Chapter 64: Musculoskeletal Problems

Sarcoma malignant tumor that can develop in

- bone - muscle - fat - nerve - cartilage Most common - Osteosarcoma - Chomdrosarcoma - Edwing's sarcoma - During childhood and young adulthood - Rapid metastasis and bone destruction

Plantar wart

Painful papillomatous growth caused by virus that may occur on any part of skin on sole of foot

Osteoclastoma

*Giant cell tumor* - arises in *cancellous ends of arm and leg bones* - 10% are locally aggressive and may spread to lungs - High rate of local recurrence after surgery and chemotherapy

Benign tumors

- Osteochondroma - Osteoclastoma - endochroma

Osteomyelitis

A severe infection of bone, bone marrow, and surrounding soft tissue

Osteomalacia

Caused by a vitamin D deficiency, resulting in decalcification and softening of bones

Acute osteomyelitis

Initial infection or an infection of less than 1 month in duration

Diskectomy

Surgical procedure to decompress the nerve root

Acute low back pain nursing implementation

- Proper body mechanics - "Back school" - maintain appropriate body weight - position assumed while sleeping - low heels and sock-absorption shoe - firm mattress - stop smoking Treatment - NSAIDs - muscle relaxants (cyclobenzaprine [Fexeril] - Massage - back manipulation - acupuncture - cold and hot compresses - opioid analgesic - rest for 1 to 2 days max -

Interventions for Paget's disease

Firm mattress Client may be required to wear a corset or light brace to relive back pain when in upright position. Discourage activities such as lifting or twisting. Physical therapy Good body mechanics

Causes of osteomalacia

Lack of UV rays. Gi malabsorption Extensive burns Chronic diarrhea Pregnancy Kidney disease And drugs(Dilantin) Obese people are at higher risk

Intervertebral foramen

Spinal nerves emerge from the spinal column through this opening between adjacent vertebrae

Manifestations of osteoporosis

Back pain Fractures Kyphosis (dowager's hump)

Hallux rigidus

Painful stiffness of first metatarsophalangeal joint caused by osteoarthritis or local trauma

osteomyelitis evaluation

- Have satisfactory pain relief - Fallow the recommended treatment regimen - Demonstrate a consistent increase in mobility and ROM

Degenerative disc disease

- Aging progressive degeneration - loss of elasticity, flexibility, and shock-absorbing capabilities

Osteomyelitis may also occur in the presence of a foreign body

- an implant or an orthopedic prosthetic device - plate - total joint prosthesis

Interspinous process decompression system

Fits onto mount that is placed on vertebrae in lower back (X-STOP); titanium

Involucrum

Part of the periosteum that continues to have a blood supply form a new bone called?

Risk factors for osteoporosis

Age Femal Low body weight White or Asian Smoking Fracture Sedentary lifestyle Postmenopausal Family history Diet low in Vit. C&D Excessive use of alcohol Long term use of corticosteroids.

after gaining entry into the blood, the microorganism grow, resulting in what?

- Increase pressure of the none-expanding nature of most bone - leading to ischemia & vascular compromise of the periosteum - infection spread through the bone cortex and marrow cavity - resulting in cortical devascularization and necrosis Once ischemia occurs, the bone die

Endochroma

- Intramedullary cartilage tumor - found in cavity of a single hand or foot bone - Rare malignant transformation - if tumor become painful a surgical resection is done - Peak incidence in persons ages 10-20

Estrogen therapy

Believed to inhibit osteoclast activity, leading to decreased bone resorption

Radiculopathy

Radiating pain, numbness, tingling, and diminished strength and/or range of motion

osteomyelitis overall goals

- Have satisfactory pain and fever control - No complications - Cooperate with treatment plan - Maintain positive outlook on the outcome of the dis

