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Flashcards in Chapter 68 Deck (79):

What are some causes of lower back pain?

Lumbosacral strain, unstable lumbosacral ligaments and muscle weakness, osteoarthritis of the spine, spinal stenosis, intervertebral disk problems, and unequal leg length.


How is lower back pain assessed?

The initial assessment includes a focused history and physical examination. It includes general observation of the patient, back examination and neurologic testing.


What is the medical management of lower back pain?

It mostly resolves in four weeks with analgesic agents, rest and relaxation. Over-the-counter analgesics and prescription muscle relaxants are effective for acute lower back pain and tricyclic antidepressants are effective for chronic back pain.


What is the nursing assessment for lower back pain?

The nurse asks the patient to describe the pain, and if it is recurrent pain what helped relieve it in the past.


What are the major goals for nursing management for lower back pain?

Pain relief, improved physical mobility, improved body mechanics and self esteem, weight loss.


What are bursitis and tendonitis?

Inflammatory conditions that commonly occur in the shoulder.


How are bursitis and tendonitis treated?

Rest of the extremity, intermittent heat and ice to the joint and NSAIDs.


What are loose bodies and how are they treated?

A loose body is a free-floating piece of bone, cartilage, or a foreign object in a joint. The knee is the most common site for loose bodies.
Surgery to remove the loose body or repair the kneecap may be needed if a loose body is causing symptoms.


What is impingement syndrome?

All lesions that involve the rotator cuff of the shoulder.


What is stage I, II and III impingement syndrome?

Stage 1, commonly affecting patients younger than 25 years, is depicted by acute inflammation, edema, and hemorrhage in the rotator cuff. This stage usually is reversible with nonoperative treatment.
Stage 2 usually affects patients aged 25-40 years, resulting as a continuum of stage 1. The rotator cuff tendon progresses to fibrosis and tendonitis, which commonly does not respond to conservative treatment and requires operative intervention.
Stage 3 commonly affects patients older than 40 years. As this condition progresses, it may lead to mechanical disruption of the rotator cuff tendon and to changes in the coracoacromial arch with osteophytosis along the anterior acromion. Surgical l anterior acromioplasty and rotator cuff repair is commonly required.


How is impingement syndrome treated?

Medications used to treat early impingement syndrome include 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.


What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome is an 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.


What are some signs and symptoms 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’s sign helps identify patients requiring intervention (Fig. 42-4).
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’s sign helps identify patients requiring intervention.


How is Carpal Tunnel Syndrome treated?

Evidence-based treatment of carpal tunnel syndrome includes oral or intra-articular injections of corticosteroids (e.g., methylprednisolone [Depo-Medrol]). Application of wrist splints to prevent hyperextension and prolonged flexion of the wrist is also effective; however, yoga, laser therapy, and ultrasound therapy are ineffective therapies, as are the use of NSAIDs, diuretics, and vitamin B6 (American College of Occupational and Environmental Medicine, 2011).

Traditional open nerve release or endoscopic laser surgery are the two most common surgical management options. 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.


What is a ganglion?

Ganglions are among the most common tumors of the hand and wrist. For the most part, they are asymptomatic masses that are primarily cosmetic rather than functional disturbances.


How are ganglions treated?

Treatment may include aspiration, corticosteroid injection, or surgical excision. After treatment, a compression dressing and immobilization splint are used.


What is Dupuytren’s Disease?

Dupuytren’s disease results in a slowly progressive contracture of the palmar fascia that causes flexion of the fourth, fifth, and, sometimes, middle finger, rendering these fingers more or less useless.


How is Dupuytren's Disease managed?

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 fasciectomies are performed to improve function.


What are the important nursing management considerations for hand and wrist surgery?

Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion. This is especially important if an intraoperative tourniquet technique was used, which is implicated in neurovascular deficits. . Percutaneous pins may be used to hold bones in position. These pins serve as potential sites of infection. Patient instructions concerning aseptic wound and pin care may be necessary.


What patient teaching is necessary with hand or wrist surgery?

