool environment and provide light clothing and bedding during temperature elevation.

Ensure a daily fluid intake of 2000 to 3000 mL.



Maintain the affected limb in functional position when immobilized.

Maintain rest, and avoid subjecting the affected extremity to weight-bearing activities.

Ensure active or passive ROM exercises every 4 hours.


Acute Pain

Use a splint or immobilizer when the patient experiences acute pain from swelling.

Ask the physician to order scheduled administration of narcotic and nonnarcotic analgesics on a 24-hour basis.

Use nonpharmacologic strategies (e.g., heat, distraction, relaxation techniques) for adjunctive pain management.

Avoid excessive manipulation of the involved area; handle the area gently.

Septic Arthritis

Septic Arthritis

Etiology

Persistent bacteremia (e.g., injectable drugs, endocarditis)

previous joint damage (e.g., trauma or rheumatoid arthritis)

impaired immunity (e.g., diabetes, renal failure, alcoholism)

loss of skin integrity

arthroscopic surgery and total joint replacements

Septic Arthritis

Manifestations

pain and stiffness of the infected joint

joint appears red and swollen, and is hot and tender to the touch

effusion

chills and fever

Septic Arthritis

Diagnosis

fluid from the affected joint is aspirated and sent for Gram stain and culture

infected synovial fluid is cloudy, with a high WBC count and a low glucose level

joint x-ray films show demineralization, bony erosions, and joint space narrowing

Septic Arthritis

Treatment

infected joint is treated with rest, immobilization, elevation

broad-spectrum parenteral antibiotic

frequent joint aspirations to remove excess fluid and pus, and to evaluate for the continued presence of bacteria

physical therapy to ensure maintenance of optimal joint function

Septic Arthritis

Nursing Care

elevate affected joint with pillows as needed

splints or traction may be used to immobilize the joint.

warm compresses for comfort

active ROM exercises preserve joint mobility

provide information about the disorder, its etiology, and its treatment

Bone Tumors

Bone Tumors

Tumors that metastasize to bone:

Particular Tumors Love Killing Bone

Prostate

Thyroid

Lung

Kidney

Breast

Benign Bone Tumors

TYPE SITE INCIDENCE

Osteochondromamost commonbenign tumor

Pelvis, scapula, ribs Higher in males

Chondroma Hands, feet, ribs, spine, sternum, or long bones

Ages 30 to 50 Higher in males

Benign Bone Tumors

TYPE SITE INCIDENCE

OsteoidOsteoma

Shaft (diaphysis) of long bones (i.e., femur, tibia)

Ages 20 to 30 Higher in males

Giant cell tumor Shaft (diaphysis) of long bones (i.e., femur, tibia, radius, humerus)

4% to 5% of bone tumors

Wide age distribution Higher in females

Malignant Bone Tumors

TYPE SITE INCIDENCE

Chondrosarcoma Femur, pelvis, ribs, head (epiphysis) of long bones

13% of malignant bone tumors

Middle age and older Higher in males

Osteosarcomamost common malignant tumor affectingnonhematopoieticbone

Long bones, knee 38%ofmalignant bone tumors

Predominant in adolescents and people ages 50 to 60

Malignant Bone Tumors

TYPE SITE INCIDENCE

Fibrosarcoma Femur, tibia 4%of malignant bone tumors Wide age distribution, but

usually occurs in people ages 40 to 50

Higher in females

Multiple myelomamost common malignant bone tumor

Axial skeleton (e.g., ribs, vertebrae, skull), proximal long bones (femur, humerus)

More common in Blacks andolder adults

Manifestations of Bone Tumors

BONY SARCOMAS

SITE MANIFESTATIONS

Upper or lower extremity and pelvis

Worsening deep bony pain Pain at night or during rest that may radiate and

become severe Muscular weakness or atrophy

Metaphysis of distal femur, proximaltibia, proximal humerus, and pelvis

Soft tissue mass extending from bone with erythematous or warm skin over tissue mass

Change in ability to perform ADLs Fever


SOFT TISSUE SARCOMAS

SITE MANIFESTATIONS

Upper or lower extremity and pelvis

Enlarging firm mass with irregular borders, which causes pain in surrounding soft tissue structures

Thigh; shoulder and pelvis

Erythema or warmth and venous dilation over skin Muscular weakness and atrophy with limited ROM,

change in ability to perform ADLs and change in gait Paresthesias with neurologic involvement and distal

swelling Palpable local lymph nodes


SOFT TISSUE SARCOMAS

SITE MANIFESTATIONS

Pelvis Altered bowel and bladder habits or pain with intercourse

Bone Tumors

Diagnosis x-rays show the location of the tumors and the extent of bone

involvement CT scan and MRI in evaluating the extent of tumor invasion into

bone, soft tissues, and neurovascular structures percutaneous needle biopsy to determine the exact type of bone

tumor alkaline phosphatase (elevated with malignant bone tumor) and

a calcium level (increased with massive bone destruction)