Nursing implementation

- Control of infections already in the body (UTI or pressure ulcers) - Monitoring and intermediately report of S&S - Provided patient comfort through pan control - Dressing (wet-to-dry) - Prevent cross-contamination - Good body alignments - Frequent body reposition - Prevent foot drop - teach patient about toxic reactions - Continuous psychologic and emotional support

Ewing's sarcoma

- Develops in medullary cavity of the long bones - usually occurs in children and teenagers - Treatment - surgical resection - radiation - chemotherapy - 5-yr survival rate of 60 %

Low back pain

- Due to musculoskeletal problem Localized -soreness or discomfort on specific area Diffuse - spread over larger area Radicular - irritation of a nerve root Referred - "felt" at the lower back but sources is another area - under 45 yrs old - Lumbar area lack of muscle tone Factors - excess body weight - stress - poor posture - cigarette smoking - pregnancy - Fx of spine - birth-defects - job position - prolonged periods of sitting Causes - Acute lumbar strain - Instability of the lumbosacral body mechanics - osteoarthritis - degenerative disc dis - herniation of an intervertebral disc

Osteosarcoma clinical manifestation

- Gradual onset pain - Swelling around the knee - Metastasis Dx - tissue biopsy - elevated alkaline phosphatase - elevated calcium - X-ray - CT - PET scan - MRI Treatment - Preoperative (neoadjuvant) chemotherapy - Limb salvage (no cancer present) 6 to 7 cm margin - adjunct chemotherapy after amputation -- increase 5 years of survival Chemotherapy - Methotrexate - Doxorubicin (Adriamycin) - Cisplatin (VePesid) - Bleomycin (Blenoxane) - Dactinomycin (Cosmegren) - Ifosfamide (Iflex)

Acute low back pain

- Lasts 4 weeks or less - Caused by trauma (Hyperflexion) - Heavy lifting - overuse of the back muscles - sport injury - car accident S&S - do not appear after 24 hrs due to gradual increase in pressure of the nerves - shooting or stabbing pain - limited flexibility and ROM - inability to stand straight DX - MRI - CT scan

Chronic low back pain

- Lasts more than 3 months - repeated incapacitating episode Causes - Degenerative dis (AR or dic dis) - osteoporosis - metabolic bone dis - prior injury (scar tissue ) - chronic strain related stooping - congenital abnormalities

Chondrosarcoma

- Occurs in cartilage - arm - legs - pelvic bones - older adults 50 to 70 - can arise from benign bone tumors (osteochondromas) - Surgical resection - rarely responds to radiation and chemotherapy - survival depends on stage, size , and grade of tumor

Landouzy-Déjérine MD (Facioscapulo-humeral) Autosomal dominant (4q35)

- Onset before 20 years of age - slowly progressive weakness of face, shoulder muscles, foot dorsiflexion - Deafness

Duchenne MD (Pseudohypertrophic) X-linked

- Onset before 5 years of age - progressive weakness of pelvic and shoulder muscles - unable to walk after 12 years of age - Cardiomyopathy - Respiratory failure in teens or 20s

Becker MD (Benign Pseudohypertrophic) X-linked

- Onset between 5 and 15 years of age - *cardiomyopathy* - respiratory failure - may survive into 30s or 40s

Erb MD (Limb-girdle) Autosmal recessive

- Onset from early childhood to early adulthood - slow progressive weakness of shoulder and hip muscles

Lumbar fusion postoperative intervention

- Place pillow under the tights ea leg when supine - pillows between legs when in the side-lying

Treatment of osteomyelitis after cultures or a bone biopsy and if the bone ischemia has not yet occur

- Vigorous and prolonged IV antibiotics - 4 to 6 wks or 3 to 6 months - Penicillin - nafcillin (Nafcil) - Neomycin - Vancomycin - cephalexin (Keflex) - cefazolin (Ancef) - cefoxitin (Mefoxin) - Gentamicin (Garamycin) - tobramycin (Nebocin) Chronic - oral therapy - fluoroquinolone (cprofloxin [Cipro]) - 6 to 8 wks - antibiotic irrigation at the site Drug therapy monitoring - bone scan - ESR test

