Module 2: Caring for Clients with Common

Musculoskeletal Health Challenges

Introduction (I) - Part A
Overview
The musculoskeletal system includes the bones, joints, muscles, tendons, and ligaments. The
problems associated with these structures are common and affect all age groups. Common health
challenges involving the musculoskeletal systems are generally not life threatening, though they
may have a significant impact on the person’s normal activities and productivity. Registered
nurses in all practice areas encounter clients with changes in musculoskeletal function.
The role of the registered nurse (RN) when providing safe and competent care for clients
experiencing common musculoskeletal health challenges will be examined in Module 2.
Specifically, this module will focus on the role of the RN associated with the following:
 Assessment of musculoskeletal function
 Strains
 Sprains
 Fractures
 Casts
 Compartment syndrome.
 Hip and knee replacement.
 Osteoarthritis
 Rheumatoid arthritis
 Lyme disease
Learning Outcomes
 Review the major structures and function of the musculoskeletal system.
 Summarize the role of the registered nurse when performing a health assessment and
physical examination of the musculoskeletal system.
 Explain the role of the registered nurse when caring for a client having common
diagnostic studies associated with the musculoskeletal system.
 Review the pathophysiology of common musculoskeletal health challenges.
 Formulate a plan of nursing care, using the nursing process, for persons experiencing
common musculoskeletal health challenges.
 Examine the role of the registered nurse when providing client education regarding
common musculoskeletal health challenges.
 Discuss the mechanism of action, indications, dosage forms, application techniques,
adverse effects, cautions, contraindications, and drug interactions of selected drugs
relevant to the health challenges in this module.
Required Readings
Lewis text
 Chapter 64 – Musculoskeletal System
 Chapter 65 – Musculoskeletal Trauma and Orthopedic Surgery
 pp. 1632-1655; 1661-1664.
 Chapter 67 – Arthritis and Connective Tissue Diseases
 pp. 1691-1709.
Jarvis text
  Chapter 24 – Musculo-skeletal system
Lilley text
 Chapter 11 – Analgesic Drugs
 Chapter 13 – CNS Depressants and Muscle Relaxants
 pp. 257-265
 Chapter 27 – Coagulation Modifier Drugs
 pp. 516-529; 533-543
 Chapter 49 – Anti-inflammatory and Antigout Drugs
 Chapter 54 – Biological Response-Modifying Drugs and Antirheumatic Drugs
 pp. 1017-1024
Other
Registered Nurses’ Association of Ontario. (2017). Preventing falls and reducing injury from
falls (4th ed.). Toronto, ON: Author. Retrieved
from https://rnao.ca/sites/rnao-ca/files/bpg/FALL_PREVENTION_WEB_1207-17.pdf

Library Streaming Videos

Please find below the link to log in to the Nipissing University Library. Following this step,
students will be able to view the available Health Sciences e-resources, specifically the library
streaming videos. After selecting the URL provided, scroll down to the ‘Jarvis Physical
Examination and Health Assessment Series’ and/ or the ‘Taylor’s Video Guide to Clinical
Nursing Skills’ to view the applicable video assigned for the weekly module.
Link: https://secure-nucc-eclibrary-ca.roxy.nipissingu.ca/site/content/health-sciences

Jarvis Physical Examination and Health Assessment Series:

Part 9, Musculoskeletal System.

Taylor’s Video Guide to Clinical Nursing Skills:

Module 2- Physical Assessment- Chapter 15, Assessing the Musculoskeletal and Neurological
Systems.

Concepts and Theory (C)- Part A

1. Summarize the role of the registered nurse when completing a musculoskeletal health
assessment and physical examination.
 Examination of the musculo-skeletal system involves inspection, palpation, motion, and
muscular assessment. The nurse should conduct a general overview, while obtaining data
in a careful health history to provide guidance in choosing areas on which to concentrate
during the local examination. Specific measurements should be taken as indicated by the
results of the local examination.
 The nurse grades the strength of individual muscles or groups of muscles during
contraction.

