chapter 41
Meds effective in treating acute low back pain:
nonsteroidal anti-inflammatory drugs (NSAIDs) and short-term prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) are effective in relieving acute low back pain. Opioid medications are indicated only short term for acute moderate to severe cases of low back pain, except in older adults, those with kidney disease, or those who must avoid chronic NSAID exposure because of its adverse gastric effects
Patients with lower back pain are taught to sit
20 to 50 minutes based on level of comfort. Absolute bed rest is no longer recommended; typical activities of daily living (ADLs) should be resumed as soon as possible.
Clinical Manifestations of pagets disease
Sclerotic changes and cortical thickening of the long bones occur.In most patients, skeletal deformity involves the skull. The skull may thicken, and the patient may report that a hat no longer fits. In some cases, the cranium, but not the face, is enlarged. This gives the face a small, triangular appearance. Most patients with skull involvement have impaired hearing from cranial nerve compression and dysfunction. Other cranial nerves may also be similarly affected.
S & S OF carpel tunnel syndrome
The patient experiences pain, numbness, paresthesia, and, possibly, weakness along the median nerve distribution (thumb, index, and middle fingers). Night pain and/or fist clenching upon awakening is common. A positive Tinel sign helps identify patients requiring intervention
callus treatment
Treatment consists of eliminating the underlying causes and having a painful callus treated by a podiatrist. 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 an adhesive backing is also used to prevent and relieve pressure. Orthotic devices can be made to remove the pressure from bony protuberances, or the protuberance may be excised
contracture
abnormal shortening of muscle or fibrosis of joint structures
Which of the following diagnostics are used to evaluate spinal nerve root disorders (radiculopathies)?
An electromyogram and nerve conduction studies are used to evaluate spinal nerve toot disorders (radiculopathies) for patients with low back pain
Morton neuroma
(plantar digital neuroma, neurofibroma) is a swelling of the third (lateral) branch of the median plantar nerve . Microscopically, digital artery changes cause an ischemia of the nerve within the third intermetatarsal (web) space.
Benign bone tumors
An osteoclastoma is a giant cell tumor that may invade local tissue; usually soft and hemorrhagic and may become malignant. An osteochondroma occurs as a large projection of bone at the ends of long bones, developing during growth periods and then becoming static bone mass. An enchondroma is a hyaline cartilage tumor that develops in the hand, ribs, femur, tibia, humerus, or pelvis. An osteoid osteoma is a painful tumor surrounded by reactive bone tissue.
risk factors of Dupuytren Disease :
Dupuytren disease is also associated with arthritis, diabetes, gout, cigarette smoking, and alcoholism
Early manifestations of impingement syndrome:
Early manifestations of this syndrome are characterized by edema from hemorrhage of these structures, pain, shoulder tenderness, limited movement, muscle spasm, and eventual disuse atrophy. The process may progress to a partial or complete rotator cuff tear
Diagnostic findings of pagets disease
Elevated serum ALP concentration and urinary hydroxyproline excretion reflect increased osteoblastic activity. Higher values suggest more active disease. Patients with Paget disease have normal blood calcium levels. X-rays confirm the diagnosis of Paget disease by revealing local areas of demineralization and bone overgrowth in the characteristic mosaic patterns. Bone scans demonstrate the extent of the disease. Bone biopsy may aid in the differential diagnosis with other bone diseases
Pes planus (flat foot)
It may be caused by congenital abnormalities or associated with bone or ligament injury, excessive weight, muscle fatigue, poorly fitting shoes, or arthritis. Signs and 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. Foot orthoses can give the foot additional support
What are facet joints?
Joints between vertebral arches
Which lumbar discs are subject to the greatest mechanical stress and the greatest degenerative changes
L4-5 and L5-S1
Loose bodies (joint mice)
Loose bodies ("joint mice") may occur in a joint space as a result of articular cartilage wear and bone erosion. These fragments can interfere with joint movement ("locking the joint"). Loose bodies are removed by arthroscopic surgery if they cause pain or mobility issues.
Osteopenia
Low bone mineral density, precursor to osteoporosis
what is not recommended for prevention of low back pain?
Orthopedic shoe and lumbar support belt
A patient is diagnosed with osteogenic sarcoma. What laboratory studies should the nurse monitor for the presence of elevation?
Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma or bone metastasis.
