Musculoskeletal Disorders



Musculoskeletal Disorders



Case Study 32


Name______________________Class/Group_____________Date___________


Group Members_______________________________________________


INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.




Scenario


M.S., a 72-year-old white woman, comes to your clinic for a complete physical examination. She has not been to a provider for 11 years because “I don’t like doctors.” Her only complaint today is “pain in my upper back.” She describes the pain as sharp and knifelike. The pain began approximately 3 weeks ago when she was getting out of bed in the morning and hasn’t changed at all. M.S. rates her pain as 6 on a 0- to 10-point pain scale and says the pain decreases to 3 or 4 after taking “a couple of ibuprofen.” She denies recent falls or trauma.


M.S. admits she needs to quit smoking and start exercising but states, “I don’t have the energy to exercise, and besides, I’ve always been thin.” She has smoked one to two packs of cigarettes per day since she was 17 years old. Her last blood work was 11 years ago, and she can’t remember the results. She went through menopause at the age of 47 and has never taken hormone replacement therapy. The physical exam was unremarkable other than moderate tenderness to deep palpation over the spinous process at T7. No masses or tenderness to the tissue surrounded the tender spot. No visible masses, skin changes, or erythema were noted. Her neurologic exam is intact, and no muscle wasting is noted.




Case Study Progress


M.S. has never had an osteoporosis screening. She confides that her mother and grandmother were diagnosed with osteoporosis when they were in their early 50s.



4. What diagnostic test is most commonly used to diagnose osteoporosis?


5. M.S.’s diagnostic test revealed a bone density T-score of –2.7. How will this be interpreted?


6. M.S. receives a prescription for alendronate (Fosamax) 70 mg/week. Which instructions are appropriate as you provide patient teaching to M.S. about this drug? (Select all that apply.)



7. M.S. is also instructed to take a calcium plus vitamin D supplement. She asks, “If I am taking the osteoporosis pill, won’t that be enough?” How do you answer her?


8. What nonpharmacologic interventions will you teach M.S. to prevent further bone loss?




Scenario


J.C. is a 41-year-old man who comes to the emergency department with complaints of acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain, which he rates as a “10” on a 1 to 10 scale. He admits to having had a similar episode of back pain years ago “after I lifted something heavy at work.” J.C. has a past medical history of peptic ulcer disease (PUD) related to nonsteroidal anti-inflammatory drug (NSAID) use. He is 6 feet tall, weighs 265 pounds, and has a prominent “potbelly.”




Case Study Progress


All serious medical conditions are ruled out, and J.C. is diagnosed with lumbar strain. The nurse practitioner (NP) orders a physical therapy consult to develop a home stretching and back-strengthening exercise program and a dietary consult for weight reduction. J.C. is given prescriptions for cyclobenzaprine (Flexeril) 10 mg tid × 3 days only, and celecoxib (Celebrex) 100 mg/day for 3 months. He receives the following instructions: heat applications to the lower back for 20 to 30 minutes four times a day (using moist heat from heat packs or hot towels), no twisting or unnecessary bending, and no lifting more than 10 pounds. J.C. is instructed to rest his back for 1 or 2 days, getting up only now and then to move around to relieve muscle spasms in his back and strengthen his back muscles. He is given a written excuse to stay off work for 5 days and, when he returns to work, specifying the limitation of lifting no more than 10 pounds for 3 months. He is instructed to contact his primary care provider if the pain gets worse.




Case Study Progress


J.C. asks, “What is Celebrex? I hope it won’t do what that Feldene did to me years ago.”




Case Study 34


Name______________________Class/Group_____________Date___________


Group Members_______________________________________________


INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.



Scenario


D.M., a 25-year-old man, hops into the emergency department (ED) with complaints of right ankle pain. He states that he was playing basketball and stepped on another player’s foot, inverting his ankle. You note swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals, and pedal pulses are 3+ bilaterally. His vital signs are 124/76, 82, 18. He has no allergies and takes no medication. He states he has had no prior surgeries or medical problems.




