This document discusses the management of patients with musculoskeletal disorders including low back pain, upper extremity conditions, foot problems, and osteoporosis. It provides information on clinical manifestations, assessment approaches, treatment strategies, and nursing interventions for related surgeries and conditions. Key points include common causes of low back pain, signs and symptoms to assess, exercise and body mechanics recommendations for low back pain patients, risk factors and prevention strategies for osteoporosis, and home care education topics for osteoporosis patients.

1. Management of Patients with
Musculoskeletal Disorders

2. ACUTE LOW BACK PAIN
• The number of medical visits resulting from low back pain is second only to
the number of visits for upper respiratory illnesses.
• Most low back pain is caused by one of many musculoskeletal problems,
including acute lumbosacral strain, unstable lumbosacral ligaments and weak
muscles, osteoarthritis of the spine, spinal stenosis, intervertebral disk
problems, and unequal leg length.

3. Clinical Manifestations
• The patient complains of either acute back pain or chronic back pain (lasting
more than 3 months without improvement) and fatigue.
• The patient may report pain radiating down the leg, which is known as
radiculopathy or sciatica and which suggests nerve root involvement.
• The patient’s gait, spinal mobility, reflexes, leg length, leg motor strength, and
sensory perception may be altered.

4. Assessment of the Patient with Low Back Pain
• Location, severity, duration, characteristics, radiation, leg weakness
• How the pain occurred and has been managed by the patient
• Work and recreational activities
• Spinal curvature, back and limb symmetry
• Palpate paraspinal muscles
• Movement ability and effects on ADLs
• DTRs, sensation, and muscle strength
• Assess posture, position changes, and gait

5. Strategies for the Patient With Low Back Pain
• Pain Management
• Limit bed rest; keep knees flexed to decrease strain on back
• Nonpharmacologic approaches: distraction, relaxation, imagery, thermal interventions (eg,
ice or heat), stress reduction
• Pharmacologic approaches: nonsteroidal anti-inflammatory drugs, analgesics, muscle
relaxants
• Exercise
• Stretch to enhance flexibility, do strengthening exercises
• Perform prescribed back exercises to increase function, emphasizing gradual increases in
time and repetitions

6. Strategies for the Patient With Low Back Pain
• Body Mechanics
• Practice good posture
• Avoid twisting body
• Push objects rather than pull them
• Keep load close to body when lifting
• Bend knees and tighten abdominal muscles when lifting

7. Proper and Improper Standing Postures
and Lifting Techniques

8. Common Conditions of the Upper Extremities
• Bursitis and tendinitis are inflammatory conditions that commonly occur
in the shoulder.
• Loose bodies (”joint mice”) may occur in a joint as a result of articular
cartilage wear and bone erosion.
• Impingement 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.

9. Tinel Sign: Assessment for Carpal Tunnel
Syndrome
Reprinted with permission from Weber, J. W., & Kelley, J. (2018). Health
assessment in nursing (6th ed.). Philadelphia, PA: Wolters Kluwer. Photo
by B. Proud.

10. Nursing Management of the Patient
Undergoing Surgery of the Hand or Wrist
• Surgery is usually an ambulatory procedure
• Patient education is a major nursing need for a patient undergoing outpatient surgery
• Neurovascular assessment is vital; every hour for the first 24 hours, assess motor function
only as prescribed; instruct patient in signs and symptoms to assess and report
• Pain control measures: medication, elevation, intermittent ice or cold
• Prevention of infection: keep dressing clean and dry, wound care, signs and symptoms of
infection
• Assistance with ADLs and measures to promote independence

11. Measures to Promote Shoulder Healing
• The nurse provides guidelines for general care that will promote shoulder healing.
• During the acute phase, rest the joint in a position that minimizes stress on the joint structures, to
prevent further damage and the development of adhesions.
• Support the affected arm on pillows while sleeping, to keep from turning onto the shoulder.
• For the first 24 to 48 hours of the acute phase, apply cold to reduce swelling and discomfort; then,
according to the treatment plan, apply heat intermittently to promote circulation and healing.
• Gradually resume motion and use of the joint. Assistance with dressing and other activities of daily
living may be needed.
• Avoid working and lifting above shoulder level or pushing an object against a “locked” shoulder.
• Perform the prescribed daily range-of-motion and strengthening exercises.