Dupuytren Disease treatment
Starting as a nodule, it may or may not progress, producing a contracture of the fingers and palmar skin changes. The patient may experience dull and aching discomfort, morning numbness, and stiffness in the affected fingers. This condition starts in one hand, but eventually both are affected. Finger-stretching exercises or intra-nodular injections of corticosteroids may prevent contractures. With loss of movement, palmar and digital fasciotomies are performed to improve function.
Morton neuroma pain
The result is a throbbing, burning pain in the foot that is usually relieved with rest and massage.
Pes Cavus (high arch)
The shortening of the foot and increased pressure produce calluses on the metatarsal area and on the dorsum of the foot.
What are Soft corns:
They are located between the toes and are kept soft by moisture. Treatment consists of drying the affected spaces and separating the affected toes with lamb's wool or gauze. A wider shoe and toe box may be helpful
Tinel Sign Test
Tinel sign may be elicited in patients with carpal tunnel syndrome by percussing lightly over the median nerve, located on the inner aspect of the wrist. If the patient reports tingling, numbness, and pain, the test for Tinel sign is considered positive.
which muscles are important in lifting activities, working together to minimize stress on the spinal units
abdominal muscles and thoracic muscles
risk factors for osteomyelitis
include older adults and those who are poorly nourished or obese. Other patients at risk include those with impaired immune systems, those with chronic illnesses (e.g., diabetes, rheumatoid arthritis), those receiving long-term corticosteroid therapy or immunosuppressive agents, and those who use IV drugs
Osteomyelitis
infection of the bone that results in inflammation, necrosis, and formation of new bone
Chronic lower back bain
last greater than 3 months
Medications for pagets disease:
specific antiosteoclastic therapy, Bisphosphonates are the cornerstone of Paget therapy in that they stabilize the rapid bone turnover. Plicamycin (Mithracin), a cytotoxic antibiotic, may be used to control the disease. This medication is reserved for severely affected patients with neurologic compromise and for those whose disease is resistant to other therapy. This medication has dramatic effects on pain reduction and on serum calcium, ALP, and urinary hydroxyproline levels; however, there are significant side effects. It is given by IV infusion; hepatic, kidney, and bone marrow function must be monitored during therapy
The spinal curves absorb:
vertical shocks from running and jumping.
T or F Back and leg pain on straight-leg raising (with the patient supine, the patient's leg is lifted upward with the knee extended) suggests nerve root involvement.
True
Secondary osteoporosis:
is the result of medications or diseases that affect bone metabolism. Men are more likely than women to have secondary causes of osteoporosis,
In carpel tunnel syndrome the use of corticosteroids over the long term is not supported due to :
substrates like collagen can potentiate an increased risk for tendon rupture
callus
A callus is a thickened area of the skin that has been exposed to persistent pressure or friction. Faulty foot mechanics usually precede the formation of a callus.
A client with osteoporosis is prescribed a selective estrogen receptor modifier (SERM) as treatment. The nurse would identify which drug as belonging to this class?
An example of a selective estrogen receptor modifier (SERM) is raloxifene (Evista). Alendronate is a bisphosphonate; calcium gluconate is an oral calcium preparation; tamoxifen is an antiestrogen agent.
Which of the following is the only selective estrogen receptor modulator approved for osteoporosis in post menopausal women?
Raloxifene is the only selective estrogen receptor modulator (SERM) approved for osteoporosis in post menopausal women as it does not increase the risk of breast or uterine cancer, but it does come with an increased risk of thromboembolism
A client is evaluated for a diagnosis of Paget's disease. Which laboratory value would the nurse find to confirm the diagnosis?
The normal range for alkaline phosphate level is 20 to 140 IU/L. An elevated serum concentration of alkaline phosphate reflects increased osteoblastic activity and is seen in clients with Paget's disease.
What increases the risk of a fracture postraumatic injury?