Bone cancer nursing management

- assess pain - high fall risk due to bone weakness - weakness caused by anemia - decreased mobility - swelling at the tumor site - changes in circulation - decrease sensation or joint function - prevent pathologic fx or to reduce complications - logrolling for those in the bed rest - side effects of chemotherapy - postoperative care after surgery Treatment for hypercalcemia - Hydration 3 L/day - Bisphosphonate therapy (inhibit osteclast) - exercise - rest - radiation therapy is used as a palliative --decrease tumor and pain

Foot disorders

- congenital conditions - structural weakness - traumatic and stress injuries - systemic conditions such as DM , RM Purpose of footwear - provide support - foot stability - protection - shock absorption - increase friction with the walking surface - treat foot abnormalities

Intradiscal electrothermoplasty (IDET)

A minimally invasive outpatient procedure that may help treat back and sciatica pain

Spinal stenosis

A narrowing of the spinal canal - Lumbar area cause low back pain Acquired - osteoarthritis changes - bone spurs - calcification of spinal ligaments - degeneration of dic - narrow of the spinal canal & nerve roots Symptoms - inflammation cause pain - weakness - numbness - pain starts in lower back and radiates to the buttock and leg - worsens with walking & standing - tingling - heaviness in legs & buttocks Others acquired conditions - rheumatoid arthritis - psinal tumors - Paget's dis - traumatic damages to the vertebral Inherit conditions - congenital spinal stenosis - scoliosis

Radiofrequency discal nucleoplasty

A needle is inserted into the disc similar to IDET

Which individuals would be at high risk for low back pain (select all that apply)? a.A 63-year-old man who is a long-distance truck driver b.A 36-year-old 6 ft, 2 in construction worker who weighs 260 lb c.A 28-year-old female yoga instructor who is 5 ft, 6 in and weighs 130 lb d.A 30-year-old male nurse who works on an orthopedic unit and smokes e.A 44-year-old female chef with prior compression fracture of the spine

A, B, D, E Risk factors associated with low back pain include a lack of muscle tone and excess body weight, stress, poor posture, cigarette smoking, pregnancy, prior compression fractures of the spine, spinal problems since birth, and a family history of back pain. Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged periods of sitting are also associated with low back pain. Low back pain is most often caused by a musculoskeletal problem. The causes of low back pain of musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniation of an intervertebral disc. Health care personnel are at high risk for the development of low back pain. Lifting and moving patients, excessive time being stooped over or leaning forward, and frequent twisting can result in low back pain.

The nurse provides instructions to a 30-year-old female office worker who has low back pain. Which statement by the patient requires an intervention by the nurse? A. "Acupuncture to the lower back would cause irreparable nerve damage." B. "Smoking may aggravate back pain by decreasing blood flow to the spine." C. "Sleeping on my side with knees and hips bent reduces stress on my back." D. "Switching between hot and cold packs provides relief of pain and stiffness."

A. "Acupuncture to the lower back would cause irreparable nerve damage." Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that is likely to be present." D. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

A. "IV antibiotics are usually required for several weeks." The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics.

The nurse is admitting a patient to the nursing unit with a history of a herniated lumbar disc and low back pain. In completing a more thorough pain assessment, the nurse should ask the patient if which action aggravates the pain? A. Bending or lifting B. Application of warm moist heat C. Sleeping in a side-lying position D. Sitting in a fully extended recliner

A. Bending or lifting Back pain that is related to a herniated lumbar disc often is aggravated by events and activities that increase the stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Application of moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.

The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? A. Bran muffin B. Scrambled eggs C. Puffed rice cereal D. Buttered white toast

A. Bran muffin Each meal should contain one or more sources of fiber, which will reduce the risk of constipation and straining with defecation, which increases back pain. Bran is typically a high-fiber food choice and is appropriate for selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber.