Bone Tumors

Chemotherapy

Alkylating AgentsIfosfamide

Cyclophosphamide

AntibioticsDoxorubicinBleomycin

AntimetabolitesMethotrexate

Plant AlkaloidsVincristine

Synthetic AgentsCisplatin

Bone Tumors

Radiation Therapy frequently applied to metastatic bone carcinomas as a method of

pain control

Surgery excising the tumor itself or by amputating the affected limb cadaver allografts or metal prostheses often are used to replace

missing bone, avoiding amputation


Risk for Injury

Teach how to avoid falls or injury to the tumor site, such as by using assistive devices when walking and ensuring the home environment is not conducive to falling

Provide referral to physical or occupational therapy for fitting of and teaching about assistive devices for ambulating, such as a cane, crutches, or a walker.


Acute Pain, Chronic Pain

Develop strategies for controlling both acute pain (from surgery, fracture, or inflammation) and chronic pain (from progression of the disease).

Provide assistive devices (e.g., canes, walkers, crutches) when the patient ambulates.



Begin muscle strengthening and active and passive ROM exercises immediately after surgery.

Encourage exercises that help strengthen the triceps muscles.

For the patient who has undergone an amputation of a lower extremity, encourage quadriceps and gluteal setting exercises and leg raises.


Decisional Conflict

Discuss issues related to diagnosis, radiologic evaluation, biopsy, surgery, chemotherapy, radiation therapy, potential complications, alternative therapies, risks, benefits, nursing management, discharge plans, home care, and long-term treatment and follow-up.

Systemic Sclerosis (Scleroderma)


Local Manifestations

diffuse, non-pitting edema

skin begins to atrophy, becoming taut, shiny, and hyperpigmented

facial skin tightening leads to loss of skin lines and a pursed-lip appearance

telangiectasias and calcium deposits, usually noted around joints

arthralgias and Raynauds phenomenon


Systemic Manifestations

dysphagia

exertional dyspnea and right sided heart failure

pericarditis and dysrhythmias

diarrhea or constipation, abdominal cramping, and malabsorption

proteinuria, hematuria, hypertension, and renal failure


Diagnosis

titer of 1:40 or higher for antinuclear antibody (ANA) sensitive test

elevated ESR

CBC - anemia.

skin biopsy - confirmatory


Medications

Immunosuppressive agents and corticosteroids

Penicillamine

Calcium channel blockers such as nifedipine (Procardia) or alpha-adrenergic blockers such as prazosin (Minipress) for Raynauds phenomenon

H2-receptor blockers such as cimetidine (Tagamet) or ranitidine (Zantac), antacids, or omeprazole (Prilosec) to block gastric secretion


Medications

Tetracycline or another broad-spectrum antibiotic to suppress intestinal flora and relieve symptoms of malabsorption

Angiotensin-converting enzyme (ACE) inhibitors such as captopril (Capoten) to control hypertension and preserve renal function


Nursing Management

Apply moisturizers to prevent dryness and cracking.

Protect the skin where it is stretched taut over joints or bony prominences.

Perform ROM exercises to help prevent joint contractures.

Provide small, frequent meals for esophagitis.

Keep the patient in a sitting or Fowlers position after meals and elevate the head of the bed to minimize esophageal reflux.


Nursing Management

Establish an atmosphere of trust with the patient.

Listen actively and acknowledge concerns about the disease and its effects on the patients life and appearance.

Encourage the patient to share these concerns with family members and significant others.

Provide referral to social services or counseling as appropriate.

Sjgrens Syndrome

Sjgrens Syndrome

Manifestations

xerophthalmia

xerostomia

parotid gland enlargement

systemic effects - arthritis, dysphagia, pancreatitis, pleuritis, neurologic manifestations including migraine, and vasculitis

Sjgrens Syndrome

Diagnosis

Diagnosis is based on the patients history and clinical presentation

Schirmers test

biopsy of lip for evidence of lymphoid foci - definitive diagnosis

Sjgrens Syndrome

Treatment

Artificial tears are used to decrease eye irritation and dryness.

Drinking fluids, using a saliva substitute, and chewing sugarless gum.

Medications that increase mouth dryness, such as atropine and decongestants, should be avoided.

Sjgrens Syndrome

Nursing Care

Instill artificial tears as needed.

Encourage the patient to sip fluids throughout the day.

Provide frequent oral hygiene, particularly before and after meals.

Ensure that the patient has sufficient fluids to drink during meals, because fluids help with chewing and swallowing.