The presence of bruising, older age and prolonged use of glucocorticoid medications increases the risk of a fracture posttraumatic injury
ganglion
collection of neurologic gelatinous material near the tendon sheaths and joints—appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. It frequently occurs in women younger than 50 years. Dorsiflexion exacerbates signs and symptoms of a ganglion. A ganglion is the most common benign soft-tissue mass in the hand, not foot.
osteomalacia
disease marked by softening of the bone caused by calcium and vitamin D deficiency
radiculopathy
disease of the spinal nerve roots, The patient may report pain radiating down the leg, which is known as radiculopathy (i.e., pain radiating from a diseased spinal nerve root) or sciatica (i.e., pain radiating from an inflamed sciatic nerve
carpel tunnel syndrome
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. It frequently occurs in women between 30 and 60 years of age. Commonly caused by repetitive hand and wrist movements, it is also associated with rheumatoid arthritis, diabetes, acromegaly, hyperthyroidism, or trauma
Acute lower back pain last
fewer than 3 months
impingement syndrome
impaired movement of the rotator cuff of the shoulder Impingement usually occurs from repetitive overhead movement of the arm or from acute trauma resulting in irritation and eventual inflammation of the rotator cuff tendons or the subacromial bursa as they grate against the coracoacromial arch.
bursitis
inflammation of a fluid-filled sac in a joint, that prevent friction between joint structures during joint activity and are painful when inflamed
ingrown toenail (onychocryptosis)
is a condition in which the free edge of a nail plate penetrates the surrounding skin. A secondary infection or granulation tissue may develop
hallux valgus
lateral or outward deviation of the great toe
Ganglion treatment
may include aspiration, corticosteroid injection, or surgical excision. After treatment, a compression dressing and immobilization splint are used.
Secondary osteoporosis causes:
the use of corticosteroids (especially if they receive doses in excess of 5 mg of prednisone daily for more than 3 months) and excessive alcohol intake. Specific disease states (e.g., celiac disease, hypogonadism) and medications such as anticonvulsants (phenytoin [Dilantin]), thyroid replacement agents (levothyroxine [Synthroid]), antiestrogens (medroxyprogesterone [Depo-Provera]), androgen inhibitors (leuprolide [Lupron]), and proton pump inhibitors (esomeprazole [Nexium]) that place patients at risk need to be identified and therapies instituted to reverse the development of osteoporosis
Nursing Management of the Patient Undergoing Surgery of the Hand or Wrist:
Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion.Intermittent use of ice packs to the surgical area during the first 24 to 48 hours may be prescribed to control edema. Unless contraindicated, active extension and flexion of the fingers to promote circulation are encouraged, even though movement is limited by the bulky dressing. To control swelling that may increase the patient's discomfort, the nurse instructs the patient to elevate the hand to heart level with pillows. If the patient is ambulatory, the arm is supported in a conventional sling with the hand elevated at heart level
Hallux Valgus (Bunion) Treatment
In uncomplicated cases, wearing a shoe that conforms to the shape of the foot, or that is molded to the foot to prevent pressure on the protruding portions, may be the only treatment needed. Corticosteroid injections control acute inflammation. In advanced cases, surgical removal of the exostosis (osseous enlargement) and toe realignment may be required to improve function, appearance, and symptoms.
what are the two most common surgical management options for carpel tunnel syndrome when nonsurgical treatments fail?
Traditional open nerve release or endoscopic laser surgery. Both of these procedures are performed under local anesthesia and involve making incisions into the affected wrist and cutting the carpal ligament so that the carpal tunnel is widened. Smaller incisions are made with the endoscopic laser procedure, resulting in less scar formation and a shorter recovery time than with the open method. Following either procedure, the patient wears a hand splint and limits hand use during healing. The patient may need assistance with personal care. Full recovery of motor and sensory function after either type of nerve release surgery may take several weeks or months.
Bouchard's nodes
are bony enlargements of the distal interphalangeal joints and are seen with osteoarthritis.
Heberden's nodes
are bony enlargements of the distal interphalangeal joints.
Corn Treatment
are treated by a podiatrist by soaking and scraping off the horny layer, by application of a protective shield or pad, or by surgical modification of the underlying offending osseous structure. Injection of bleomycin (Blenoxane; a chemotherapy drug) is being evaluated as a solution for hard to treat corns that are surgically treated .
Morton's neuroma treatment
conservative care, metatarsal pad, change of footwear to a wider softer shoe , corticosteroid injections. If these fail, surgical excision of the neuroma is necessary. Pain relief and loss of sensation are immediate and permanent with surgery. The risk of falls is increased because of the loss of all sensation
Active treatment of ingrown toenail (onychocryptosis)
consists of washing the foot twice a day and relieving the pain by decreasing the pressure of the nail plate on the surrounding soft tissue (ACFAS, 2010). Warm, wet soaks help drain an infection. A toenail may need to be excised by the podiatrist or primary provider if there are recurrent infections.
