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Musculoskeletal Disorders Part II. Osteoporosis Fractures Degenerative Joint Disease/Osteoarthritis Total Hip and Knee Prostheses Bone Infections / Osteomyelitis Gout. Concept Map: Selected Topics in Musculo -Skeletal Nursing. PATHOPHYSIOLOGY Fracture Osteoporosis

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Musculoskeletal Disorders Part II

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Musculoskeletal DisordersPart II



Degenerative Joint Disease/Osteoarthritis

Total Hip and Knee Prostheses

Bone Infections / Osteomyelitis


Concept Map: Selected Topics in Musculo-Skeletal Nursing




Degenerative Joint Disease





Total Joint Replacement


Physical Assessment





“Neuro / Circ Checks”

--”The 6 P’s”

Lab Monitoring





Disease Specific

Care Planning

Plan for client adl’s,

Monitoring, med admin.,

Patient education, more…based

On Nursing Process:



Nursing Interventions & Evaluation

Execute the care plan, evaluate for

Efficacy, revise as necessary

Nursing Diagnoses That (Might) Apply

Pain, acute

Comfort, impaired

Mobility, altered

Self-care deficit –feeding, grooming; bathing, hygeine; toileting

Falls, risk for

Skin breakdown, risk for

Constipation, risk for

Diversional activity, risk for

Mobility, Physical, impaired

Mobility, bed, risk for

Walking, impaired,

Tissue perfusion, impaired peripheral

Peripheral neurovascular dysfunction, risk for

Knowledge, deficient

Body image, disturbed






Musculoskeletal Disorders

  • Degenerative Joint Disease (DJD)

    • a degenerating arthritic condition that affects any joint in the body, including the spine (then it is called DDD – Degenerative Disc Disease)

    • Risk Factors:

      • Obesity (More in the weight – bearing joints)

      • Poor nutrition, low in calcium or vitamin D

      • Genetics – familial arthritis

      • Overuse injuries or manual labor

      • Sports injuries which affect the bursae or tendon - meniscal tissues that cushion the joint

      • Smoking – as it dehydrates and constricts tissues

Musculoskeletal Disorders

  • Degenerative Joint Disease (DJD)

  • Pathophysiology - the bone and supporting tissues start to degenerate, causing atrophy of tendons, and bone spurring, with degeneration of menisci and bursa which would normally protect the joint. Main symptoms are “stiffness in the morning” and pain. Eventually the bone spurring and breakdown will cause joint deformities.

Musculoskeletal Disorders

  • Degenerative Joint Disease (DJD)

  • Also called OA – Osteoarthritis

  • Diagnosis:

    • Symptoms and history

    • Arthroscopy

    • X-rays

    • MRI – for soft tissue visualization, i.e of menisci or bursae

    • Bone scan if cancer has to be ruled out

Musculoskeletal Disorders

  • Degenerative Joint Disease (DJD)

    • Note the loss of joint space with bone on bone

Musculoskeletal Disorders

  • Degenerative Joint Disease (DJD)

Musculoskeletal Disorders

  • Degenerative Joint Disease (DJD)

  • Treatments – heat and cold therapy

  • Preventative exercises – to strengthen supporting muscles

  • Joint Injections – Hydralan, cortisone, etc.

  • Analgesics/Anti-inflammatories –

    • COX – 2 inhibitors i.e. Mobic, Celebrex

    • Tylenol – contraindicated for liver patients

    • Indocin - more risk for peptic ulcers

    • Aspirin – more risk for peptic ulcers

  • Partial or complete surgical repair

  • Joint prosthesis

Musculoskeletal Disorders

  • Degenerative Joint Disease (DJD) –

Musculoskeletal Disorders

  • Hip Prosthesis

Musculoskeletal Disorders

  • knee prosthesis

Musculoskeletal Disorders

  • Care of Patients –

    • Pain control

    • Ambulation with assistance - only

    • Prevent falls

    • Exercise; usually has physical therapy from 6 - 8 weeks

    • Non-smoking

    • Encourage adequate intakes of vitamin C

    • Post-op anti-coagulants, whether Lovenox, coumadin, heparin, or aspirin

Musculoskeletal Disorders

  • Hip prosthesis – NEVER adduct the leg (letting the hip and leg cross the other one will pop the prosthetic ball out of the pelvis)

