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Nurs 341 Ch. 53
Medical Surgical Nursing: Patient-Centered Collaborative Care, 7th Edition; Ignatavicius, Workman; Chapter 53: Care of Patients with Musculoskeletal Problems
Terms in this set (79)
decreased bone mass from lack of Ca; chronic metabolic disease in which bone loss causes decreased density & potential fracture; silent disease
Osteopenia & Osteoporosis
Occur when osteoclastic activity is greater than osteoblastic activity
Bone Mineral Density (BMD) or Bone Densitometry, DXA; often seen in hip, wrist, spine (lower than -2.5 score determines osteoporosis dx)
bone resorption/destruction; occurs as estrogen decreases
Bone Activity Peak Years
20-30; when osteoblastic & osteoclastic occur in equal proportions
Estrogen & Bone Loss
decreases probability of bone loss
Generalized Primary Osteoporosis
occurs most commonly in postmenopausal women & men (age 70-80)
Generalized Secondary Osteoporosis
results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility.
occurs when a limb is immobilized related to a fracture, injury, for paralysis for longer than 8-12 weeks
African Americans have high bone density; Asian & Caucasian have highest incidence of osteoporosis
Osteoporosis Modifiable Risk Factors
Ensure adequate calcium intake.(dairy & dark green leafy vegetables); Sun exposure or adequate dietary Vit. D, limit carbonated beverages, Avoid sedentary lifestyle- weight bearing exercise. Avoid activities that jar, limit caffeine, limit ETOH and tobacco
Health Promotion Osteoporosis
Teaching should begin with young women who begin to lose bone after 30 years of age; focus on decreasing modifiable risk factors; walk for 30 min 3-5 times/wk; may occur in anorexic/bulimic pts; decrease risk for falls
Osteoporosis Physical Assessment
Dexascan on wrist, hip, spine; assess for lordosis
Osteoporosis Psychosocial Assessment
may have decreased self esteem due to inability to perform ADLs and poor body image
Osteoporosis Lab Assessment
no definitive lab tests but they can rule out secondary osteoporosis and other illnesses
Osteoporosis Imaging Assessment
DXA, QCT, QUS
dual xray absopriometry; best tool to dx osteoporosis; measures wrists, hips, and spine density
Quantitative Computed Tomography
QCT; bone density measure, more expensive than DXA; sensitive to vertebral changes & has more radiation
QUS; low cost screening; predicts risk for hip fracture
Osteoporosis Nutrition Therapy
Overall diet: fruits, veg, low-fat dairy, protein, increased fiber, moderate use of ETOH & caffeine; adequate protein, mg, vit K, calcium, vit D; pts who have had fractures: protein, vitC, and iron **Calcium & Vitamin D
walking 30min 3-5 times/wk is single most effective exercise for osteoporosis prevention
Osteoporosis Lifestyle Change
avoid tobacco, prevent falls *promote hazard-free environment: no throw rugs, cluttered rooms, wet floors
Osteoporosis Drug Therapy
Estrogen or hormone therapy; parathyroid hormone; calcium & vitamin D supplements; bisphosphonates; selective estrogen receptor modulators; calcitonin
Primarin; good for bones but may cause heart problems
Calcium/Vit D Supplement
Os-Cal; Os-Cal Ultra (contains Vitamin D)
take 30 minutes before meals with full glass of water & sit upright for 30 minutes after taking; may cause esophageal erosion; Fosamax (alendronate), Boniva (ilbandronate), Actonel (risedronate)
Boniva (Ibandronate)-also given oral; Aredia (Pamidronate)-given q3-6 mos; Reclast (Zoledronic acid)-give once/year
Selective estrogen receptor modulators
Thyroid hormone that decreases bone loss; decreases progression of osteoporosis; derived from salmon; may be given subQ or intranasally; nasal is preferred due to convenience & decreased SE; alternate nares when using
Androgens for Osteoporosis
decrease bone reabsorption & increase bone growth in men; cause masculine traits in women; which is worse a beard or brittle bones?