After the patient has undergone surgery, the nurse instructs the patient how to monitor neurovascular status and the signs of complications that need to be reported to the surgeon (e.g., paresthesia, paralysis, uncontrolled pain, coolness of fingers, extreme swelling, excessive bleeding, purulent drainage, foul odor, fever). In addition, the nurse instructs the patient how to elevate the extremity and to apply ice (if prescribed) to control swelling. The use of assistive devices is demonstrated if such devices would be helpful in promoting accomplishment of ADLs


What is plantar fasciitis?

Plantar fasciitis, an inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with the first steps in the morning.


How is plantar fasciitis managed?

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 (Lee, McKeon, & Hertel, 2009). Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs.


What is a corn?

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.


How are corns treated?

Treatment consists of eliminating the underlying causes and having a painful callus treated by a podiatrist.


What is an ingrown toenail?

An ingrown toenail (onychocryptosis) is a condition in which the free edge of a nail plate penetrates the surrounding skin.


How are ingrown toenails treated?

Active treatment 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.


What is hammer toe?

Hammer toe is a flexion deformity of the interphalangeal joint, which may involve several toes.


How are hammer toes treated?

Treatment consists of conservative measures: wearing open-toed sandals or shoes that conform to the shape of the foot, carrying out manipulative exercises, and protecting the protruding joints with pads. Surgery (osteotomy) may be used to correct a resulting deformity. There is little evidence to support treatment of hammer toe when the patient does not report pain or other symptoms (ACFAS, 2009).


What is a hallux valgus or bunion?

Hallux valgus (bunion) is a deformity in which the great toe deviates laterally.


What are contributing factors and treatments for bunions?

Factors contributing to bunion formation include heredity, ill-fitting shoes, osteoarthritis, and the gradual lengthening and widening of the foot associated with aging. Treatment depends on the patient’s age, the degree of deformity, and the severity of symptoms. 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 and toe realignment may be required to improve function, appearance, and symptoms.


What is pes cavus?

Pes cavus (claw foot) refers to a foot with an abnormally high arch and a fixed equines deformity of the forefoot.


How is pes cavus managed?

Exercises are prescribed to manipulate the forefoot into dorsiflexion and relax the toes. Orthotic devices alleviate pain and can protect the foot (Burns, Landorf, Ryan, et al., 2010). In severe cases, arthrodesis (fusion) is performed to reshape and stabilize the foot.


What is Morton's Neuroma?

A swelling of the third branch (lateral) of the plantar nerve.


How is Morton's Neuroma treated?

Conservative treatment consists of inserting innersoles and metatarsal pads designed to spread the metatarsal heads and balance the foot posture. Local injections of a corticosteroid and a local anesthetic may provide relief. 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 (ACFAS, 2010).


What is pes planus?

A diminished foot arch.


How is pes planus treated?

Exercises to strengthen the muscles and to improve posture and walking habits are helpful. A number of foot orthoses are available to give the foot additional support (Burns et al., 2010).


What nursing management is important with foot surgery?

After surgery, neurovascular assessment of the exposed toes (every 1 to 2 hours for the first 24 hours) is essential to monitor the function of the nerves and the perfusion of the tissues. If the patient is discharged within several hours after the surgery, the nurse educates the patient and family about how to assess for edema and neurovascular status (circulation, motion, sensation). Compromised neurovascular function can increase the patient’s pain (see Chart 40-3 in Chapter 40).


What is a major risks of surgery on the lower extremity?

The immobility of lower extremity surgery increases the risk of venous thromboembolism (VTE) development. (See Chapter 30 for VTE risk assessment and treatment.) Other postoperative complications may include limited range of motion, paresthesias, tendon injury, and recurrence of deformity (ACFAS, 2009).


What is osteoporosis?

Osteoporosis is the most common metabolic bone disease in the United States and can result in devastating physical, psychosocial, and economic consequences.


What can be done to prevent primary osteoporosis?

Early identification of at-risk teenagers and young adults, increased calcium and vitamin D intake, participation in regular weight-bearing exercise, and modification of lifestyle (e.g., reduced use of caffeine, cigarettes, carbonated soft drinks, and alcohol) are interventions that decrease the risk of fractures and associated disability later in life (NOF, 2013).


What is a gerontologic consideration with osteoporosis?