  • Only allow hip flexion to 90 degrees

  • Turn patients using an adductor pillow while aligning the spine

Musculoskeletal Disorders

  • Adductor pillow between knees

Musculoskeletal Disorders

  • Bone infections

  • Causes:

    • Immunological problems

    • Diabetes, nutritional problems

    • Injury which allows pathogens into the bone

      • fractures

      • coral cuts

      • trauma

      • post-operative surgery

Musculoskeletal Disorders

  • Bone infections

    • Chronic Osteomylitis in a diabetic

Musculoskeletal Disorders

  • Bone infections

  • Diagnosis:

    • Bone scan

    • X-rays

    • MRI for soft tissue view

    • Blood cultures – need to be done 15 minutes apart from two different sites

    • Wound cultures – if drainage is apparent

Musculoskeletal Disorders

  • Bone infection symptoms:

    • Foul smelling drainage

    • Fever

    • Lethargy

    • Swelling

    • Redness

    • Increased WBC’s on CBC with differential

      • With increased neutrophils on the CBC, sometimes called PMN’s or polymorphic neutrophils. These cells in particular replicate to fight infection. If the WBC is not elevated with these symptoms, the patient is immunosuppressed and at risk for sepsis.

Musculoskeletal Disorders

Bone Infections

Most common organisms:

StaphlococciAureus– MRSA in the hospital post- operatively (a drug resistant organism)

Enterococcifrom wounds/trauma

Clostridium Perfringens– gangrene

E-Coli – fecal contamination

Musculoskeletal Disorders

  • Osteomylitis Treatments/Interventions

    • #1 Pain control

    • Monitor Vital signs every 4 hours and prn

      • (Observe for signs of sepsis or drug reaction)

      • Monitor skin integrity and site

        - intravenous antibiotics to get rid of infection (need a physician’s order)

    • Surgical repair or debridement

    • Removal of infected prostheses

    • Sometimes it is necessary for amputation

Musculoskeletal Disorders

  • Ewing’s Sarcoma of the bone – usually malignant with mets, often treated with amputation

Musculoskeletal Disorders

  • Osteosarcoma –

  • most common type of malignant bone tumor, most often in males between 10 and 30 y.o. or in older patients with Paget’s Disease



  • This is a photograph of 70 year old woman who first presented like this with a massive chondrosarcoma of her right upper humerus of 8 months duration. She refused all treatment, and she died of a massive haemorrhage when the tumour burst the following week.

Musculoskeletal Disorders



Musculoskeletal Disorders

  • Types of amputations

  • Simple Toe – uncomplicated, most often due to injury and diabetes

Musculoskeletal Disorders

  • Amputations – BKA

    • Below the knee

    • Treatments for amputations will be further covered in Adult Health Care II

Musculoskeletal Disorders

  • Types of Amputations

  • AKA – above the knee – a surgical technique for saving a person’s life from an infected prosthesis or necrotic limb

Musculoskeletal Disorders

  • Amputations - facts and figures:

  • More than 100,000 amputations are performed in the USA every year.

  • The most common cause of amputations is diabetes & infection

  • Of the 9,985 nonfatal workplace amputations in 1999, more than 1 in 3 cases required 31+ days away from work to recuperate (OSHA study)

  • The third most common cause today is war-related.

Musculoskeletal Disorders

  • Assessment must include:

  • Pain as a no. 1priority

    • Proper patient assessment must include pain intensity, radiation, relief, medication side effects, and reassessment on a regular basis.

