CHAPTER 72

UNIT 10 NURSING CARE OF CLIENTS WHO HAVE In addition to back pain, the client can
MUSCULOSKELETAL DISORDERS
SECTION: MUSCULOSKELETAL DISORDERS experience foot, ankle, and leg weakness or

Osteoarthritis and burning/stabbing pain radiating to the leg or

CHAPTER 72
foot. LBP can be related to an injury, fall, or heavy
Low‑Back Pain lifting. LBP is the leading cause of work disability.
It is most prevalent between ages 30 and 60.
Osteoarthritis (OA), or degenerative joint Smoking and obesity contribute to LBP.
disease (DJD), is a disorder characterized
by progressive deterioration of the articular HEALTH PROMOTION AND
cartilage. It is a noninflammatory (unless DISEASE PREVENTION
localized), nonsystemic disease. Osteoarthritis
●● Encourage the client to use joint‑saving measures (good
It is no longer thought to be only a body mechanics, labor‑saving devices).
wear‑and‑tear disease associated with aging, but ●● Encourage the client to maintain a healthy weight to
decrease joint degeneration of the hips and knees.
rather a process in which new tissue is produced ●● Recommend that the client stop smoking to reduce
as a result of cartilage destruction within the cartilage loss, especially if there is a family history of OA.
●● Encourage the client to avoid or limit repetitive strain
joint. The destruction outweighs the production. on joints (jogging, contact sports, risk‑taking activities).
The cartilage and bone beneath the cartilage ●● Recommend wearing well‑fitted shoes with supports to
prevent falls.
erode and osteophytes (bone spurs) form,
resulting in narrowed joint spaces. The changes Low‑back pain
within the joint lead to pain, immobility, muscle ●● Exercise to keep back healthy and strong.
●● Use body mechanics and proper lifting techniques
spasms, and potential inflammation. (ergonomics).
●● Maintain correct posture.
Early in the disease process of OA, it can ●● Wear low‑heeled shoes.
be difficult to distinguish from rheumatoid ●● Maintain a healthy weight.
●● Smoking cessation, as smoking is linked to disk
arthritis (RA). (72.1) degeneration.
●● Avoid prolonged sitting/standing.
Low‑back pain (LBP) occurs along the ●● Healthy diet including adequate calcium and vitamin D.
lumbosacral area of the vertebral column. LBP
can be acute (self‑limiting) or chronic (longer
than 3 months or repeated episodes of pain).

72.1 Characteristics of osteoarthritis and rheumatoid arthritis

Osteoarthritis Rheumatoid arthritis

Cartilage destruction with bone spur
DISEASE PROCESS
growth at joint ends; degenerative
FINDINGS Pain with activity that improves at rest
EFFUSIONS Localized inflammatory response
BODY SIZE Usually overweight
NODES Heberden’s and Bouchard’s nodes
SYSTEMIC INVOLVEMENT No: articular
SYMMETRICAL No
DIAGNOSTIC TESTS X‑rays
Synovial membrane inflammation resulting in cartilage
destruction and bone erosion; inflammatory
Swelling, redness, warmth, pain at rest or
after immobility (morning stiffness)
All joints
Usually underweight
Swan neck and boutonnière deformities of hands
Yes: lungs, heart, skin, and extra‑articular
Yes
X‑rays and positive rheumatoid factor

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 72  Osteoarthritis and Low‑Back Pain  461
 ASSESSMENT CAUSES OF LOW‑BACK PAIN
●● Muscle strain/spasm
Ligament sprain
RISK FACTORS
●●