Which nursing intervention is most appropriate when turning a patient following spinal surgery? A. Placing a pillow between the patient's legs and turning the body as a unit B. Having the patient turn to the side by grasping the side rails to help turn over C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

A. Placing a pillow between the patient's legs and turning the body as a unit Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort following spinal surgery. Having the patient turn by grasping the side rail to help, elevating the head of the bed, and turning with extended legs or turning the patient's head and shoulders and then the hips will not maintain proper spine alignment and may cause damage.

Nursing care for osteoporosis

Adequate calcium intake: whole and skim milk, yogurt, turnip greens, cottage cheese, ice cream, sardine and spinach. Take calcium supplements with food. Weight bearing exercises: walking, hiking, weight gaining, stair climbing, tennis and dancing. Quit smoking and cut down on alcohol.

During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? A. The presence of bowed legs B. A measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation

B. A measurable loss of height A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative it is present. A wide gait is used to support balance and does not indicate osteoporosis.

intervertabral Disc dis collaborative care

Collaborative therapy- Restricted activity for several days - limit total bed rest - Local ice or heat - physical therapy Drug therapy - Analgesics (tramadol [Ultra, Ryzolt]) - Nonsteroidal antiiflammatory drugs (NSAIDs) - Muscle relaxants (cyclobenzapine [Flexeril]) - Antiseizure drugs (GABA [Neurotin]) - Antidepressants (pregabalin [Lyrica]) - Epidural corticosteroid injections DX - history and physical examination - X-ray - CT-scan - MRI - Myelogram - Diskogram - Electromyogram (EMG) Surgical - Intradiscal electrothermoplasty (IDET) - Radiofrequency discal nucleoplasty - Interspinous process decompression system (X-Stop) - Laminectomy with or without spinal fusion - Diskectomy - Percutaneous laser diskectomy - Artificail disc replacement (charite disc) - Spinal fusion with instrumentation(plates, screws) or without

The 24-year-old male patient who was successfully treated for Paget's disease has come to the clinic with a gradual onset of pain and swelling around the left knee. The patient is diagnosed with osteosarcoma without metastasis. The patient wants to know why he will be given chemotherapy before the surgery. What is the best rationale the nurse should tell the patient? A. The chemotherapy is being used to save your left leg. B. Chemotherapy is being used to decrease the tumor size. C. The chemotherapy will increase your 5-year survival rate. D. Chemotherapy will help decrease the pain before and after surgery.

B. Chemotherapy is being used to decrease the tumor size. Preoperative chemotherapy is used to decrease tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rate in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from a herniated lumbar disc. What would be an appropriate nursing intervention to treat this problem? A. Provide gentle ROM to the lower extremities. B. Elevate the head of the bed 20 degrees and flex the knees. C. Place the bed in reverse Trendelenburg with the feet firmly against the footboard. D. Place a small pillow under the patient's upper back to gently flex the lumbar spine.

B. Elevate the head of the bed 20 degrees and flex the knees. The nurse should elevate the head of the bed 20 degrees and flex the knees to avoid extension of the spine and increasing the pain. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient's upper back will more likely increase pain.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg

B. Localized pain and warmth Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg.

The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? A. Yoga B. Walking C. Calisthenics D. Weight lifting

B. Walking The patient would benefit from an aerobic exercise that takes into account the patient's health status and fits the patient's lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. Yoga, calisthenics, and weight lifting would all put pressure on or strain the spine.

Drug therapy for osteoporosis

Bisphosphonates Alendronate(fosamax) Calcitonin Raloxifene (evista)

Microorganisms cause infection through Indirect entry for a primary infection to spread via the blood to the bone

Blunt trauma - affect growing bone in boys younger than 12yr vascular insufficiency disorders - DM - genitourinary tract - respiratory tract most common sites - vascular-rich sites of bone - pelvis - tibia - vertebrae

Osteopenia

Bone loss more than normal but not yet at the level for a diagnosis of osteoporosis

Manifestations of osteomalacia

Bone pain Difficulty rising from chair and walking Muscular weakness Weight loss Progressive deformities of the spine(kyphosis) or extremities.