injection of bone cement into the vertebral body to reduce fracture or fill the space created by osteoporosis
Use of a balloon in the vertebral body to contain bone cement
Demineralized bone (bone loss) related to Vitamin D deficiency; bone softens because of inadequate deposits of Ca & phosphorous in bone matrix; Rickets is Vit D deficiency in peds
Most important history is dietary intake of Vit D; muscle weakness in shoulder/pelvis/lower extremities; bone pain aggravated by activity, worse at night; Looser's Line
Radiolucent bands; represents stress fractures that have not mineralized
Vitamin D; recommended daily allowance: 400 IU; eat foods high in Vit D; sun exposure for at least 5 min/d
Chronic metabolic disorder in which bone is excessively broken down & reformed; genetic predisposition
Genetic Considerations for Paget's
suspected viral respiratory etiology present for several years; if family history of disease educate regarding need for genetic counseling
usually in age 50+; mild-moderate bone/joint pain; common sites for pain are hip/pelvis; pain is aching/poorly described/deep/worsened by pressure & weight bearing; most noticeable at night/rest; may report redness/warmth at affected sites; loss of normal spine curvature; enlarged/thick skull; nerve pinch in lower back; patho fracture; change in hearing/vision/speech; loose teeth; gout; urinary calculi; CHF; hyperparathyroidism
Paget's Non-Surg Management
Goal: relieve pain/decrease bone reabsorption; analgesics (advil/motrin); bisphosphonates; calcitonin; plicamycin; diet therapy
chemotherapeutic; suppresses platelet count-bleeding precautions; treatment for Paget's
Nonpharm Pain Relief for Paget
heat; non-impact exercise; gentle stretching & massage; orthopedic devices to mobilize & provide support
Can be caused by bacteria, viruses, fungi; occurs from infection, underlying disease, nonpenetrating trauma; may be caused from open fracture or internal infection such as UTI, salmonella, poor dental hygiene, dialysis
most common type; pt complains of bone pain that is constant, localized, pulsating sensation that worsens with movement; presents with fever; infected area swells & is tender with movement; erythema present; elevated WBC
Pathogen invasion-->tissue inflammation--> edema formation-->decreased blood flow to bone-->bone necrosis-->bone abscess
difficult to treat; may end up losing function or bone; big issue is ulceration of skin
fever, swelling, tenderness, bone pain, erythema
occurs if treatment is too short or delayed; localized pain, drainage; chart 53-4
ATB therapy goes on for weeks; takes a long time to heal and difficult to control because it is in the bone
ATB therapy; Cover wound with dressing & use clean technique to change dressing; hyperbaric oxygen therapy (prevents necrotizing faciitis); Surgical management: sequestrectomy & microvascular bone transfers
Osteomyelitis Surgical Management
Sequestrectomy: taking infected piece of bone out; debrides necrotic bone & allows revascularization
Microvascular bone transfer: require frequent neurovascular checks (see p1167 to finish)
Slowly progressive contracture of the palmar fascia resulting in flexion of the 4th-5th digit of the hand; unknown cause; occurs in men; can be bilateral; assoc with rheumatoid arthritis
Round, benign cyst often found on wrist or food joint or tendon; can disappear & reappear; usually painless on palpation; age 15-50; aspirated or surgically removed;
Seen in patients with rheumatoid arthritis; great toe drifts to the side resulting in a bunion; affects women more than men
Corns on toe; painful; keep returning; may require surgical removal of one digit of the toe
small tumor in digital nerve; accompanied by burning pain
Common in athletes; pain near arch **see book
Changes in muscles & ligaments on the concave side of the spinal column; three types: congenital, neuromuscular, idiopathic; bend them over & scapula on one side rises-if rises more than 50 degrees it requires rods or a brace; common with adolescent females; may treat with exercise, brace, surgery, rods
a loss of lumbar curvature; "sway back"
The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the physician will request which medication?
A. Ascorbic acid (vitamin C)
B. Ergocalciferol (calciferol)
C. Phenytoin (Dilantin)
D. Prednisone (Deltasone)
An older adult client is discharged from the hospital for treatment of osteoporosis. What will the nurse include in client teaching related to the client's home safety?
A. Use area rugs on tile floors.
B. Keep walkways free of clutter.
C. Walk slowly on wet floor areas after mopping.
D. Keep light low to prevent glare.
Keep walkways free of clutter.
The nurse plans to refer a client diagnosed with osteoporosis to which community resource?
A. American Bone Society
C. I Can Cope
D. Hospital support group
Hospital support group
The nurse is assessing a client with Ewing's sarcoma. Which finding will the nurse expect to observe?
B. High fever
D. Migraine headaches
Which nursing intervention helps to prevent the incidence of osteomyelitis for a client receiving hemodialysis?
A. Instructing the client to brush teeth after every meal
B. Maintaining clean dressing change technique for long-term IV catheters
C. Using clean technique
D. Using Standard Precautions
Instructing the client to brush teeth after every meal
The nurse is teaching a client newly diagnosed with osteoporosis about dietary and lifestyle interventions to decrease risk factors for osteoporosis. Which is the best way to decrease the risk for osteoporosis?
A. Increase nutritional intake of calcium.
B. Engage in high-impact exercise, such as running.
C. Increase nutritional intake of phosphorus.
D. Walk for 30 minutes three times a week.
Walk for 30 minutes three times a week.
