NCLEX: MUSCULOSKELETAL DISORDERS

Musculoskeletal Disorders: Nursing diagnoses

Focus Topic: Musculoskeletal Disorders

Several nursing diagnoses are used for patients with musculoskeletal disorders. Common ones appear in this section, along with appropriate nursing interventions and rationales.

Activity intolerance

Focus Topic: Musculoskeletal Disorders

Related to impaired physical mobility, Activity intolerance may be associated with pain or edema. Alternatively, the patient’s activity may be severely restricted by such conditions as fractures requiring skeletal traction, rheumatoid arthritis, vertebral fractures, neurogenic arthropathy, Paget’s disease, muscular dystrophy, and other disorders.

Expected outcomes
• Patient reports factors that decrease his activity tolerance.
• Patient progresses to his highest level of possible activity.

Nursing interventions and rationales
• Perform active or passive ROM exercises to all extremities every 2 to 4 hours to foster muscle strength and tone, maintain joint mobility, and prevent contractures.
• Turn and reposition the patient every 2 hours to prevent skin breakdown and improve breathing. Establish a turning schedule for the dependent patient. Post a schedule at the patient’s bedside and monitor frequency.
• Maintain proper body alignment at all times to avoid contractures and maintain optimal musculoskeletal balance and physiologic function.
• Encourage active exercise. Provide a trapeze or other assistive device whenever possible. Such devices simplify moving and turning for many patients and allow them to strengthen some upper-body muscles.
• Teach isometric exercises to allow the patient to maintain or increase muscle tone and joint mobility.
• Have the patient perform self-care activities. Begin slowly and increase daily, as tolerated. These activities help the patient regain his health.

You can do it!

• Provide emotional support and encouragement to help improve patient self-esteem and provide the motivation to perform ADLs.
• Involve the patient in care-related planning and decision making to improve compliance.
• Monitor physiologic responses to increased activity level, including respirations, heart rate and rhythm, and blood pressure to ensure that they return to normal within a few minutes after exercising.
• Teach caregivers to assist the patient with self-care activities in a way that maximizes the patient’s potential. This encourages caregivers to participate in patient care and to support patient independence. Place needed objects within reach to encourage independence.
• Explain the importance of following the prescribed medical and physical therapy regimens. As the patient’s understanding of his condition improves, his compliance increases.

Deficient knowledge

Focus Topic: Musculoskeletal Disorders

Deficient knowledge is related to a lack of information about management and control of disease. Your patient’s understanding of his condition will directly affect his ability to cope and his recovery.

Expected outcomes
• Patient reports an increase in knowledge regarding disease.
• Patient demonstrates ability to perform new skill related to his lifestyle.

Nursing interventions and rationales
• Assess the patient’s level of understanding of the disease, its course, and its management. This helps you formulate an appropriate teaching plan. Provide a quiet environment, conducive to teaching and learning.
• Provide information at a pace and in a form appropriate for the patient to enhance his understanding and retention of information.
• Identify the patient’s learning style. Then select teaching strategies — such as discussion, demonstration, role-playing, and visual materials — that are appropriate to his style. This makes your teaching more effective.
• Identify and teach the skills the patient must incorporate into his daily lifestyle. Ask for a return demonstration of each new skill to help him gain confidence.

• Have the patient incorporate learned skills into his daily routine during hospitalization. This allows him to practice them and receive feedback.
• Provide the patient with the names and telephone numbers of resource people or organizations to provide continuity of care and follow-up after discharge.

Impaired physical mobility

Focus Topic: Musculoskeletal Disorders

Impaired physical mobility is related to many musculoskeletal disorders involving joint inflammation as well as to fractures, bone disorders, and other disorders that cause decreased mobility.

Expected outcomes
• Patient demonstrates safety measures while increasing mobility.
• Patient reports an increase or optimum mobility.
• Patient describes ways to increase physical mobility.

Nursing interventions and rationales
• Instruct the patient in ROM exercises (active and passive) to increase strength.
• Teach him how to use adaptive aids for mobility so that he can do as much as possible for himself.
• Encourage increased mobility for short durations several times per day to increase strength and confidence.
• Provide emotional support and encouragement to help improve the patient’s self-esteem and provide motivation.
• Teach the patient how to walk and transfer from a wheelchair safely to prevent falls or accidents.