●● Osteoarthritis
●● Osteoporosis
Osteoarthritis ●● Scoliosis
●● Aging: majority of adults over age 60 have joint changes ●● Compression fracture
on x‑ray). ●● A defect of a vertebrae (spondylolysis)
●● Genetic factors ●● A vertebra that slips forward on the one below it
●● Joint injury due to acute or repetitive stress on joints (spondylolisthesis)
predisposes to later OA. ●● Narrowing of the spinal canal (spinal stenosis)
●● Obesity: OA affects weight‑bearing joints such as knees, ●● Herniated disk (herniated nucleus pulposus), which
hips in overweight clients. can cause sciatic nerve involvement with burning or
●● Metabolic disorders, such as diabetes, and blood stabbing pain into one leg or foot
disorders, such as sickle cell disease predisposes to
joint degeneration.
EXPECTED FINDINGS
Low‑back pain
Osteoarthritis
●● Can occur at any time but most prevalent from ●● Joint pain and stiffness
ages 30 to 60 ●● Pain with joint palpation or range of motion (observe
●● Family history of back pain or history of a back injury
for muscle atrophy, loss of function, limp when walking,
●● Being pregnant (changes in posture and
and restricted activity due to pain)
weight distribution) ●● Crepitus in one or more of the affected joints
●● History of spine problems, back surgery, or ●● Enlarged joint related to bone hypertrophy
compression fracture ●● Heberden’s nodes enlarged at the distal
●● Job or occupation that requires heavy lifting, twisting,
interphalangeal joints
or repetitive motion ●● Bouchard’s nodes located at the proximal
●● Smoking (linked to disk degeneration)
interphalangeal joints (OA is not a symmetrical disease,
●● Overweight
but these nodes can occur bilaterally). These nodes can
●● Having poor posture
be inflamed and painful.
●● Inflammation resulting from secondary synovitis,
indicating advanced disease
●● Joint effusion (excess joint fluid) that is easily moved
from one area of the joint to another area
●● Vertebral radiating pain affected by cervical or lumbar
compression of nerve roots
●● Limping gait due to hip or knee pain
●● Back pain due to OA of the spine

Low‑back pain
72.2 Heberden’s and Bouchard’s nodes ●● Dull or sharp low back pain
●● Pain aggravated by coughing, sneezing, or straining
●● Muscle spasms, cramping, and stiffness
●● Pain in the buttock
●● Sciatic nerve compression causes severe pain when leg is
straightened and held up.
●● Numbness/tingling of the leg (paresthesia); burning or
stabbing pain in the leg or foot
●● Report chills/fever, bowel or bladder incontinence,
progression of decreased ability to move, and
paresthesias to the provider promptly (can indicate a
more serious condition).

LABORATORY TESTS
OA: Laboratory tests are usually normal with OA. Erythrocyte
sedimentation rate and high‑sensitivity C‑reactive protein
can be increased slightly related to secondary synovitis.

LBP: CBC, erythrocyte sedimentation rate and urinalysis may

be ordered with LBP to rule out cancer or infection. Serum
electrophoresis can help to rule out multiple myeloma.

462  CHAPTER 72  Osteoarthritis and Low‑Back Pain CONTENT MASTERY SERIES
 DIAGNOSTIC PROCEDURES CLIENT EDUCATION
●● Acute LBP often resolves spontaneously.
X‑rays: to rule out fracture, spondylosis (spinal ●● Positioning (e.g., William’s position: semi‑Fowler’s
degeneration), or neoplasm
position with a pillow under flexed knees) can alleviate
Magnetic resonance imaging with or without contrast: pain associated with LBP from a herniated disk.
shows soft tissue structures of the back, including ●● Instruct the client about the use of analgesics and
intervertebral disks, the spinal cord and spinal nerves NSAIDs prior to activity and around the clock as needed.
●● Balance rest with activity.
Computed tomography (CT) scans ●● Instruct the client on proper body mechanics.
●● Shows injuries or pathology that involves bone
●● Encourage the use of thermal applications: heat (dry or
●● Can be done with or without contrast

moist) to alleviate pain and ice for acute inflammation.