The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis?
A. Consuming 12 ounces of carbonated beverages daily
B. Working at a desk and playing the piano for a hobby
C. Having a hysterectomy and taking estrogen replacement therapy
D. Consuming one alcoholic drink per week
Working at a desk and playing the piano for a hobby
A mother is a carrier of muscular dystrophy (MD) and has a daughter. The client asks the nurse what the daughter's genetic risk is for having MD. What is the nurse's best response?
A. "Because you are a carrier of the MD gene, your daughter will develop MD."
B. "She will not have MD nor will she be a carrier."
C. "There is a 50% chance that your daughter may carry the gene."
D. "Your daughter is X-linked dominant for the MD gene."
"There is a 50% chance that your daughter may carry the gene."
The nurse is assessing a client with osteomalacia. Which findings will the nurse expect to observe? Select all that apply.
D. Looser's lines or zones
E. Unsteady gait
Looser's lines or zones
The nurse is caring for a client with bone cancer of the right hip who has undergone radical resection of the tumor and has received a prosthetic implant. Which client statement indicates effective coping after the procedure?
A. "After I recover, I'll be just as strong as I was before the surgery."
B. "I won't be able to go out in public like I did before."
C. "Physical therapy and counseling will help me adjust to my prosthesis."
D. "I'll be able to return to work and drive without assistance."
"Physical therapy and counseling will help me adjust to my prosthesis."
The client with bone cancer is scheduled for a right upper extremity amputation. Which statement by the client's spouse indicates an effective coping strategy?
A. "I'll have to find ways to help my spouse focus on positive aspects of his or her body."
B. "The family will avoid direct discussion of the spouse's amputation."
C. "I'll try to limit visitors."
D. "The family will use diversional methods to help my spouse not focus on the amputation."
"I'll have to find ways to help my spouse focus on positive aspects of his or her body."
The nurse is caring for a client with prostate cancer who has bone metastasis. The nurse anticipates that the physician will prescribe which medication?
A. Calcitonin (Calcimar)
B. Medroxyprogesterone (Prempro)
C. Pamidronate (Aredia)
D. Tamsulosin hydrochloride (Flomax)
The nursing instructor asks a nursing student to identify risk factors that are shared by clients who have osteoporosis or osteomalacia. Which statement by the student is correct?
A. "High alcohol intake is a risk factor for both conditions."
B. "A history of smoking is a risk factor for both conditions."
C. "Inadequate exposure to sunlight is a risk factor for both conditions."
D. "Being homeless is a risk factor for both conditions."
"High alcohol intake is a risk factor for both conditions."
The nurse admits a client diagnosed with Paget's disease. The nurse anticipates that the client will have which condition?
A. Progressive muscle weakness
B. Low body weight, thin build
C. Enlarged thick skull
D. Bone infection
Enlarged thick skull
Which finding will the nurse expect to observe for a client with suspected common chronic osteomyelitis?
A. Erythema of the affected area
B. Fever; temperature usually above 101° F (38° C)
C. Ulceration of the skin
D. Constant, localized, and pulsating bone pain
Ulceration of the skin
The client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon?
A. Swelling of the right lower extremity
B. 1+ to 2+ bilateral palpable pedal pulses
C. Pain of right lower extremity on movement
D. Paresis of right lower extremity
Paresis of right lower extremity
Which is problem for the older adult client diagnosed with bone cancer?
A. Potential for injury related to weakness and drug therapy
B. Altered self-esteem related to fear of death and dying
C. Reduced mobility related to weakness and fatigue
D. Chronic Pain related to tumor invasion on other organs
Potential for injury related to weakness and drug therapy
The nurse suspects that a client may have plantar fasciitis if the client has which finding?
A. Lateral deviation of the great toe; first metatarsal head becomes enlarged
B. Dorsiflexion of any metatarsophalangeal (MTP), with plantar flexion of the adjacent proximal interphalangeal (PIP) joint
C. Severe pain in the arch of the foot, especially when getting out of bed
D. A small tumor in a digital nerve of the foot
Severe pain in the arch of the foot, especially when getting out of bed
What is the primary role of the nurse when caring for the adult client with muscular dystrophy (MD)?
A. Pain management
B. Supportive care
C. Teaching the importance of keeping appointments
D. Advocating for the client and the family
The nurse is instructing a client who has been prescribed calcium citrate (Citracal). The nurse plans to include which instruction?
A. Take Citracal with food.
B. For best absorption, take Citracal with a carbonated beverage.
C. One third of the daily dose is best taken during the day.
D. Milk of magnesia (MOM) should be taken with Citracal.
Take Citracal with food.
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