Musculoskeletal Disorders: Common musculoskeletal disorders

Focus Topic: Musculoskeletal Disorders

This section discusses musculoskeletal disorders. For each disorder you’ll find information on causes, assessment findings, diagnostic tests, treatments, nursing interventions, and patient teaching.

 

Carpal tunnel syndrome

Focus Topic: Musculoskeletal Disorders

Carpal tunnel syndrome is the most common nerve entrapment syndrome. It results from compression of the median nerve at the wrist, within the carpal tunnel (formed by the carpal bones and the transverse carpal ligament). The median nerve, along with blood vessels and flexor tendons, passes through this tunnel to the fingers and thumb.

Definitely a hands-on disorder

Carpal tunnel syndrome usually occurs in women between ages 30 and 60 and poses a serious occupational health problem. Assembly- line workers, packers, and people who repeatedly use poorly designed tools are most likely to develop this disorder. Any strenuous use of the hands aggravates this condition.

What causes it
The cause of carpal tunnel syndrome is unknown, but damage to the median nerve may result from:
• repetitive wrist motions involving excessive flexion or extension
• dislocation
• acute sprain.

Pathophysiology
The median nerve controls motions in the forearm, wrist, and hand and supplies sensation to the index, middle, and ring fingers. Compression of the median nerve results in sensory and motor changes in the median distribution of the hand.

What to look for
Signs and symptoms of carpal tunnel syndrome include weakness, pain, burning, numbness, or tingling in one or both hands. This paresthesia affects the thumb, forefinger, middle finger, and one-half of the fourth finger.

A surplus of signs and symptoms

Other indications include decreased sensation to light touch or pinpricks in the affected fingers; an inability to clench the hand into a fist; nail atrophy; dry, shiny skin; and pain, possibly spreading to the forearm and, in severe cases, as far as the shoulder.

What tests tell you
• Diagnosis of carpal tunnel syndrome is based on these characteristic tests and findings:
– Tinel’s sign: Tingling occurs over the median nerve on light percussion.
– Phalen’s maneuver: Carpal tunnel syndrome symptoms occur when the patient holds his forearms vertically and allows both hands to drop into complete flexion at the wrists for 1 minute.

– Compression test: Blood pressure cuff inflated above systolic pressure on the forearm for 1 to 2 minutes provokes pain and paresthesia along the distribution of the median nerve.
– Electromyography: A median nerve motor conduction delay of more than 5 milliseconds suggests carpal tunnel syndrome.

How it’s treated
Conservative treatment includes resting the hands by splinting the wrists in neutral extension for 1 to 2 weeks. If a definite link has been established between the patient’s occupation and carpal tunnel syndrome, he may have to seek other work. Effective treatment may also require correction of an underlying disorder.

Free at last!

When conservative treatment fails, the only alternative is surgical decompression of the nerve by sectioning the entire transverse carpal tunnel ligament. Neurolysis (freeing of the nerve fibers) may also be necessary.

What to do
• Administer mild analgesics as needed. Encourage the patient to use his hands as much as possible; however, if the dominant hand is impaired, you may have to help with eating and bathing.
• After surgery, monitor vital signs, and regularly check the color, sensation, and motion of the affected hand. Suggest occupational counseling for the patient who has to change jobs because of carpal tunnel syndrome.
• Evaluate the patient. Following successful interventions (such as splinting and surgery), muscle strength and normal ROM in the affected hand and wrist should progressively return. The patient should be free from pain or paresthesia in the affected hand.

Musculoskeletal Disorders

Herniated intervertebral disk

Focus Topic: Musculoskeletal Disorders

A herniated disk occurs when all or part of the nucleus pulposus (the soft, gelatinous, central portion of an intervertebral disk) forces through the weakened or torn anulus fibrosus (outer ring).

Impingement is irritating

The extruded disk may impinge on spinal nerve roots as they exit from the spinal canal or on the spinal cord itself, resulting in back pain and other signs of nerve root irritation. Most herniation occurs in the lumbar and lumbosacral regions.