  • Skin integrity

  • Tissue Perfusion

  • Prevention of infection

  • Promotion of nutrition

  • Exercise & ROM

  • Body Image


Musculoskeletal Disorders

  • Gout –

  • Pathophysiology

  • Gout isa disease caused by the kidneys not clearing the uric acid out of the blood stream. Uric acid is the end product of purines in our diet (one of the amino acids in the body). This causes a hyperuricemia (high levels of uric acid in the blood) and initiates an inflammatory response in the joints. The urate crystals deposit into a joint and/or subcutaneous tissues.. This deposit and inflammation causes “gouty arthritis” and may appear the same as OA on X-ray. The deposits can also cause kidney stones, as deposits build up in the kidneys. Renal stones are `1000 times more common in people with gout.

Musculoskeletal Disorders

Gout Symptoms:

  • Tophi - white crystalized deposits in the tissue, usually seen on the hands or toes.

  • Heat & Redness

  • Pain – Severe & sudden onset

  • Swelling

  • Inflammation – usually on one side of the body first, a ankle joint, knee, or toe

  • May become an acute inflammation after an injury, i.e. stubbing your toe on the sprinkler

Musculoskeletal Disorders

Gout –


- X-ray of limb to rule out regular arthritis, or osteomylitis/cellulitis

- blood test for a uric acid level

normal is 4.0-5.2 (lab values may differ based on the age of the patient)

- Anything over 6.0 is consider high

- An aspiration of the fluid in the joint will demonstrate crystalline deposits by microscope

Musculoskeletal Disorders

  • Treatments

    • Anti-inflammatories STAT – drugs of choice are colchicine and indocin – Patients need to be educated to side effects and dosing.

    • Sometimes, doctors will give Toradol IM for immediate pain relief, as it acts like injectable aspirin and reacts quickly

    • Pain control

    • Maintenance on daily allopurinol – to allow the kidneys to secrete the acid

    • Educate patient to avoid high purine foods

Musculoskeletal Disorders

  • gout

Musculoskeletal Disorders

  • Gout tophi

Musculoskeletal Disorders

  • Gouty tophi (in red)




Pharmacology Associated with Musculoskeletal Patients--General Information

  • Assess/monitor the client’s need for pain medication, and plan and provide care to meet the client’s needs for pain intervention.

  • Assess/monitor the effectiveness of pain intervention, and advocate for the client’s needs as indicated.

  • Provide appropriate client education, and reinforce client teaching regarding the purposes and possible effects of pain medications.

  • Assess/monitor the client for expected effects of medications.

  • Assess/monitor the client for side/adverse effects of medications.

  • Assess/monitor the client for actual/potential specific food and medication interactions.

  • Identify contraindications, actual/potential incompatibilities, and interactions between medications, and intervene appropriately.

  • Identify symptoms/evidence of an allergic reaction, and respond appropriately.

  • Evaluate/monitor and document the therapeutic and adverse/side effects of medications.

  • Assess/collect data regarding the client’s medication use over time.

Musculoskeletal Pharmacology : Medications for Pain & InflammationNSAIDs—Non Steroidal Anti-Inflammatory DrugsPrototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®)

Pharmacological Action

Inhibition of cyclooxygenase: Inhibition of COX-2 results in ↓ inflammation, pain, and fever. Inhibition of COX-1 results in the ↓ of platelet aggregation

Therapeutic Uses

  • Inflammation suppression

  • Analgesia for mild to moderate pain

  • Fever reduction

  • Dysmenorrhea

  • Low level suppression of platelet aggregation

  • Aspirin contraindications include:

  • Peptic ulcer disease.

  • Bleeding disorders (e.g., hemophilia, vitamin K deficiency)

  • Hypersensitivity to aspirin and other NSAIDs.

  • Pregnancy (Pregnancy Risk Category D).

  • Children with chickenpox or influenza.