The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? A. "Is the pain worse in the morning or in the evening?" B. "Is the pain sharp or stabbing or burning or aching?" C. "Does the pain radiate down the buttock or into the leg?" D. "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?"

C. "Does the pain radiate down the buttock or into the leg?" Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve and can be commonly described as traveling through the buttock, to the posterior thigh, or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data.

The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? A. "I should sleep on my side or back with my hips and knees bent." B. "I should exercise at least 15 minutes every morning and evening." C. "I should pick up items by leaning forward without bending my knees." D. "I should try to keep one foot on a stool whenever I have to stand for a period of time."

C. "I should pick up items by leaning forward without bending my knees." The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics when lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside.

Calcaneus stress fracture

Complaint of heel pain after moderate walking

Cauda equina

Compressions from a herniated disc, a tumor, or an epidural abscess

The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."

C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience paralytic ileus and interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery patients often wear a soft or hard cervical collar to immobilize the neck.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. 22-year-old female with gonorrhea who is an IV drug user B. 48-year-old male with muscular dystrophy and acute bronchitis C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago

C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest-calcium meal? A. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium, but not as much as the sardines, yogurt, and milk.

The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate? A. Serum calcium B. Serum creatinine C. Serum phosphate D. Serum alkaline phosphatase

C. Serum phosphate Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min).

Metastatic bone cancer

Cells travel from the primary tumor to the bone via the lymph and blood supply Primary tumors - breast - prostate - lung - kidney - thyroid Metastatic bone lesions found - vertebrae - pelvis - femur - humerus - ribs - pathological fx DX - high serum calcium (damages bone) - Radionuclide bone scans Treatments - palliative and consists of radiation and pain management

Osteochondroma

Characterized by an overgrowth of *cartilage and bone* near the end of the bone at the growth plate - Most common benign tumor - located metaphyseals portion - ages 10-25 - - Malignant transformation (chondrosarcoma) - long bones of leg - pelvis - scapula Clinical manifestations - Painless - hard - immobile mass - lower-than-normal height for age - Soreness of muscles in close proximity to the tumor - one arm or leg longer than the other one - pressure or irritation with exercise - may asymptomatic - DX: - X-ray - CT scan - MRI Treatment - No treatment for asymptomatic - tumor causing pain or neurologic symptoms: surgical resection - regular screening examination for early detection

Osteoporosis

Characterized by low bone mass and structural deterioration of bone tissue. Known as "silent thief" because it's slow and insidious.

Paget's disease

Chronic skeletal bone disorder characterized by excessive bone resorption. Aka (osteitis deformans)

Transcutaneous electrical nerve stimulation

Collaborative care for cervical disc disease

Collaborative care of osteomalacia

Correction of vitamin D deficiency. Encourage ingestion of eggs, meat, oily fish, milk and breakfast cereals. Exposure to sunlight Weight bearing exercise.

The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? A. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. B. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements and/or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.

The nurse cares for a 58-year-old woman with breast cancer who is admitted for severe back pain related to a compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms will the nurse expect the patient to exhibit? A. Anxiety, irregular pulse, and weakness B. Muscle stiffness, dysphagia, and dyspnea C. Hyperactive reflexes, tremors, and seizures D. Nausea, vomiting, and altered mental status

D. Nausea, vomiting, and altered mental status Breast cancer can metastasize to the bone. Vertebrae are a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium levels result as calcium is released from damaged bones. Normal serum calcium is between 8.6 to 10.2 mg/dL. Clinical manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Other manifestations include weakness, depressed reflexes, anorexia, bone pain, fractures, polyuria, dehydration, and nephrolithiasis. Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.