Musculoskeletal Disorders

What causes it
Herniated intervertebral disk has two causes:

Trauma or strain

Degenerative disk disease.

Pathophysiology
The ligament and posterior capsule of the disk are usually torn, allowing the nucleus pulposus to extrude, compressing the nerve root. Occasionally, the injury tears the entire disk loose, causing protrusion onto the nerve root or compression of the spinal cord. Large amounts of extruded nucleus pulposus or complete disk herniation of the capsule and nucleus pulposus may compress the spinal cord.

What to look for
The overriding symptom of lumbar herniated disk is severe lower back pain that radiates to the buttocks, legs, and feet (usually unilaterally). The pain intensifies with Valsalva’s maneuver, coughing, sneezing, or bending.
The patient may also experience motor and sensory loss in the area innervated by the compressed spinal nerve root and, in later stages, weakness and atrophy of leg muscles.

What tests tell you
Although the straight-leg-raising test and Lasègue’s test are perhaps the best tests to determine herniated disk, other tests are used as well:
• Straight-leg-raising test: The patient lies supine while the examiner places one hand on the ilium (to stabilize the pelvis) and the other hand under the ankle. Then the examiner slowly raises the patient’s leg. This test is positive only if the patient complains of sciatic (posterior leg) pain and not lower back pain.
• Lasègue’s test: The patient lies supine while the examiner flexes his thigh and knee to a 90-degree angle. Resistance and pain as well as absent or decreased ankle or knee deep tendon reflexes indicate spinal root compression.
• Myelography, CT scan, and MRI: These tests provide the most specific diagnostic information, showing spinal compression caused by the herniated disk. CT scan and MRI have, for the most part, replaced myelography.

X out the X-rays

Although X-ray is essential to rule out other abnormalities, it isn’t a good diagnostic tool for herniated intervertebral disk. Marked disk herniation can be present despite a normal X-ray.

How it’s treated
Initially, conservative treatment consists of several days of bed rest (possibly with pelvic traction), heat applications, and an exercise program.

Medications that mend

Drug therapy includes aspirin to reduce inflammation and edema at the injury site and (rarely) corticosteroids for the same purpose. The patient may also benefit from muscle relaxants, especially diazepam (Valium) or the analgesic hydrocodone with acetaminophen (Vicodin).

Calling the disk doctor

If neurologic impairment progresses rapidly, or a herniated disk fails to respond to conservative treatment, surgery may be necessary:
• Laminectomy, the most common procedure, involves excision of a portion of the lamina and removal of the protruding disk.
• Spinal fusion may be necessary to overcome segmental instability if laminectomy doesn’t alleviate pain and disability. Laminectomy and spinal fusion may be performed concurrently to stabilize the spine.

• Chemonucleolysis — injection of the enzyme chymopapain into the herniated disk to dissolve the nucleus pulposus — is a possible alternative to laminectomy. However, this procedure isn’t as popular as it once was because it has been found to be less effective than other treatments and may cause severe allergic reaction or nerve damage.
• Microdiskectomy can be used to remove fragments of nucleus pulposus. This form of microsurgery is becoming more popular.

What to do
• During conservative treatment, watch for a deterioration in neurologic status (especially during the first 24 hours after admission). This may indicate an urgent need for surgery.
• Use antiembolism stockings or a sequential pressure device (stockings) as prescribed, and encourage the patient to move his legs as allowed. Provide high-topped sneakers to prevent footdrop.
• Work closely with the physical therapy department to ensure a consistent regimen of leg- and back-strengthening exercises.
• Give plenty of fluids to prevent renal stasis and constipation and remind the patient to cough, deep-breathe, and use an incentive spirometer to help prevent pulmonary complications.
• Provide good skin care.