12. Common Foot Problems
• Callus:- is a discretely thickened area of the skin that has been exposed to persistent
pressure or friction.
• A corn is an area of hyperkeratosis (overgrowth of a horny layer of epidermis)
produced by internal pressure (the underlying bone is prominent because of
congenital or acquired abnormality, commonly arthritis) or external pressure (ill-
fitting shoes).
• Hammer toe is a flexion deformity of the interphalangeal joint, which may involve
several toes
• Ingrown toenail: Onychocryptosis is a condition in which the free edge of a nail
plate penetrates the surrounding skin, either laterally or anteriorly.

13. Common Foot Problems
• Hallux valgus Hallux valgus (commonly called a bunion) is a deformity in
which the great toe deviates laterally.
• Pes cavus (clawfoot) refers to a foot with an abnormally high arch and a fixed
equinus deformity of the forefoot
• Flatfoot: is a common disorder in which the longitudinal arch of the foot is
diminished.

14. Common Foot Deformities

15. Assessment of the Patient Undergoing Foot
Surgery
• The nurse assesses the patient’s ambulatory ability and balance and the
neurovascular status of the foot.
• Neurovascular assessment is vital
• Assess swelling and neurovascular status every 1 to 2 hours for the first 24 hours
• Instruct patient in signs and symptoms to assess and report
• Explore the need for home assistance and the structural characteristics of
the home (e.g., distances required to walk and the presence of stairs or steps)

16. Nursing Interventions for the Patient
Undergoing Foot Surgery
• Relieve pain related to inflammation and edema
• Elevate foot
• Use of intermittent ice packs
• Medications; oral analgesics
• Improving mobility
• Instruction in weight-bearing restrictions as prescribed
• Use of assistive devices (crutches or walker)
• Measures to ensure patient safety
• Measures to prevent infection
• Wound or pin care
• Keep dressing clean and dry
• Signs and symptoms of infections

17. Osteoporosis
• Most prevalent bone disease in the world; more than 1.5 million osteoporotic
fractures occur each year
• Normal homeostatic bone turnover is altered, and the rate of bone resorption is
greater than the rate of bone formation, resulting in loss of total bone mass
• Bone becomes porous, brittle, and fragile and breaks easily under stress
• Frequently results in compression fractures of the spine, fractures of the neck or
intertrochanteric region of the femur, and Colles fractures of the wrist

18. Typical Loss of Height Associated with
Osteoporosis and Aging

19. Risk Factors for Osteoporosis
• Increased age
• Low weight and body mass index
• Estrogen deficiency or menopause
• Diets low in calcium and vitamin D
• Cigarette smoking, Use of alcohol and/or caffeine
• Lack of weight-bearing exercise
• Lack of exposure to sunshine

20. Osteoporosis Prevention
• Balanced diet high in calcium and vitamin D throughout life
• Use of calcium supplements to ensure adequate calcium intake: take in
divided doses with vitamin C
• Regular weight-bearing exercises: 20 to 30 minutes a day
• Increases balance
• Reduces incidence of falls and fractures
• Weight training stimulates bone mineral density (BMD)

21. Pharmacologic Therapy for Osteoporosis
• Calcium and vitamin D
• Bisphosphonates
• Calcitonin
• Estrogen agonists/antagonists
• Parathyroid hormone
• Receptor activator of nuclear factor kappa-B ligand inhibitors

22. HOME CARE AND CONTINUING
EDUCATION
• Identify calcium- and vitamin D-rich foods.
• Consume diet with adequate calcium and vitamin D.
• Engage in weight-bearing exercise daily.
• Modify lifestyle choices—avoid smoking, alcohol, caffeine, and sodas.
• Demonstrate good body mechanics.
• Discuss pharmacologic agents to maintain and enhance bone mass.
• Assess home environment for hazards contributing to falls.