Nuclear bone scan
●● Provides ability to scan entire skeleton
●● Detects tumors, arthritis, osteomyelitis, osteoporosis,
vertebral compression fractures, and unexplained
bone pain
CT myelogram
●● Uses x‑ray and contrast which is put into the
●● Encourage the use of complementary and alternative
therapies, including acupuncture, tai chi, hypnosis,
magnets, and music therapy.
●● Encourage the use of splinting for joint protection, and
the use of larger joints.
●● Encourage the use of assistive devices to promote safety
and independence, including an elevated toilet seat,

shower bench, long‑handled reacher, and shoe horn.

subarachnoid space with a thin needle (lumbar puncture) ●● Encourage the use of a daily schedule of activities that
●● The contrast moves through the space so the nerve roots

will promote independence (high‑energy activities in

and spinal cord can be visualized
the morning).
Electromyogram (EMG) and nerve conduction ●● Encourage a well‑balanced diet and ideal body weight.
●● Measures electrical impulses produced by nerves and Consult a dietitian to provide meal planning for
muscle response. balanced nutrition.
●● Looks for bone, nerve or muscle problems that might be

causing pain
MEDICATIONS
Arthrogram
●● X‑ray study of a joint after contrast medium (air or contrast, Analgesic therapy
or both) has been injected to enhance visualization
Acetaminophen does not provide anti‑inflammatory
●● Bone chips, torn ligaments, or other loose bodies within a

benefits, which might not be needed if synovitis is

joint can be visualized
not present

NURSING ACTIONS
PATIENT‑CENTERED CARE ●● Limit administration of acetaminophen to a maximum
of 4,000 mg/24 hr. Some experts recommend a
maximum daily dose of 2,500 to 3,000 mg/day when
NURSING CARE used long‑term to prevent liver toxicity.
PAIN ASSESSMENT/MONITORING ●● Make sure clients are aware of opioids that contain
●● Location, characteristics, quality, severity, precipitating acetaminophen, such as hydrocodone bitartrate
or relieving factors 5 mg/acetaminophen 500 mg, which contains various
●● Sciatic nerve pain becomes worse when the leg is held amounts of hydrocodone and acetaminophen.
straight and lifted upward ●● Monitor liver function tests.

MUSCULOSKELETAL ASSESSMENT/MUSCLE TONE AND

Nonsteroidal anti‑inflammatory drugs (NSAIDs)
STRENGTH
●● Inspect back for vertebral alignment and tenderness ●● Analgesics and anti‑inflammatories (celecoxib,
●● Degree of functional limitation; ability to perform ADLs naproxen, ibuprofen) are used to relieve pain and
●● Gait ability and characteristics synovitis if present.
●● Proper functional/joint alignment (OA)/vertebral ●● Baseline liver and kidney function tests and CBC are
alignment (low back pain) needed if NSAIDs are to be given.
●● Levels of fatigue and pain after activity ●● May replace acetaminophen with an NSAID if adequate
●● Range of motion relief is not obtained.
●● Topical NSAID (diclofenac epolamine patch) may be used
NEUROLOGICAL ASSESSMENT/SENSORY PERCEPTION
and is non‑systemic.
●● Genitourinary: bowel or bladder problems
●● Home barriers NURSING ACTIONS
●● Monitor kidney function (BUN and creatinine).
PSYCHOSOCIAL ASSESSMENT ●● Educate the client that NSAIDs are nephrotoxic and
●● Pain interference with sexuality
should be taken as prescribed.
●● Depression related to pain ●● Teach the client to report evidence of black tarry stool,
●● Anxiety related to pain
indigestion, and shortness of breath.
●● Alteration in self‑esteem and body image due to joint
deformities and nodules in OA