Subjective Data:
Important Health Information
Joints:
  Stiffness- Do you experience any stiffness in your joints? Are there any activities that
increase your joint stiffness? • Is the joint pain associated with fever, recent infection,
trauma, or repetitive activity?
 Pain - Do you have any pain? (If so, ask patient to describe location, quality, severity,
onset, timing, frequency; aggravating/relieving factors)
 Swelling, heat - Have you noticed any stiffness, swelling, heat, or redness in your joints?
 Limitation of movement - Do you have any limitations in movement or function of any
joint? Which activities give you problems?
Muscles:
 Pain (cramps) - Do you have any problems with your muscles (pain, cramping)? Is the
pain widespread and associated with fatigue? Do you have any pain in your calf muscles?
With walking? Does it go away with rest? Are your muscle aches associated with fever,
chills, or the “flu”?
 Weakness - Do you have any muscular weakness? Where? How long have you noticed
the weakness? Do the muscles look smaller there?
Bones:
 Pain - Do you have any bone pain? Is it affected by movement? How do you manage the
pain?
 Deformity - Do you have any deformity of any bone or joint? What is the cause? Does it
affect range of motion?
 Trauma (fractures, sprains, dislocations) - Have any accidents or trauma ever affected
your bones or joints? When? What was the treatment? Have any ongoing limitations
resulted?
Functional assessment for activities of daily living (ADLs):
 Any self-care deficit in bathing, toileting, dressing, grooming, eating, communicating,
mobility - Do your joint, muscle, or bone problems limit any of your usual daily
activities? Bathing: getting in and out of tub, turning faucets, Toileting: voiding,
defecating, getting on or off toilet, wiping self, Dressing: fastening buttons, zippers,
pulling clothes over head, pulling up pants or skirt, tying shoes, Grooming: shaving,
brushing teeth, fixing hair, applying makeup, Eating: preparing meals, pouring liquids,
cutting up foods, bringing food to mouth, drinking.
 Use of mobility aids - Mobility: walking up and down stairs, getting in and out of bed,
getting out of the house.
Communicating: talking, using phone, writing
Self-care behaviours:
 Occupational hazards- Heavy lifting, repetitive motion to joints - Are there any
occupational hazards that could affect your muscles and joints? Does your work involve
heavy lifting or repetitive motion? Do you use any mechanical assistive devices or
prosthetic or orthotic devices?
 Nature of exercise program - Describe your exercise pattern (frequency, warm-up, type of
exercise, any pain)
 Recent weight gain - Have you had any recent weight gain or loss? What is your usual
daily diet? What dietary supplements do you take? (Ask specifically about calcium,
vitamin D supplements, and herbal products.)
Additional history for the aging adult
  Past Health History - Have you noticed any change in strength or weakness over the past
weeks or months? Have you been falling or stumbling more often over the past weeks or
months? Do you use any mobility aids to help you get around (cane, walker)?
 Medications - Are you taking any medications for the musculo-skeletal system (anti-
inflammatory, pain reliever)?
 Surgery or Other Treatments - The nurse should obtain specific information about any
surgical procedure and the postoperative course. If the patient experienced a period of
prolonged immobilization, the development of osteoporosis and muscle atrophy should
be considered.
Objective Data
1. Physical Examination
 Inspection - Inspection begins during the nurse's initial contact with the patient.
The nurse notes the use of an assistive device such as a walker or cane. The nurse
also observes general body build, muscle configuration, and symmetry of joint
movement. If the patient is able to move independently, the nurse should assess
posture and gait by watching the patient walk, stand, and sit. Musculo-skeletal
and neurological problems can result in changes from a normal gait. A systematic
inspection is performed, starting at the head and neck and proceeding to the upper
extremities, lower extremities, and trunk. The skin is inspected for general colour,
scars, or other overt signs of previous injury or surgery. The nurse notes any
swelling, deformity, nodules or masses, and discrepancies in limb length or
muscle size. The patient's opposite-side body part is observed for comparison