Older people absorb dietary calcium less efficiently and excrete it more readily through their kidneys. Postmenopausal women and older adults need to consume approximately 1,200 mg of daily calcium; quantities larger than this may place patients at heightened risk of renal calculi or cardiovascular disease (United States Preventive Services Task Force [USPSTF], 2013).


What are some characteristics of osteoporosis?

Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength.


What are some risk factors for osteoporosis?

Small-framed, Asian, and Caucasian women are at greatest risk for osteoporosis (see Fig. 42-7). African American women generally are less susceptible to osteoporosis. Men have a greater peak bone mass and do not experience a sudden midlife estrogen reduction; as a result, osteoporosis occurs in men at a lower rate and at an older age (about one decade later) (Ducharme, 2010).


How is osteoporosis diagnosed?

Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DEXA), which provides information about BMD at the spine and hip


What is recommended to help prevent osteoporosis?

A lifetime diet rich in calcium and vitamin D with an increase during adolescence and middle years, as well as weight bearing exercises.


What medications are used for osteoporosis?

The first-line medications used to treat and prevent osteoporosis include calcium and vitamin D supplements and bisphosphonates for both genders.
Bisphosphonates that include daily or weekly oral preparations of alendronate (Fosamax), risedronate (Actonel), monthly oral preparations of ibandronate (Boniva), or yearly intravenous (IV) infusions of zoledronic acid (Reclast) all increase bone mass and decrease bone loss by inhibiting osteoclast function (Watts et al., 2010). However, primary prevention of fractures is limited mostly to vertebral bones; hip fracture prevention is less evident.
Selective estrogen receptor modulators (SERMs), such as raloxifene (Evista), reduce the risk of osteoporosis in postmenopausal women by preserving BMD without estrogenic effects on the uterus. They are indicated for both prevention and treatment of osteoporosis. SERMS are contraindicated in women with a history of VTE (Watts et al., 2010).
Teriparatide (Forteo) is an anabolic agent used for both genders that is administered subcutaneously once daily for 2 years. It is reserved for those with high fracture risk and longterm corticosteroid use.


How are fractures managed with osteoporosis?

Fractures of the hip that occur as a consequence of osteoporosis are managed surgically by joint replacement or by closed or open reduction with internal fixation.
Osteoporotic compression fractures of the vertebrae are managed conservatively. Percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacrylate [PMMA] bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra) can provide rapid relief of acute pain and improve quality of life.


What is osteomalacia?

Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. As a result, the skeleton softens and weakens, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures. On physical examination, skeletal deformities (spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling gait.


What causes osteomalacia?

The major defect in osteomalacia is a deficiency of activated vitamin D, which promotes calcium absorption from the gastrointestinal tract and facilitates mineralization of bone. The supply of calcium and phosphate in the extracellular fluid is low and does not move to calcification sites in bones.


What are gerontologic concerns with osteomalacia?

Prevention, identification, and management of osteomalacia in older adults are essential to reduce the incidence of fractures. When osteomalacia is combined with osteoporosis, the risk of fracture increases.


How is osteomalacia diagnosed?

X-Ray, lab studies and bone biopsy?


How is osteomalacia managed?

Physical, psychological, and pharmaceutical measures are used to reduce the patient’s discomfort and pain. If the underlying cause of osteomalacia is corrected, the disorder may resolve.


What is Paget's Disease?

Paget’s disease (osteitis deformans) is a disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae.


How does Paget's Disease manifest?

In Paget’s disease, a primary proliferation of osteoclasts occurs, which induces bone resorption. This is followed by a compensatory increase in osteoblastic activity that replaces the bone. As bone turnover continues, a classic mosaic (disorganized) pattern of bone develops. Because the diseased bone is highly vascularized and structurally weak, pathologic fractures occur. Structural bowing of the legs causes malalignment of the hip, knee, and ankle joints, which contributes to the development of arthritis and back and joint pain (Brandi, 2010).


How is Paget's Disease diagnosed?

Elevated serum ALP concentration and urinary hydroxyproline excretion reflect increased osteoblastic activity. Higher values suggest more active disease. X-ray and bone biopsy are also used.


How is Paget's Disease managed?