  • Use NSAIDs cautiously in older adults, clients who smoke cigarettes, and in clients with H. pylori infection, hypovolemia, hay fever, chronic urticaria, and/or a history of alcoholism.

Musculoskeletal Pharmacology : Medications for Pain & InflammationNSAIDs—Non Steroidal Anti-Inflammatory DrugsPrototypes: 1st Generation: Aspirin 2nd Generation: celecoxib (Celebrex®) CONTINUED…

Therapeutic Nursing Interventions and Client Education

  • Advise the client to stop aspirin 1 week before an elective surgery or expected date of childbirth.

  • Advise the client to take aspirin with food, milk, or a full glass of water to reduce gastric discomfort.

  • Instruct the client not to chew or crush enteric-coated or sustained-release aspirin tablets.

  • Advise the client to notify the primary care provider if signs and symptoms of gastric discomfort or ulceration occur.

  • Clients unable to tolerate aspirin due to GI ulceration, risk of bleeding, or renal impairment should be prescribed a 2nd generation NSAID, such as celecoxib(Celebrex).

  • One 1st generation NSAID, ketorolac (Toradol), is used for short-term treatment of moderate to severe pain such as that associated with postoperative recovery.

  • Ketorolac provides analgesia without anti-inflammatory effect.

  • When ketorolac is used concurrently with opioids, the analgesic effect of opioids is enhanced without the occurrence of adverse effects associated with opioids (e.g., respiratory depression, constipation).

  • When ketorolac is used with other NSAIDs serious adverse effects can occur; therefore, ketorolac should be used no more than 5 days. Usually started as parenteral administration and then progresses to oral doses.

  • Depending on therapeutic intent, effectiveness of NSAID USE may be evidenced by:

  • Reduction in inflammation.

  • Reduction of fever.

  • Relief from mild to moderate pain or dysmenorrhea.

  • Platelet aggregation suppression.

Musculoskeletal Pharmacology : Medications for Pain & InflammationAcetaminophenPrototypes: acetaminophen (Tylenol® )

  • Pharmacological Action

  • Acetaminophen slows the production of prostaglandins in the central nervous system.

  • Therapeutic Uses

  • Analgesic (relief of pain) effect

  • Antipyretic (reduction of fever) effects

  • Side/Adverse Effects:

  • Nursing Interventions and Client Education

  • Acute toxicity that results in liver damage with early symptoms of nausea, vomiting, diarrhea, sweating, and abdominal discomfort progressing to hepatic failure, coma, and death

  • Advise the client to take acetaminophen as prescribed and not to exceed 4 g per day.

  • Administer the antidote,

    Acetylcysteine (Mucomyst® ).

  • Use cautiously in clients who consume three or more alcoholic drinks/day and those taking warfarin (interferes with metabolism).

  • Nursing Interventions and Client Education

  • Acetaminophen is a component of multiple prescribed and over-the-counter medications. Keep a running total of daily acetaminophen intake and follow recommended dosages as prescribed by the primary care provider to prevent toxicity, not to exceed 4 g per day.

  • In the event of an acetaminophen overdose, liver damage can be reduced by administering a weight-based dosage of the antidote acetylcysteine (Mucomyst) in a diluted form via an oroduodenal tube (has an unpleasant odor that ↑ risk of emesis).

  • Nursing Evaluation of Medication Effectiveness

  • Depending on therapeutic intent, effectiveness may be evidenced by:

  • Relief of pain.

  • Reduction of fever.

Musculoskeletal Pharmacology : Medications for Pain & InflammationOpioid AgonistsPrototypes: Morphine sulfate

  • Pharmacological Action

  • Opioid agonists, such as morphine, codeine, meperidine, and other morphine-like medications (fentanyl), act on the mu receptors, and to a lesser degree on kappa receptors. Activation of mu receptors produces analgesia, respiratory depression, euphoria, and sedation, whereas kappa receptor activation produces analgesia, sedation, and ↓ GI motility.