A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.

D. Perform frequent position changes and range-of-motion exercises. The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion (ROM) exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every 2 to 4 hours may be too painful. The priority is position changes and ROM exercises.

When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching about this disorder? A. Prolonged bed rest will be used to decrease fatigue. B. An orthotic jacket will limit mobility and may contribute to deformity. C. Continuous positive airway pressure will be used to facilitate sleeping. D. Remain active to prevent skin breakdown and respiratory complications.

D. Remain active to prevent skin breakdown and respiratory complications. With muscular dystrophy, it is important for the patient to remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) is used as respiratory function decreases, before mechanical ventilation is needed to sustain respiratory function.

Diagnostic studies of osteomalacia

Decreased calcium and phosphorus levels Elevated alkaline phosphatase. Looser's transformation zones found on X-ray are diagnostic osteomalacia.

Hammer toe

Deformity of 2nd to 5th toes, including flexion deformity of proximal interphalangeal joints

Sequestra

Devitalized bone that has separated from the surrounding living bone after occurrence of ischemia - reservoir for microorganisms that spread other sites (lungs and brain) - blood-borne antibiotics or WBC cannot reach trough it. If not resolve on its own or is debrided surgically, a sinus tract may develop - Resulting in chronic, purulent cutaneous drainage

Diagnostic studies of Paget's disease

Elevated Serum alkaline phosphatase levels. X-rays Bone scans Salmon calcitonin NSAIDs

Osteosarcoma

Extremely aggressive primary malignant bone tumor that rapidly metastasizes to distant sites Occurs in metaphyseal region of long bones - Extremities - distal femur - proximal tibia - proximal humerus - Pelvis Associated with Paget's disease and prior radiation

Nursing management of osteomyelitis objective data

General - Restlessness - high spiking temp - night sweats Integumentary - Diaphoresis - Erythema - Warmth - Edema at infected bone Musculoskeletal - Restricted movement - wound drainage - spontaneous fx Possible DX findings - Leukocytosis - Positive blood &/or wound culture - high ESR - presence of sequestrum & involucrum on X-ray - radionuclide bone scan - CT and MRI

Muscular dystrophy (MD)

Genetic regressive symmetric wasting of skeletal muscles without neurologic involvement Types - Duchenne - Becker - Landouzy Dejerine - Erb DX - muscle serum enzymes (CK) - EMG - muscle fiber biopsy * fat and CT depositis * degeneration and necrosis of muscle fiber - electrocardiogram abnormalities reflective of cardiomyophaty Clinical manifestations - progressive weakness of muscle around the trunk lead to spinal collapse -cardiomyophaty lead to HF - Dysrhythmias cause deaths - Decrease repiratory function lead to positive air pressure (CPAP) Treatment - Exercise - physical therapy - orthopedic appliances - Orthopedic jacket prevent further deformities - Tracheostomy and mechanical ventilation - ZCorticosteroid therapy (help for 2 years) - ROM - nutritional therapy - keep patient active as long as possible - ongoing treatment

Calcitonin therapy

Inhibits osteoclastic bone resorption by directly interacting with active osteoclasts

Manifestations of paget's disease

Insidious development of bone pain. Fatigue Waddling fair. "Heads becoming larger" complaint. Headaches Dementia Visual deficits Loss of hearing Pathologic fracture (may be 1st indication of disease)

Lumbar dis hernation manifestations

L 3 to 4 pain - Back to buttocks to posterior thigh to inner calf - patellar reflex - quadriceps and anterior tibialis - Sensation on inner aspect of lower anterior part of tight L 4 to 5 pain - Back to buttocks to dorsum of foot and big toe - anterior tibialis, extensor hallucis longus, gluteus medius - sensation on dorsum of foot and big toe L 5 to S1 pain - Back to buttocks to sole of foot and heel - achilles reflex affected - Gastrocnemius, hamstring, gluteus maximus - sensation on heel and lateral foot