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 72  Osteoarthritis and Low‑Back Pain  463
 Muscle relaxants
●● Cyclobenzaprine hydrochloride may be given for
muscles spasms due to LBP.
●● Can cause acute confusion in older adults.
●● Do not drive or operate dangerous equipment.
Opioids
Opioid analgesics, such as hydrocodone and oxycodone,
are appropriate for treating moderate to severe pain.
●● Tramadol is considered a weak opioid that can be used
for OA.
●● Monitor and intervene for adverse effects of opioid use,
especially for older adults.
●● If used, opioids should be taken on a short‑term basis
by most clients. Some clients who have chronic back
pain may receive prescriptions for opioids for
long‑term use.
Topical analgesics
Trolamine salicylate: Can provide varying amounts of
temporary pain relief, depending on client response.
●● Apply topically over the area of involvement.
●● Contains salicylate.
Lidocaine 5% patch: Can be helpful for nerve pain and OA
of knees for short‑term use.
●● Apply to clean, dry, intact skin for 12 hr each day.
●● Can cause skin irritation.
●● Contraindicated with class I
antidysrhythmic medications.
Capsaicin: Can provide varying amounts of temporary
pain relief depending on client response.
●● Apply topically over an area of involvement.
●● Use gloves for application; wash hands thoroughly to
prevent burning of eyes.
●● Made from alkaloid that is derived from hot peppers.
●● It is thought to prevent transmission of pain sensations
from peripheral neural transmitters.
CLIENT EDUCATION FOR CAPSAICIN
●● Instruct the client to wear gloves during application
of capsaicin.
●● Advise the client to wear nitrile gloves when applying
capsaicin patch.
●● Instruct the client to avoid applying tight dressings
to area where capsaicin cream was applied to prevent
skin irritation.
●● Tell the client to wash hands immediately after applying
capsaicin and avoid touching eyes or applying over
broken skin areas, which can cause painful burning.
●● Explain to the client that a burning sensation of the
skin after application is normal and should subside.
●● Instruct the client to apply frequently (up to four times
a day) for maximum benefit.
464  CHAPTER 72  Osteoarthritis and Low‑Back Pain
COMPLEMENTARY AND ALTERNATIVE
THERAPIES FOR SHORT‑TERM PAIN RELIEF
●● Chiropractic or spinal manipulation
●● Imagery, acupuncture, acupressure, music therapy,
massage, biofeedback, and herbal medicines
Glucosamine supplements
●● Glucosamine is a naturally occurring chemical involved
in the makeup of cartilage. Glucosamine sulfate is
believed to aid in the synthesis of synovial fluid and
rebuild cartilage.
●● Glucosamine can decrease the cells that cause joint
inflammation and degradation of cartilage.
●● Glucosamine is often taken in combination with
chondroitin and might not have a pain reduction effect.
CLIENT EDUCATION
●● Consult the provider regarding use and dosage.
●● Contraindicated for clients who have hypertension or
are pregnant or breastfeeding.
●● Chondroitin can cause bleeding, especially for clients
taking anticoagulants.
●● Can cause mild GI upset (nausea, heartburn).
●● Use with caution with shellfish allergy.
●● Question clients about concurrent use of chondroitin,
NSAIDs, heparin, and warfarin.
Intra‑articular injections
●● Glucocorticoids are used to treat localized inflammation.
One joint may be injected no more than 4 times a year.
●● Hyaluronic acid is used to replace the body’s
natural hyaluronic acid, which is destroyed by joint
inflammation. It is currently only approved for
treatment of hip and knee joints.
CLIENT EDUCATION: For hyaluronic acid, instruct clients
to notify the provider of allergy to birds, feathers, or eggs
because this medication is made from combs of chickens.
INTERPROFESSIONAL CARE
Physical therapy: Services can teach muscle
strengthening exercises, application of heat, diathermy
(treatment with electrical currents), ultrasonography
(treatment with sound waves), or stretching and
strengthening exercises.
●● Phonophoresis: application of a topical medication, such
as lidocaine, followed by ultrasound or iontophoresis
(using heat and dexamethasone) may be used by a
physical therapist to force medication into subcutaneous
tissue and increase relief of pain.
●● A transcutaneous electrical nerve stimulation (TENS)
unit may be prescribed by the provider and applied by
the physical therapist with client instruction on how
to use it.
A nutritionist: may assist the client in diet for weight loss
or control in relation to reduced activity level, providing
teaching regarding foods high in calcium and vitamin D.
Occupational therapy: to increase independent function
such as personal care or home skills.
CONTENT MASTERY SERIES
 THERAPEUTIC PROCEDURES
Conservative therapy includes balancing rest with
activity, exercising with water therapy, joint positioning,
using bracing or splints, cane, proper posture, wearing
supportive shoes, and applying thermal therapies (heat
or cold).
Osteoarthritis
Total joint arthroplasty or total joint replacement: When
all other conservative measures fail, the client may choose
to undergo total joint arthroplasty to relieve the pain and
improve mobility and quality of life.
●● Joint replacement is contraindicated with any type
Low‑back pain
MINIMALLY INVASIVE SURGERY
●● Microscopic endoscopic diskectomy or percutaneous
endoscopy diskectomy: Fluoroscopy is used to guide
a tubular device through which the herniated disk is
removed by cutting it out, or suctioning out the center
of the disk.
●● Laser‑assisted laparoscopic lumbar diskectomy:
Laparoscope and laser are used to treat the
herniated disks.
●● Kyphoplasty: A needle is inserted into the back to
inflate a balloon to help the vertebra regain its shape.
Then a cement substance is injected into the space.