  • Therapeutic Uses

  • Relief of moderate to severe pain (e.g., postoperative pain, myocardial infarction pain, cancer pain)

  • Sedation

  • Reduction of bowel motility

  • Codeine: cough suppression

  • Contraindications/Precautions

  • Contraindicated:

  • after biliary tract surgery.

  • for premature infants (during and after deliverydue to respiratory depressant effects).

  • Used Cautiously: because of respiratory depression

  • asthma, emphysema, and/or head injuries

  • Infants and older adult clients

  • Pregnant clients

  • Clients in labor

  • Clients with inflammatory bowel disease

  • Clients with an enlarged prostate

Demerol ® -- meperidine

Repeated use of meperidine (Demerol) can result in the accumulation of normeperidine, which can result in seizures and neurotoxicity.

Do not administer meperidine more than

600 mg/24 hr, and limit its use to less than 48 hr.

Musculoskeletal Pharmacology Medications for Pain & InflammationAgonist – Antagonist OpioidsPrototypes: pentazocine (Talwin ®)

  • Pharmacological Action

  • Compared to pure opioid agonists, agonist-antagonists have:

  • --A low potential for abuse causing little euphoria. In fact, high doses can cause adverse effects (e.g., anxiety, restlessness, mental confusion).

  • --Less respiratory depression. Kappa receptors will cause a certain degree of

    respiratory depression and then no more (have a “ceiling”).

    Therapeutic Uses

  • Agonists-antagonists opioids relieve mild to moderate pain; not used for treatment of severe pain.

  • Contraindications/Precautions

  • Use cautiously in clients with a history of myocardial infarction (↑ cardiac workload) and clients who are physically dependent on opioids.

  • Nursing Interventions and Client Education

  • Take the client’s baseline vital signs. If the client’s respiratory rate is less than 12/min, withhold the medication and notify the primary care provider.

  • Warn the client not to ↑ dosage without consulting the primary care provider.

  • Nursing Evaluation of Medication Effectiveness

    --Monitor for improvement of symptoms, such as relief of pain.

Musculoskeletal Pharmacology Medications for Pain & InflammationOpioid AntagonistsPrototypes: naloxone (Narcan ®)

  • Pharmacological Action

  • Opioid antagonists interfere with the action of opioids by competing for opioid receptors. Opioid antagonists have no effect in the absence of opioids.

  • Therapeutic Uses

  • Treatment of opioid overdose

  • Reversal of effects of opioids, such as respiratory depression

  • Reversal of respiratory depression in an infant

  • Contraindications/Precautions

  • Hypersensitivity

  • Opioid dependency

  • Pregnancy Risk Category B

  • Therapeutic Nursing Interventions and Client Education

  • Naloxone has rapid first-pass inactivation and should be administered IV, IM, or SC. Do not administer orally.

  • Observe the client for withdrawal symptoms and/or abrupt onset of pain. Be prepared to address the client’s need for analgesia (e.g., if given for postoperative opioid-related respiratory depression).

  • Nursing Evaluation of Medication Effectiveness

  • Reversal of respiratory depression (e.g., respirations are regular, client is without shortness of breath, respiratory rate is 16 to 20/min in adults and 40 to 60/min in newborns)

Musculoskeletal Pharmacology Medications for Pain & InflammationAdjuvant Pain MedicationsPrototypes:Tricyclic anti-depressants; anticonvulsants; CNS Stimulants; antihistamines; glucocorticoids; & biphosphonates

  • Tricyclic antidepressants: amitriptyline(Elavil)

  • Anticonvulsants: carbamazepine (Tegretol), gabapentin (Neurontin), phenytoin (Dilantin

  • CNS stimulants: methylphenidate (Ritalin), dextroamphetamine (Dexedrine)

  • Antihistamines: hydroxyzine (Vistaril)

  • Glucocorticoids: dexamethasone(Decadron), prednisone (Deltasone)

  • Bisphosphonates: etidronate (Didronel), pamidronate (Aredia)

  • Pharmacological Actions

  • Adjuvant medications for pain enhance the effects of opioids.