Pain usually responds to NSAIDs. Gait problems from bowing of the legs are managed with walking aids, shoe lifts, and physical therapy. Weight is controlled to reduce stress on weakened bones and misaligned joints. Asymptomatic patients may be managed with diets adequate in calcium and vitamin D and periodic monitoring.


How is Paget's Disease medically managed?

Patients with moderate to severe disease may benefit from specific antiosteoclastic therapy. These medications reduce bone turnover, reverse the course of the disease, relieve pain, and improve mobility.
Bisphosphonates are the cornerstone of Paget therapy in that they stabilize the rapid bone turnover. Their use may not suppress all Paget symptoms (Brandi, 2010), but they reduce serum ALP and urinary hydroxyproline levels. 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.


What is the gerontologic consideration for Paget's Disease?

Because Paget’s disease tends to affect older adults, patients and their families and caregivers should be educated about how to compensate for altered musculoskeletal functioning with an emphasis on the risk of falls.


What is osteomyelitis?

Osteomyelitis is an infection of the bone that results in inflammation, necrosis, and formation of new bone.


What organisms cause osteomyelitis?

More than 50% of bone infections are caused by Staphylococcus aureus and increasingly of the variety that is methicillin resistant (i.e., methicillin-resistant Staphylococcus aureus [MRSA]) (Miller & Kaplan, 2009). Other pathogens include the gram-positive organisms streptococci and enterococci, followed by gram-negative bacteria, including pseudomonas.


How does osteomyelitis manifest?

Chills, high fever, tachycardia, general malaise. The infected area becomes swollen, painful and tender. Chronic osteomyelitis presents as a non-healing ulcer over the infected bone.


How is osteomyelitis diagnosed?

In acute osteomyelitis, x-rays first show edema and then areas of bone necrosis. Radioisotope bone scan, MRI and blood tests with elevated WBC help diagnose. With chronic osteomyelitis, bone scans are used to diagnose as WBC may be normal.


What is the main goal with osteomyelitis?

Prevention is the main goal. Prophylactic antibiotics can be administered when there is a risk for osteomyelitis.


How is osteomyelitis treated?

Antibiotic treatment depends on a c&s. General supportive measures include hydration, diet high in vitamins and protein and correcting anemia.


How is osteomyelitis surgically treated?

If it doesn't respond to IV abx, surgical debridement may be appropriate.


What are some nursing diagnoses associated with osteomyelitis?

Acute pain, impaired physical mobility, risk for extension of infection and deficient knowledge related to treatment. Interventions would involve these areas.


What is infectious/septic arthritis?

Joints become infected by a spreading infectious process or directly through trauma or surgical instruments.


How does septic arthritis manifest?

Warm, painful, swollen joints and decreased ROM.


How is septic arthritis diagnosed?

Aspiration, examination and culture of synovial fluid, CT and MRI.


How is septic arthritis treated?

Broad spectrum IV abx as well as needle aspiration of excess fluid, exudate and debris in joints. The inflamed joint is immobilized in a splint. NSAIDs can help prevent joint damage and progressive range of motion exercises can help prevent decrease in joint mobility.


What are some benign bone tumors?

Osteochondroma, enchondroma, bone cyst, osteoid osteoma, rhabdomyoma and fibroma.


What are some malignant bone tumors?

Osteosarcoma is the most common primary bone tumor and the most often fatal. Chondrosarcomas are malignant tumors of the hyaline cartilage.


What is metastatic bone disease?

Secondary bone tumors which are much more common than primary bone tumors.


What are some common symptoms of bone tumors?

Pain, weight loss, malaise, fever and pathological fractures.


How are bone tumors diagnosed?

CT, bone scan, myelography, arteriography, MRI, biopsy, biochemical assay of blood and urine.


What is medical management for primary bone tumors?

The goal is to destroy or remove the bone tumors using surgical excision, chemotherapy or radiation therapy or a combination.


What is the goal for treatment of secondary or metastatic bone tumors?

Palliative care the relieve pain and to improve quality of life.


How does the nurse help patients who have bone tumors?

The nurse assists in planning a pain management regimen. The nurse also helps in preventing pathological fractures and in verbalizing feelings and fears of the patient and family related to the medical condition.


What are some complications with bone tumors?

Delayed wound healing, inadequate nutrition, osteomyelitis and wound infections, and hypercalcemia.