Vertebroplasty is very similar, but a balloon is not used.

of infection.
●● A dental exam and/or dental procedures should be done OPEN SURGICAL PROCEDURES
before surgery to decrease risk of infection. ●● Open diskectomy: removal of the herniated disk
●● Uncontrolled diabetes or hypertension can cause major ●● Laminectomy: removal of part of the laminae and
postoperative complications. facet joints
●● Surgery for tumors or infection
●● Arthrodesis/spinal fusion: surgery to join or fuse two or
more vertebrae
◯◯ A bone graft from the pelvic bone or bone bank is

used to make a bridge between vertebrae that are next

to each other.
◯◯ Metal implants can also be used.

Application Exercises
1. A nurse is assessing a client who 3. A nurse is providing information
has osteoarthritis of the knees and about capsaicin cream to a client
fingers. Which of the following who reports continuous knee pain
manifestations should the nurse from osteoarthritis. Which of the
expect to find? (Select all that apply.) following information should the
A. Heberden’s nodes nurse include in the discussion?
5. A nurse is providing teaching for
a client who has a history of low
back injury. Which of the following
instructions should the nurse give the
client to prevent future problems with
low back pain? (Select all that apply)

B. Swelling of all joints A. Continuous pain A. Engage in regular exercise

C. Small body frame
D. Enlarged joint size
E. Limp when walking
2. A nurse is providing information
to a client who has osteoarthritis
of the hip and knee. Which of the
following information should the
nurse include in the information?
(Select all that apply.)
A. Apply heat to joints
to alleviate pain.
B. Ice inflamed joints
following activity.
C. Install an elevated toilet seat.
D. Take tub baths.
E. Complete high‑energy
activities in the morning.
relief is provided. including walking.
B. Inspect for skin irritation and B. Sit for up to 10 hr each
cuts prior to application. day to rest the back.
C. Cover the area with tight C. Maintain weight within 25%
bandages after application. of ideal body weight.
D. Apply the medication every D. Create a smoking
2 hr during the day. cessation plan.
E. Wear low‑heeled shoes.
4. A nurse is caring for a client who
injured her lower back during a fall
and describes sharp pain in her back
and down her left leg. In which of
the following positions should the
nurse plan to place the client to
attempt to decrease her pain?
A. Prone without use of pillows
B. Semi‑Fowler’s with a
pillow under the knees
C. High‑Fowler’s with the
knees flat on the bed
D. Supine with the head flat