Fibromyalgia

Fibromyalgia

Etiology

women are affected nine times more frequently than men

older age

genetic and environmental factors

physical or emotional trauma

Fibromyalgia

Manifestations

Pain is produced by palpating localized tender points

Local tightness or muscle spasm

Systemic manifestations include fatigue, sleep disruptions, headaches, morning stiffness, painful menstrual periods, and problems with thinking and memory (fibro fog)

Fibromyalgia

Fibromyalgia

Diagnosis

history of widespread pain that has been present for at least 3 months and pain at 11 or more of the 18 tender points on palpation

Fibromyalgia

Treatment

Program of structured aerobic exercise for conditioning, as well as stretching exercises.

Heated pool treatments with or without exercise.

Cognitive behavioral therapy, hypnotherapy, biofeedback, and acupuncture.

Tricyclic antidepressants (e.g., amitriptyline, nortriptyline, or doxepin), to promote better sleep and relieve manifestations of fibromyalgia.

Fibromyalgia

Treatment

Selective serotonin reuptake inhibitor (SSRI) antidepressants (e.g., fluoxetine [Prozac] and paroxetine [Paxil]). O

Duloxetine (Cymbalta) and milnacipran (Savella) are mixed reuptake inhibitors that increase both serotonin and norepinephrine levels.

Pregabalin (Lyrica), was developed to treat neuropathic pain.

Tramadol (Ultram) or an NSAID analgesic for pain relief.

Fibromyalgia

Nursing Care

Acknowledgment of the patients symptoms and the chronic but treatable nature of this disease.

Teach patients about the disorder, and reassure them that its course is not progressive and it does not cause crippling or deformity.

Provide verbal and written instructions about the use of heat, exercise, stress-reduction techniques, and prescribed medications to relieve manifestations.

Spinal Deformity

Spinal Deformity

DEFORMITY PATHOPHYSIOLOGY

Scoliosis lateral curvature of the spine right thoracic curve is the most common curves greater than 40 degrees are considered severe

Kyphosis excessive angulation of the normal posterior curve of the thoracic spine

result from congenital malformations or pediatricdisorders such as rickets or poliomyelitis

Spinal Deformity

Spinal Deformity

Manifestations of Scoliosis and Kyphosis

SCOLIOSIS

Asymmetry of shoulders, scapulae, waist creases

Prominence of the thoracic ribs or paravertebral muscles on forward bend

Lateral curvature and vertebral rotation on posteroanterior x-ray film

Spinal Deformity

Manifestations of Scoliosis and Kyphosis

SEVERE SCOLIOSIS

Back pain

Shortness of breath

Anorexia, nausea

KYPHOSIS

Posterior rounding at the thoracic level

Kyphotic curve of over 45 degrees on x-ray film

Spinal Deformity

Diagnosis

Upright posteroanterior and lateral x-rays confirmatory

For scoliosis, the degree of curvature is measured by determining the amount of lateral deviation to the left or right.

For kyphosis, anteroposterior and lateral views typically reveal wedging of the vertebrae.

Spinal Deformity

Treatment

Weight reduction, active and passive exercises, and the use of braces for support

Surgical procedure involves attaching metal reinforcing rods to the vertebrae


Risk for Injury

Assess the environment for safety hazards.

Teach the patient ways to reduce irritation of skin surfaces beneath the brace: wearing a smooth cotton t-shirt or cotton tube under the brace at all times, changing undergarments at least once daily, and washing them with a mild soap.

Teach the patient to loosen the brace during meals and for the first 30 minutes after each meal.


Risk for Injury

Teach patients how to apply the brace, and explain ambulatory restrictions.

Turn patients who have undergone spinal surgery by using the log-rolling technique.

Patients require a position change at least every 2 hours.

Use a fracture bedpan following surgery.


Risk for Peripheral Neurovascular Dysfunction

Monitor the movement and sensation of lower extremities every 2 hours for the first 8 hours then every shift and as needed.

Low Back Pain

Low Back Pain


Local pain compression or irritation of sensory nerves fractures, strains, and sprains are common causes tumors may press on pain-sensitive structures

Referred pain originate from abdominal or pelvic viscera

Pain of spinal origin

associated with pathology of the spine such as disk Referred to other structures such as the buttocks, groin,

or legs

Low Back Pain


Radicular back pain sharp, radiating from the back to the leg along a nerve root.

aggravated by movements such as coughing, sneezing, or sitting

Muscle spasm pain associated with many spine disorders pain is dull and may be accompanied by abnormal

posture and taut spinal muscles

Low Back Pain

Etiology

Mechanical Injury or Trauma Muscle strain or spasm Compression fracture Lumbar disk disease

Degenerative Disorders Spondylosis Spinal stenosis Osteoarthritis

Low Back Pain

Etiology

Systemic Disorders Osteomyelitis Osteoporosis or osteomalacia Neoplasms, primary or metastatic

Low Back Pain

Etiology

Referred Pain Gastrointestinal disorders Genitourinary disorders Gynecologic disorders Abdominal aortic aneurysm Hip pathology