Rollin’, rollin’, rollin’

• After laminectomy, diskectomy, or spinal fusion, enforce activity limitations as ordered. Monitor vital signs and check for bowel sounds and abdominal distention. Use a logrolling technique to turn the patient.
• If a closed drainage system is in use, check the tubing frequently for kinks and a secure vacuum. Empty the Hemovac at the end of each shift as ordered, and record the amount and color of drainage. Report colorless moisture on dressings (possible CSF leakage) or excessive drainage immediately. Observe the neurovascular status of the legs, including color, motion, temperature, and sensation.
• Administer analgesics as ordered, especially 30 minutes before initial attempts at sitting or walking. Assist the patient during his first attempt to walk. Provide a straight-backed chair for limited sitting.
• Before chemonucleolysis, make sure the patient isn’t allergic to meat tenderizers (chymopapain is a similar substance). Such an allergy contraindicates the use of this enzyme, which can produce severe anaphylaxis in a sensitive patient.

• After chemonucleolysis, enforce activity limitations as ordered. Administer analgesics and apply heat as needed. Urge the patient to cough and breathe deeply. Assist with special exercises, and tell the patient to continue these exercises after discharge.
• Provide emotional support. Try to raise the patient’s spirits during periods of frustration and depression. Assure him of his progress and offer encouragement.
• Evaluate the patient’s response to treatment. Look for absence of pain, ability to maintain adequate mobility, and ability to perform ADLs. The patient should also express an understanding of his treatments and any adjustments he must make in his lifestyle.

Musculoskeletal Disorders

Gout

Focus Topic: Musculoskeletal Disorders

In gout, urate deposits lead to painfully arthritic joints. It can strike any joint but occurs most commonly in the feet and legs. Primary gout usually occurs in men age 30 and older and in postmenopausal women. Secondary gout occurs in the elderly.

All about gout

Gout follows an intermittent course and commonly leaves patients symptom-free for years between attacks. It can lead to chronic disability or incapacitation and, rarely, severe hypertension and progressive renal disease. Prognosis is good with treatment.

What causes it
Although the cause of primary gout remains unknown, it appears to be linked to a genetic defect in purine metabolism, which causes hyperuricemia (overproduction of uric acid), retention of uric acid, or both.
Secondary gout develops during the course of other diseases, such as obesity, diabetes mellitis, hypertension, polycythemia, leukemia, myeloma, sickle cell anemia, and renal disease. It can also follow drug therapy, especially after hydrochlorothiazide or pyrazinamide.

Pathophysiology
In gout, increased concentration of uric acid leads to tophi (urate deposits) in joints or tissues. These crystals trigger an immune response, causing local necrosis or fibrosis.

What to look for
Gout develops in four stages:

asymptomatic

acute

intercritical
chronic.
In asymptomatic gout, serum urate levels rise but produce no symptoms. As the disease progresses, it may cause hypertension or nephrolithiasis with severe back pain.

You can’t flout gout

The first acute attack strikes suddenly and peaks quickly. Although it usually involves only one joint or a few joints, it’s extremely painful. Affected joints appear hot, tender, inflamed, dusky red, or cyanotic.
The metatarsophalangeal joint of the great toe usually becomes inflamed first (podagra), and then the instep, ankle, heel, knee, or wrist joints. Sometimes a low-grade fever is present. Mild acute attacks typically subside quickly but tend to recur at irregular intervals. Severe attacks may persist for days or weeks.

A gap between attacks

Intercritical periods are the symptom-free intervals between gout attacks. Most patients have a second attack within 6 months to 2 years, but in some people, the second attack is delayed for 5 to 10 years.
Delayed attacks are more common in those who are untreated and tend to be longer and more severe than initial attacks. Such attacks are also polyarticular, invariably affecting joints in the feet and legs, and are sometimes accompanied by fever.

Persistent and painful

Eventually, chronic polyarticular gout sets in. This final, unremitting stage of the disease — also called chronic or tophaceous gout — is marked by persistent painful polyarthritis, with large, subcutaneous tophi in cartilage, synovial membranes, tendons, and soft tissue.
Tophi form in the fingers, hands, knees, feet, ulnar sides of the forearms, helix of the ear, Achilles tendons, and, rarely, in internal organs, such as the kidneys and myocardium. The skin over the tophus may ulcerate and release a chalky, white exudate or pus. Chronic inflammation and tophaceous deposits precipitate secondary joint degeneration, with eventual erosions, deformity, and disability. Kidney involvement, with associated tubular damage, leads to chronic renal dysfunction. Hypertension and albuminuria occur in some patients and urolithiasis is common.

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