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 72  Osteoarthritis and Low‑Back Pain  465
 Application Exercises Key
1. A. CORRECT: Heberden’s nodes are enlarged nodules
on the distal interphalangeal joints of the hands
and feet of a client who has osteoarthritis.
B. Swelling and pain of all joints is a manifestation of rheumatoid
arthritis. A local inflammation of a joint is related to osteoarthritis.
C. A small body frame is a risk factor for rheumatoid
arthritis. Obesity is a risk factor for osteoarthritis.
D. CORRECT: A client can manifest enlarged
joints due to bone hypertrophy.
E. CORRECT: A client can manifest a limp when walking
due to pain from inflammation in the localized joint.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
PRACTICE  Active Learning Scenario
A nurse is providing information on collaborative and
nonpharmacologic therapies for a client who is having
continual joint pain from osteoarthritis. What information
should the nurse include? Use the ATI Active Learning
Template: Basic Concept to complete this item.
RELATED CONTENT: Describe two activities
each for collaborative care involving physical
therapy and nutrition therapy.
NURSING INTERVENTIONS: Describe three actions
the nurse could add to a teaching plan for this client.

2. A. CORRECT: Applying heat to joints can

provide temporary relief of pain.
B. CORRECT: Applying ice to inflamed joints
following activity can decrease edema.
C. CORRECT: Installing an elevated toilet seat can help
decrease strain and pain of the affected joints. PRACTICE Answer
D. Taking a tub bath places the client at risk for increased
strain and pain on the affected joints when getting in
Using the ATI Active Learning Template: Basic Concept
and out of the tub and increases the risk for falls.
E. CORRECT: Encouraging high‑energy activity in the morning is RELATED CONTENT
recommended as part of a daily routine to promote independence. Physical therapy
Apply heat, diathermy, and ultrasound.
●●

NCLEX® Connection: Physiological Adaptation,

Alterations in Body Systems Perform stretching and strengthening exercises.
●●

Use transcutaneous electrical nerve stimulation (TENS).

●●

3. A. Capsaicin cream provides temporary relief of pain rather Nutritional therapy

than continuous relief when applied several times daily. Provide nutritional information on weight loss.
●●

B. CORRECT: Inspect the skin for irritation and cuts before Provide nutritional information on a balanced diet.
●●

applying capsaicin cream, because hot peppers in the cream can Provide information on use of vitamin D and calcium.
●●

cause a painful burning sensation in areas of skin breakdown.

NURSING INTERVENTIONS
C. After capsaicin cream is applied, avoid covering the area with
Balance rest with activity.
●●

a tight bandage, which can cause increased skin irritation.

Use braces, splints, and cane.
●●

D. For maximum pain relief benefit, apply Apply thermal therapies (heat or cold).
●●

capsaicin cream up to four times a day.

Use assistive devices such as a long‑handled
●●

NCLEX® Connection: Pharmacological and Parenteral Therapies, reacher and an elevated toilet seat.
Medication Administration Plan high‑energy activities in the morning
●●

when feeling most rested.

4. A. Prone position without use of pillows has not been
found to decrease acute low back pain. NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
B. CORRECT: Williams position, with the client in semi‑Fowler’s
position with the knees flexed by pillows, has been found to relieve
low‑back pain caused by a bulging disk and nerve root involvement.
C. High‑Fowler’s position with the knees flat has not
been found to decrease acute low back pain.
D. Supine position with the head flat has not been
found to decrease acute low back pain.

NCLEX® Connection: Basic Care and Comfort,

Non-Pharmacological Comfort Interventions

5. A. CORRECT: Regular exercise, including walking or

swimming, is a strategy that can prevent low back pain
B. Long periods of sitting or standing can cause low‑back pain. Advise
the client to use footstools or ergonomic chairs when sitting is necessary.
C. The client should maintain weight within 10% of ideal
body weight, as obesity can cause low‑back pain.
D. CORRECT: Stopping or cutting down on smoking
is a strategy that can decrease problems with low‑back
pain, as smoking can cause disk degeneration.
E. CORRECT: Wearing low‑heeled, well‑fitting
shoes can prevent low back pain. The nurse should
instruct the client to avoid high‑heeled shoes.

NCLEX Connection: Physiological Integrity, Mobility/Immobility

466  CHAPTER 72  Osteoarthritis and Low‑Back Pain CONTENT MASTERY SERIES