when an abnormality is suspected.
 Palpation - Any area that has aroused concern because of a subjective complaint
or appears abnormal on inspection should be carefully palpated. Palpation usually
proceeds from head to toe to examine neck, shoulders, elbows, wrists, hands,
back, hips, knees, ankles, and feet. Both superficial and deep palpation are usually
performed, one after the other. The nurse's hands should be warm to prevent
muscle spasm, which can interfere with identification of essential landmarks or
soft tissue structures. Palpation allows for evaluation of skin temperature, local
tenderness, swelling, crepitation, and presence of nodules. Muscles are palpated
during active and passive motion for tone, strength, and ease of movement.
 Motion - When assessing the patient's joint mobility, the nurse must carefully
evaluate both passive and active ranges of joint motion. Measurements should be
similar for both. Active range of motion means the patient takes his or her own
joints through all movements without assistance. Passive range of motion occurs
when someone else moves the patient's joints without the patient's participation.
The nurse should be cautious in performing passive range of motion because of
the risk of injury to underlying structures. Manipulation must cease immediately
if pain or resistance is encountered. If deficits in active or passive range of motion
are noted, the nurse must also assess functional range of motion to determine
whether performance of activities of daily living has been affected by joint
changes. In this assessment, the patient is asked whether activities such as eating
and bathing must be performed with assistance or cannot be done at all.
 Muscle Strength Testing - The nurse grades the strength of individual muscles or
groups of muscles during contraction. The patient should be instructed to apply
 resistance to the force exerted by the nurse. For example, if the examiner tries to
pull the patient's bent arm down, the patient tries to raise it. Muscle strength
should also be compared with the strength of the opposite extremity. Subtle
variations in muscle strength may be noted when the patient's dominant side is
compared with the nondominant side.
 Measurement - When length discrepancies or subjective problems are noted, the
nurse obtains limb length and circumferential muscle mass measurements. For
example, leg length should be measured when gait disorders are observed. The
affected limb is measured between two bony prominences, and that measurement
is compared with the corresponding measurement of the opposite extremity.
Muscle mass is measured circumferentially at the largest area of the muscle.
When recording measurements, the nurse documents the exact location at which
the measurements were obtained (e.g., the quadriceps muscle is measured 15 cm
above the patella). This informs the next examiner of the exact area to be
measured and ensures consistency during reassessment.
 Reflexes - Measurement of the stretch reflexes reveals an involuntary muscle
contraction, the intactness of the reflex arc at specific spinal levels, and the
normal override on the reflex of the higher cortical levels. For an adequate
response, the limb should be relaxed, and the muscle partially stretched. Stimulate
the reflex by directing a short, snappy blow of the reflex hammer onto the
insertion tendon of the muscle. Use a relaxed hold on the hammer. As with the
percussion technique, the action takes place at your wrist. Strike a brief, well-
aimed blow and bounce up promptly; do not let the hammer rest on the tendon. It
is the swing of the hammer, not the strength of the strike, that gets the best result.
Use the pointed end of the reflex hammer when aiming at a smaller target such as
your thumb on the tendon site; use the flat end when the target is wider or to
diffuse the impact and prevent pain. Use just enough force to get a response.
Compare right and left sides—the responses should be equal. The reflex response
is graded on a 4-point scale:
o 4+ Very brisk, hyperactive with clonus, indicative of disease
o 3+ Brisker than average, may indicate disease, probably normal.
o 2+ Average, normal
o 1+ Diminished, low normal, or occurs only with reinforcement.
2. Explain briefly the role of the registered nurse when caring for a client having the following
diagnostic studies associated with musculoskeletal health challenges:

Diagnostic Test Nursing Role

X-Rays • Instruct patient to avoid excessive exposure of patient and

self to radiation.
• Remove any radiopaque objects that can interfere with
results.
• Explain procedure to patient.
• Instruct the patient to remain still.
 • Pregnancy is a contraindication to x-ray studies; however,
sometimes the benefits outweigh the risks.

Computed Tomography (CT) • Same as for radiography.

• Also, assess for adverse reactions to iodinated dye.
• Patients with kidney disease or diabetes require adequate
hydration to flush out the dye.

Magnetic Resonance • MRI is contraindicated in patients with metallic implants.

Imaging (MRI) • Ensure that patient has no metal on clothing (e.g., snaps,
zippers, jewellery, credit cards).
• Inform patient that procedure is painless, and emphasize
importance of remaining still throughout examination.
• Claustrophobic patients may require antianxiety agents if
indicated and ordered.
• Open MRI may be indicated for patients with large chest
and abdominal girth or severe claustrophobia.

Arthrography • Same as for radiography.

• Assess patient for possible allergy to contrast medium.
• Inform patient that procedure is painless.

Bone Mineral Density • Same as for radiography.

• Inform patient that procedure is painless.

Bone Scan • Pregnancy and lactation are usually contraindicated.

• The technician gives a calculated dose of radioisotope 2 hr
before procedure.
• The patient's bladder is emptied before the procedure.
• The procedure requires 1 hr while patient lies supine.
• Increase patient's fluid intake after the examination.
• The isotopes are excreted from the body within 6–24 hr.

Serological Studies RF
• Inform patient that fasting is not required.
• In older adults, results are often falsely positive.
• False-positive results also occur with hemolysis or lipemia.
ESR
• Numerous interfering factors can affect test results (e.g.,
pregnancy, menstruation, anemias, medications).
• Withhold medications that may affect results, if indicated.
 ANA
• Inform patient that fasting is not required.
• Note any medications that may affect test results.
• Assess for signs of infection at the venipuncture site in
patients with autoimmune diseases.
CRP
• Fasting may sometimes be required (laboratory specific).
• Note any medications that may affect test results.
Uric Acid
• Fasting may sometimes be required (laboratory specific).
HLA-B27
• Inform patient that fasting or other preparation is not
needed.

Muscle Enzymes CK
• Obtain blood samples by venipuncture.
• Observed venipuncture site for bleeding or hematoma
formation.
• Inform patient that procedure does not necessitate fasting.
• Values can be increased after strenuous exercise, recent
surgery, and intramuscular injections and with certain
medications.
K+
• Monitor patients in trauma unit for cardiac dysrhythmias
related to hypokalemia or hyperkalemia.
• Note any medications that may affect test results.
• Hemolysis of the blood sample and prolonged tourniquet
application can elevate potassium levels.

Arthrocentesis • Inform patient that procedure is usually done at bedside or

in examination room.
• Send samples of synovial fluid to laboratory for
examination (if indicated).
• After procedure, apply pressure dressing.
• Observe dressing for leakage of blood or fluid.

Electromyography (EMG) • Inform patient that procedure is usually done in EMG

laboratory while patient lies supine on special table.
• Keep patient awake to cooperate with voluntary
movement.
• Inform patient that procedure involves some discomfort
from needle insertion.
 • Contraindications include anticoagulant therapy and
extensive skin infection.
• Fasting is not required, but some laboratories may restrict
intake of stimulants (e.g., coffee, cigarettes) 2–3 hr before
procedure.

3. a) Formulate a plan of nursing care for a simulated client with a hip replacement, using the
information from the readings and posted project assignment.

Care plan: Description and Rationale

Hip Replacement

Pathophysiology Joint replacements (arthroplasty) are indicated for

irreversibly damaged joints with loss of function and
unremitting pain, selected fractures, joint instability, and
congenital hip disorders.

Nursing assessments  Pain and discomfort

 Swelling
 Stiffness
 Limited ROM; decreased muscle strength/control
 Bruising and discoloration
 Muscle weakness
 Numbness and tingling sensation around
the surgical area
 Difficulty in performing with ADLs

Nursing diagnoses Risk for skin infection as evidence by joint replacement.

Planning and goals  The client will achieve timely wound healing, be free of
purulent drainage or erythema, and be afebrile.
 The client will be free from infections.