Corn

Localized thickening of skin caused by continual pressure over bony prominences

Lumbar disc disease

Low back pain

Neck pain

May result from benign (e.g., poor posture) and serious (e.g., herniated cervical disc) conditions

Intervention for foot disorders

NSAIDs Shock wave therapy Icing Physical therapy Alterations in footwear Stretching Warm soaks Orthodontics Ultrasound Corticosteroid injections. Postop may require immobilization by bulky dressing, cast, slipper or a platform shoe(bunion boot) Elevate heel off the bed

Herniated disc

Nucleus pulposus may seep through torn or stretched annulus with structural damage - natural degeneration - Repeated stress - Trauma - placing pressure on nearby nerves - result of spinal stenosis - cause radiculopathy - Osteoarthritis in spine cause DDD

Cervical disc disease

Pain radiating into the arms and the hands, following the pattern of the nerve involved Surgery on the cervical spine - spinal cord edema cause respiratory distress and worsening neurologic status of the upper extremities - After surgery: neck may be immobilized with soft or hard cervical collar

Hallux valgus

Painful deformity of great toe consisting of lateral angulation of great toe toward second toe

Chronic osteomyelitis

Persists longer than 1 month or has failed to respond to initial course of antibiotic therapy

Nursing management vertebral disc surgery

Postoperative - focus on maintaining proper alignment of the spine - opioids Morphine IV for 24 to 48 hr (PCA) - document pain management Oral -acetaminophen with codeine - Hydrocodone (Vicodin) - Oxycodone (Percocet) - Diazepam (Valium) CSF leakage - report severe headache leakage of CSF on the dressing - test for glucose with dipstick - note amount, color of drainage Peripheral neurologic signs - movements of arms & legs - assessment of sensation "unchanged" qd 2 to 4 hr 1st 48 hrs - paresthesia (numbness & tingling) - muscle weakness - Report the HCP immediately - circulation, temp, capillary refill, and pulses Parlytic ileus - NA, abdominal distention, & constipation - passing flatus - bowel sounds - flat soft abdomen - stool softners (docusate (Cloace)) Preventive Bladder emptying - due to opioid or anesthesia - men stand to urinate - ambulation to the bathroom - ensure privacy - intermittent catherization or indwelling catheter Loss of sphincter tone or bladder tone - nerve damage - monitor incontinence - difficulty evacuating the bowel or bladder

Nursing management for foot disorders

Shoes should be wide enough to allow foot muscles to move freely toes to bend. Heel of the shoe should not rise more han 1 inch higher than the forefoot support. Wearing higher heeled shoes with a narrow toe box will cause hammertoes and corns over time.

Organisms causing osteomyelitis

Staphy aureus - Pressure ulcer - penetrating wound - open fracture - orthopedic surgery - vascular insufficiency dis (DM or atherosclerosis) Staphy. epidermidis - Indwelling prosthetic devices (joint replacements, Fx fixation devices)

Laminectomy

Surgical excision of part of a vertebra to gain access to protruding disc to remove it - Prolonged healing time - Rigid orthosis or chair-back - logrolling in bed

Spinal fusion walking

Surgical procedure to provide stability through ankylosis of contiguous vertebrae with bone graft - Instruct patient proper body mechanics - Avoid sitting or standing for prolonged periods - shifting weight from one foot to the other when standing - restricted weight lifting - twisted is contradicted - use thighs and knee, rather the back - Firm mattress or bed board is essential

Chronic low back pain NR collaborative management Chronic low back pain = yoga

Treatments - weight reduction - rest - local heat and cold - physical therapy - exercise - biofeedback - acupuncture - "back school NSAIDs - pain & stiffness Antidepressants duloxetine (Cymbalta) - pain & sleep problems Gabapentin (Neurontin) - improve walking and relieve legs symptoms minimally invasive - epidural corticosteroid injection - implanted devices that deliver pain medication - Surgery

Morton's neuroma

Tumor growing from a nerve occuring in the web space between the third and fourth metatarsal heads

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) a."The beads are used to directly deliver antibiotics to the site of the infection." b."There are no effective oral or IV antibiotics to treat most cases of bone infection." c."This is the safest method of delivering long-term antibiotic therapy for a bone infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics."

a."The beads are used to directly deliver antibiotics to the site of the infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection.