Case Study Progress


X-ray results are negative for fracture, and a second-degree sprain is diagnosed. The physician orders immobilization with an elastic bandage and an air stirrup brace, with instructions for crutches. The physician instructs D.M. not to bear weight on his ankle for 2 days, then to use only partial weight-bearing until the ankle heals.



4. Describe the technique for applying an elastic wrap. Give the rationale.


5. When instructing D.M. to use crutches, D.M. states that he “likes it better” when the crutches rest under his arms while walking with the crutches. Is this correct? Explain.


6. You instruct D.M. on using the three-point gait with the crutches. Which would be the correct first step for the three-point gait?



7. You are to instruct D.M. on application of cold, activity, and care of the ankle. What would be appropriate instructions in these areas?


8. D.M. is given a prescription for Lortab 2.5/500. Explain the meaning of the numbers.


9. What instructions concerning the Lortab are needed?


10. Four days later, D.M. hobbles into the ED and boldly informs you that he “did it again, only this time it was touch football.” He states that the pain pills worked so well, he thought it would be OK. You detect the odor of beer on his breath. What are you going to do?


11. You remove his sock and find a large hematoma forming on the lateral aspect of an already swollen ankle. The ankle also shows the color of a bruise that is several days old. You inquire about D.M.’s pain perception. He states, “It doesn’t feel too bad now, but I sure saw stars when it popped.” What is the significance of his statement?



Case Study 35


Name______________________Class/Group_____________Date___________


Group Members_______________________________________________


INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.



Scenario


S.P. is admitted to the orthopedic ward. She has fallen at home and has sustained an intracapsular fracture of the hip at the femoral neck. The following history is obtained from her: She is a 75-year-old widow with three children living nearby. Her father died of cancer at age 62; mother died of heart failure at age 79. Her height is 5 feet 3 inches; weight is 118 pounds. She has a 50-pack-year smoking history and denies alcohol use. She has severe rheumatoid arthritis (RA), had an upper gastrointestinal bleed in 1993, and had coronary artery disease with a coronary artery bypass graft 9 months ago. Since that time she has engaged in “very mild exercises at home.” Vital signs (VS) are 128/60, 98, 14, 99° F (37.2° C), SaO2 94% on 2 L oxygen by nasal cannula. Her oral medications are rabeprazole (Aciphex) 20 mg/day, prednisone (Deltasone) 5 mg/day, and methotrexate (Amethopterin) 2.5 mg/wk.




Case Study Progress


S.P. is taken to surgery for a total hip replacement. Because of the intracapsular location of the fracture, the surgeon chooses to perform an arthroplasty rather than internal fixation. The postoperative orders include:



Chart View


Physician’s Orders





3. Why is the patient receiving enoxaparin (Lovenox) and warfarin (Coumadin)?


4. S.P. had an arthroplasty. For each characteristic listed, mark A for arthroplasty and O for open reduction and internal fixation (ORIF) of the hip.



5. S.P. received blood as an intraoperative blood salvage. Which statements about this procedure are true? (Select all that apply.)



6. List four critical potential postoperative problems for S.P.


7. How will you monitor for excessive postoperative blood loss?


8. According to the lateral traditional surgical approach, there are two main goals for maintaining proper alignment of S.P.’s operative leg. What are they, and how are they achieved?


9. Postoperative wound infection is a concern for S.P. Describe what you would do to monitor her for a wound infection.


10. Taking S.P.’s RA into consideration, what interventions should be implemented to prevent complications secondary to immobility?


11. What predisposing factor, identified in S.P.’s medical history, places her at risk for infection, bleeding, and anemia?


12. Briefly discuss S.P.’s nutritional needs.


13. Explain four techniques you can teach S.P. to help her protect herself from infection related to medication-induced immunosuppression.

Related posts:

  1. Immunologic Disorders
  2. Neurologic Disorders
  3. Pediatric Disorders
  4. Emergency Situations

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Jan 16, 2017 | Posted by in NURSING | Comments Off on Musculoskeletal Disorders

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