Nursing interventions Preventing Infection Risk and Promoting Infection Control

Assess skin/incision color, temperature, and integrity; note
the presence of erythema or inflammation and loss of
wound approximation.
Monitor temperature. Note the presence of chills.
Use strict aseptic or clean techniques as indicated to
 reinforce or change dressings and when handling drains.
Instruct patient not to touch or scratch incision.
Encourage fluid intake and a high-protein diet with
roughage.

Teaching self-care/ Managing pain, educate for signs of infection, encourage a

Continuing care balanced diet for proper wound healing.

Evaluation Wound stages of healing and assess any signs of purulent

or foul smelling drainage.

b) Formulate a plan of nursing care for a simulated client experiencing osteoarthritis using the
information from the readings and posted project assignment.

Care plan: Osteoarthritis Description and Rationale

Pathophysiology Osteoarthritis (OA) also known as a degenerative joint

disease (DJD) or osteoarthrosis is the most common kind
of arthritis associated with progressive degeneration of
articular cartilage in synovial joints. Usually, weight-
bearing joints (knees, hips, feet) and the spine are affected.

Nursing assessments Assess for the following:

 Joint pain worsens with movement or activity.
 Joint stiffness, especially in the morning
 Joint swelling and tenderness
 Limited range of motion
 Joint instability
 A grating or crackling sound or sensation in the joint
during movement (crepitus)
 Muscle weakness
 Bone deformities
 Physical mobility

Nursing diagnoses Impaired physical mobility related to Osteoarthritis

Planning and goals The client will perform physical activity independently or
within limits of activity restrictions.
 The client will demonstrate the use of adaptive changes that
promote ambulation and transferring.
  The client will identify measures to prevent injury.

Nursing interventions Managing and Reliving Acute and Chronic Pain

Enhancing Physical Mobility
Promoting Tolerance to Activity
Preventing Risk for Injury and Trauma
Enhancing Self Body Image and Self-Esteem
Administering Medications and Pharmacologic Support

Teaching self-care/ Assess the client’s ability to perform activities of daily

Continuing care living (ADLs) and instrumental activities of daily living
(IADLs).
Assist the client with active and passive ROM exercises and
isometrics as tolerated.
Instruct the use of adaptive mobility equipment such as
walkers, canes, and crutches as indicated.

Evaluation Patient can describe preventative measure to abstain from

falls.
Increased mobility with independently doing ADLs

c) Formulate a plan of nursing care for a simulated client with a bone fracture, using the
information from the readings and posted project assignment.

Description and Rationale

Care plan:
Bone Fracture

Pathophysiology A fracture is a medical term used for a broken bone. They

occur when the physical force exerted on the bone is
stronger than the bone itself. They commonly happen
because of car accidents, falls, or sports injuries. Other
causes are low bone density and osteoporosis, which cause
the weakening of the bones.

Nursing assessments  Visible deformity or swelling at the site of the

fracture.
 Pain or tenderness at the site of the fracture, which
may worsen with movement or pressure.
  Loss of function or decreased range of motion in
the affected area
 Numbness or tingling in the affected limb or
extremity.
 Presence of an open wound or exposed bone
 Edema in the surrounding area
 Ecchymosis (bruising) or hematoma formation
 Crepitus or abnormal movement at the fracture site
 Decreased sensation, diminished pulses,
or cyanosis.

Nursing diagnoses Risk for peripheral neuro-vascular dysfunction as

evidenced by fracture (vascular insufficiency and nerve
compression, mechanical compression by traction, splints,
or casts)

Planning and goals The overall goals are that the patient with a fracture will (1)
have healing with no associated complications, (2) obtain
satisfactory pain relief, and (3) achieve maximal
rehabilitation potential.