Before discharge from the same-day surgery unit, instruct the patient who has had a surgical correction of bilateral hallux valgus to a.rest frequently with the feet elevated. b.soak the feet in warm water several times a day. c.expect the feet to be numb for the next few days. d.expect continued pain in the feet, since this is not uncommon.

a.rest frequently with the feet elevated. After surgical correction of bilateral hallux valgus, the feet should be elevated with the heel off the bed to help reduce discomfort and prevent edema.

Microorganisms gain entry to the body through Direct entry

an open wound - penetrating wounds - fractures

A patient has been diagnosed with osteosarcoma of the humerus. He shows an understanding of his treatment options when he states a."I accept that I have to lose my arm with surgery." b."The chemotherapy before surgery will shrink the tumor." c."This tumor is related to the melanoma I had 3 years ago." d."I'm glad they can take out the cancer with such a small scar."

b."The chemotherapy before surgery will shrink the tumor." A patient with osteosarcoma usually has preoperative chemotherapy to decrease tumor size before surgery. As a result, limb-salvage procedures, including a wide surgical resection of the tumor, are being used more often. Osteosarcoma is a primary bone tumor that is extremely aggressive and rapidly metastasizes to distant sites.

You are teaching a patient with osteopenia. What is important to include in the teaching plan? a.Lose weight. b.Stop smoking. c.Eat a high-protein diet. d.Start swimming for exercise

b.Stop smoking. Patients with osteopenia should be instructed to quit smoking in order to decrease loss of bone mass.

In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom? a.The patient experiences a single episode of emesis. b.The patient is unable to move the lower extremities. c. The patient is nauseated and has not voided in 4 hours. d. The patient complains of pain at the bone graft donor site.

b.The patient is unable to move the lower extremities. After spinal fusion surgery, the nurse should frequently monitor peripheral neurologic signs. Movement of the arms and legs and assessment of sensation should be unchanged in comparison with the preoperative status. These assessments are usually repeated every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with those of the preoperative assessment. Paresthesias, such as numbness and tingling sensation, may not be relieved immediately after surgery. The nurse should document any new muscle weakness or paresthesias and report this to the surgeon immediately.

Multiple nerve root (caudal equina) compression from a herniated disc, a tumor, or an epidural abscess may manifested as

bowel and bladder incontinence is a medical emergency

4. The nurse's responsibility for a patient with a suspected disc herniation who is experiencing acute pain and muscle spasms is a.encouraging total bed rest for several days. b.teaching the principles of back strengthening exercises. c.stressing the importance of straight-leg raises to decrease pain. d.promoting the use of cold and hot compresses and pain medication.

d.promoting the use of cold and hot compresses and pain medication. If the acute muscle spasms and accompanying pain are not severe and debilitating, the patient may be treated on an outpatient basis with nonsteroidal antiinflammatory drugs (NSAIDs; e.g., acetaminophen) and muscle relaxants (e.g., cyclobenzaprine [Flexeril]). Massage and back manipulation, acupuncture, and the application of cold and hot compresses may help some patients. Severe pain may necessitate a brief course of opioid analgesics. A brief period (1 to 2 days) of rest at home may be necessary for some people; most patients do better with a continuation of their regular activities. Prolonged bed rest should be avoided. All patients during this time should refrain from activities that aggravate the pain, including lifting, bending, twisting, and prolonged sitting.