  • Therapeutic Uses

  • Used in combination with opioids – cannot be used as a substitute for opioids

  • Treating pain with an adjuvant medication allows for lower dosages of opioids, and thereby ↓ the adverse effects experienced with opioids (e.g., sedation and constipation).

  • Help alleviate other symptoms that aggravate pain (e.g., depression, seizures, dysrhythmias)

  • Used in the treatment of neuropathic pain (e.g., cramping, aching, burning, darting and lancinating pain).

  • Used in cancer-related conditions (e.g., ↑ intracranial pressure, spinal cord compression, bone pain).

Musculoskeletal Pharmacology Medications for Pain & InflammationAntigout MedicationPrototypes: colchicine

  • Pharmacological Action

  • Colchicine and indomethacin ↓ inflammation in clients with gout by possibly preventing infiltration of leukocytes. These medications do not effect uric acid production or excretion.

  • Allopurinol inhibits uric acid production.

  • Probenecid inhibits uric acid reabsorption by the renal tubules.

  • Therapeutic Uses

  • Colchicine and indomethacin:

  • --Treatment of acute gout attacks.

  • --If given in response to precursor symptoms of an acute gout attack, can abort the attack.

  • --↓ in the incidence of acute attacks for clients with chronic gout.

  • Allopurinol and probenecid:

  • --Hyperuricemia (chronic gout secondary to cancer chemotherapy).

  • Probenecid:

  • --Prolongs the effects of penicillins and cephalosporins by delaying their elimination.

  • Contraindications/Precautions

  • Avoid use of colchicine during pregnancy (FDA Pregnancy Risk Category C, if used orally; Category D, if used intravenously).

  • Use colchicine cautiously in older adults, debilitated clients, and clients with renal, cardiac, and gastrointestinal dysfunction.

  • Therapeutic Nursing Interventions and Client Education

  • Instruct the client to concurrently take preventive measures such as avoiding alcohol and foods high in purine (e.g., red meat, scallops, cream sauces). The client should ensure an adequate intake of water, exercise regularly, and maintain an appropriate body weight.

  • Nursing Evaluation of Medication Effectiveness

  • Depending on the therapeutic intent, effectiveness may be evidenced by:

  • --Improvement of pain caused by a gout attack (e.g., ↓ in joint swelling, redness, and uric acid levels).

  • --↓ in number of gout attacks.

  • --↓ in uric acid levels.

Musculoskeletal Disorders

  • Case Study Exercise Group I

  • John is a 34 y.o. skier with a spiral fracture of the right tibia. He has pins set to traction below his knee to continue with 5 pounds of pressure to hold the ones in place.

    Create a nursing care plan, that you will present to the class.

    Complete with two references:

    Research articles on

    Traction, pins, and

    spiral fractures.

Musculoskeletal Disorders

  • Case Study Exercise Group II

  • Maria is a 48 y.o. with osteomyelitis and MRSA of the (R) tibia. Medical history includes Diabetes Mellitus, Type 2. She is returning from the operating room, S/P Right BKA

    Create a nursing care plan, that you will present to the class.

    Complete with two references:

    Research articles on amputation.

Musculoskeletal Disorders

  • Case Study Exercise Group III

    Franklin is a 64 y.o. male who is returning from the operating room, S/P (R) Total knee replacement. He is otherwise “healthy,” on no home medications other than NSAIDs.

    Create a nursing care plan, that you will present to the class.

    Complete with two references:

    Research articles on TJR.

Musculoskeletal Disorders

  • Case Study Exercise Group IV

  • Johnna is a 48 y.o. with severe pain to her right ankle. Has just been diagnosed with gout.

    Create a nursing care plan, that you will present to the class.

    Complete with two references:

    Research articles on Gout

    and its treatment.

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