Low Back Pain

Etiology

Other

Fibromyalgia

Psychiatric syndromes

Chronic anxiety

Depression

Low Back Pain

Manifestations

ALTERATIONS IN GAIT AND FLEXION Walking in a stiff, flexed state Inability to bend at waist Limp, which may indicate impairment of the sciatic nerve

NEUROLOGIC INVOLVEMENT Loss of both bowel and bladder control due to involvement of

the sacral nerve

Low Back Pain

Manifestations

PAIN Pain in the affected leg when walking on heel or toes Continuous, knifelike localized pain in muscles close to the

affected disk Pain that radiates down posterior of leg Sharp, burning pain in the posterior thigh or calf Pain in middle of buttock Tenderness when muscle close to the affected disk is palpated Severe pain with straight leg-raising maneuver

Low Back Pain

Diagnosis

radiography

CT scans

MRI

Low Back Pain

Medications

NSAIDs and analgesics

Muscle relaxants, such as cyclobenzaprine (Flexeril), methocarbamol (Robaxin), or carisoprodol (Soma)

Epidural steroid injections

Low Back Pain

Treatment

limited rest, combined with appropriate exercise and education

active rehabilitation helps to restore function and reduce pain

ice bag or heating pad applied to the back

physical therapy procedures include diathermy (deep heat therapy), ultrasonography, hydrotherapy, and transcutaneous electrical nerve stimulation (TENS) units

complementary and alternative medicine include chiropractic, acupuncture, and massage

Low Back Pain

Health Promotion

Have a regular exercise program.

Stretch before working in the yard, jogging, and playing sports.

Quit smoking.

Lose weight, if needed.

Maintain a correct posture.

Use supportive seats when driving.

Lift by bending at the knees rather than at the waist.

Reduce emotional stress that causes muscle tension.


Acute Pain

Teach the patient appropriate comfort measures.

Instruct the patient to take NSAIDs or analgesics on a routine schedule rather than as needed.


Readiness for Enhanced Knowledge

Encourage patients to stay active.

Teach the patient about the rebound phenomenon of prolonged heat or ice therapy.

Provide instructions about appropriate back exercises such as partial sit-ups with the knees bent and knee-chest exercises to stretch hamstrings and spinal muscles.



Teach the use of appropriate body mechanics in lifting and reaching. The patient should be instructed to plan the lift, keep the object being lifted close to the body, and avoid twisting when lifting.

Instruct the patient to modify the workplace or environment to minimize stress to the lower back.

Encourage obese patients to lose weight.

Common Foot Disorders

Common Foot disorders

DISORDER PATHOPHYSIOLOGY

Hallux Valgus enlargement and lateral displacement of the first metatarsal (the great toe)

calluses form over the metatarsal head, and bursitis develops in the MTP

joint pain or pain around calluses develop In advanced or severe cases, the first metatarsal joint

may have limited ROM, particularly in dorsiflexion, and crepitus may occur



Hammertoe dorsiflexion of the first phalanx with accompanying plantar flexion of the second and third phalanges

mild inflammation of the synovial membranes of the involved joints

dorsiflexed joint rubs against the overlying shoe, causing painful corns to develop



Mortons Neuroma tumor like mass formed within the neurovascular bundle of the intermetatarsal spaces

caused by wearing tight, confining shoes burning pain at the web space of the affected foot that

radiates into the tips of the involved toes weight bearing usually worsens any symptoms


Diagnosis

X-ray

Treatment

Orthotic devices that cushion and stretch the affected joints may be placed within shoes or between the patients toes.

For Mortons neuroma, metatarsal pads are used to spread the patients toes and decompress the affected nerve.

Analgesics may be prescribed to relieve pain and inflammation.


Treatment

Corticosteroid drugs may be injected into the affected joints or surrounding tissue to relieve acute inflammation.

Hallux valgus is treated with bunionectomy.


Chronic Pain

Instruct patients to wear corrective footwear to assist in the conservative treatment of foot problems.

Suggest purchasing appropriate pads to wear over painful bunions, calluses/corns, and the ball of the foot.

Instruct patients to remove pads and inspect the skin every other day.


Risk for Infection

Teach patients proper care and cleaning of exposed pins implanted during the surgical procedure.

Teach patients how to keep pins and casts dry while bathing or ambulating in inclement weather.

References1. LeMone, P. et al. (2011). Medical-Surgical Nursing: Critical

Thinking in Client Care. 5th Edition. New Jersey: Pearson Education, Inc.

2. Smeltzer, S. C. et al. (2010). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 12th Edition. Philadelphia: Lippincott Williams and Wilkins.

3. Williams. L. S. & Hopper, P. D. (2011). Understanding Medical-Surgical Nursing. 5th Edition. Philadelphia: F. A. Davis Company

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