Osteoporosis
degenerative disease of the bone characterized by reduced mass, deterioration of matrix, and diminished architectural strength
primary osteoporosis
occurs in women after menopause (usually by age 51) and in men later in life. This id due to Failure to develop optimal peak bone mass and low vitamin D levels contribute to the development of osteopenia without associated bone loss
Medications for impingement syndrome:
oral NSAIDs or intra-articular injections of corticosteroids. Application of superficial cold or heat may subjectively improve patients' symptoms; however, a therapeutic exercise program is required to improve outcomes, including reduction of pain and improved shoulder function
Evidence-based treatment of acute carpal tunnel syndrome includes:
oral or intra-articular injections of corticosteroids, use of NSAIDs and acupuncture with and without electrical stimulation (attached to the needles). Application of wrist splints to prevent hyperextension and prolonged flexion of the wrist is also effective;
Dupuytren disease
results in a slowly progressive contracture (i.e., an abnormal shortening) of the palmar fascia that causes flexion of the fourth, fifth, and, sometimes, middle finger, rendering these fingers more or less useless It is linked to an inherited autosomal dominant trait and occurs most frequently in men of Scandinavian or Celtic heritage who are older than 50 years
corn
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 a 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.
Medications for Osteoporosis:
Bisphosphonates, along with calcium and vitamin D supplements, are the first-line medications given to prevent/treat osteoporosis .These types of drugs include bisphosphonates, estrogen agonist/antagonists, and receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors
Diagnostic Procedures for Low Back Pain: Take Good LOOK AT THIS ONE
Diagnostic Procedures for Low Back Pain 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 discs Magnetic resonance imaging (MRI) scan: permits visualization of the nature and location of spinal pathology Electromyogram (EMG) and nerve conduction studies: used to evaluate spinal nerve root disorders (radiculopathies) Myelogram: permits visualization of segments of the spinal cord that may have herniated or may be compressed (infrequently performed; indicated when MRI scan is contraindicated) Ultrasound: useful in detecting tears in ligaments, muscles, tendons, and soft tissues in the back
Osteomyelitis is classified as:
Hematogenous osteomyelitis (i.e., due to bloodborne spread of infection) Contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (e.g., gunshot wound) Osteomyelitis with vascular insufficiency, seen most commonly among patients with diabetes and peripheral vascular disease, most commonly affecting the feet
Meds effective in treating chronic low back pain:
Tricyclic antidepressants (e.g., amitriptyline [Elavil]) and the dual-action serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine [Cymbalta])or atypical anticonvulsant medications (e.g., gabapentin [Neurontin], which is prescribed for pain from radiculopathy) are used effectively in chronic low back pain.
Plantar Faciitis
an inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with the first steps in the morning. 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 (e.g., heel cups, arch supports, night splints), and corticosteroid injections. Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs.
How much calcium should older adults and post menopausal women consume:
approximately 1200 mg of daily calcium. Quantities larger than this may place patients at heightened risk of renal calculi or cardiovascular disease
A home care nurse assesses for disease complications in a client with bone cancer. Which laboratory value may indicate the presence of a disease complication?
in clients with bone cancer, tumor destruction of bone commonly causes excessive calcium release. When the calcium-excreting capacity of the kidneys and GI tract is exceeded, the serum calcium level rises above normal, leading to hypercalcemia (a serum calcium level greater than 10.2 mg/dl).
Contributing factors of hallux valgus (Bunion):
include heredity, ill-fitting shoes, osteoarthritis, and the gradual lengthening and widening of the foot associated with aging.
sciatica
inflammation of the sciatic nerve,(i.e., pain radiating from an inflamed sciatic nerve through the thigh and leg
Paget disease (osteitis deformans)
is a disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae. In Paget disease, a primary proliferation of osteoclasts occurs, which induces bone resorption.
involocrum
new bone growth around a sequestrum(a piece of dead bone tissue occurring within a diseased or injured bone, typically in chronic osteomyelitis.)
true or false Hyperparathyroidism leads to skeletal decalcification and thus to osteomalacia by increasing phosphate excretion in the urine. Prolonged use of anticonvulsant medication (e.g., phenytoin [Dilantin], phenobarbital) poses a risk of osteomalacia, as does insufficient vitamin D (dietary, sunlight).
true