Nursing interventions Preventing Fall Risk and Injury

Promoting Pain Relief and Pain Management
Monitoring and Preventing Complications
Promoting Effective Gas Exchange
Enhancing Physical Mobility
Wound Care and Skin Integrity
Preventing Infection Risk
Assisting in Self-Care
Initiating Patient Education and Health Teachings
Managing Constipation and Improving Bowel Movement
Administering Medications and Pharmacological Support
Monitoring Diagnostic Procedures and Laboratory Studies

Teaching self-care/ Teach the patient or assist with active and passive ROM
Continuing care exercises of affected and unaffected extremities.
List activities the patient can perform independently and
those that require assistance.
Encourage the patient to continue active exercises for the
joints above and below the fracture.
 Evaluation Experience no peripheral neuro-vascular dysfunction

4. Summarize the priority nursing care considerations in the following simulated scenarios.
a. Caring for a client with a cast.
Neurovascular Assessment - Circulation: Monitor for adequate blood flow by checking skin
color, temperature, capillary refill, and pulses distal to the cast. Sensation and Movement:
Assess for any changes in sensation (numbness, tingling) and ability to move fingers or toes.
Report any abnormalities immediately as they can indicate neurovascular compromise.
Monitoring for Complications - Compartment Syndrome: Watch for signs such as increased
pain unrelieved by medication, swelling, tightness, and changes in sensation. This is a medical
emergency requiring prompt intervention. Infection: Look for symptoms like foul odor,
increased pain, fever, and drainage. Educate the patient to report these symptoms promptly.
Pressure Ulcers: Inspect skin around the cast edges for redness, warmth, or breakdown. Pad any
rough edges to prevent skin irritation.
Pain management – administer pain meds.
Skin Integrity - Regularly assess skin condition at the cast edges and around any openings.
Ensure padding is adequate to prevent pressure sores and skin breakdown.
Mobility & Positioning, Hydration & Nutrition, Cast care education.

b. Assessing and monitoring a client for compartment syndrome. Be sure to include the
six Ps. Compartment syndrome may occur initially from the body's physiological response to the
injury, or it may be delayed for several days after the original insult or injury. Ischemia can occur
within 4 to 8 hours after the onset of compartment syndrome. The “six Ps” are a neuro-vascular
assessment mnemonic that can be used to assess for impending compartment syndrome: (1) pain
distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle
travelling through the compartment; (2) increasing pressure in the compartment; (3) paresthesia
(numbness and tingling); (4) pallor, coolness, and loss of normal colour of the extremity; (5)
paralysis or loss of function; and (6) pulselessness or diminished or absent peripheral pulses.
Prompt, accurate diagnosis of compartment syndrome is critical. Prevention or early recognition
is the key. Regular neuro-vascular assessments should be performed and documented on all
patients with fractures but especially those with injury of the distal humerus or proximal tibia or
soft tissue disruption in these areas. Carefully assess the location, quality, and intensity of the
pain. Evaluate the pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to
the level of injury and pain on passive muscle stretch appear to be the most effective clinical
observations (Ali et al., 2014) and some of the first indications of impending compartment
syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome.
The health care provider should be notified immediately of a patient's changing condition.
Because of the possibility of muscle damage, urine output should be assessed. Myoglobin
released from damaged muscle cells precipitates as a gel-like substance and causes obstruction in
renal tubules. This condition results in acute tubular necrosis and acute kidney injury. Common
signs are dark, reddish-brown urine and clinical manifestations associated with acute kidney
injury. Elevation of the extremity may lower venous pressure and slow arterial perfusion; thus,
the extremity should not be elevated above heart level. Similarly, the application of cold
compresses may result in vasoconstriction and exacerbate compartment syndrome. It may also be
necessary to remove or loosen the bandage and bivalve or split the cast in half. A reduction in
traction weight may also decrease external circumferential pressures. Surgical decompression
(e.g., fasciotomy) of the involved compartment may be necessary. The fasciotomy site is left
open for several days to ensure adequate soft tissue decompression. Infection resulting from
delayed wound closure is a potential problem following a fasciotomy. In severe cases of
compartment syndrome, an amputation may be required.

c. Health teaching following knee and hip joint replacements.

After surgery, an emphasis is placed on physiotherapy.
DO - • Use an elevated toilet seat. • Place chair inside shower or tub and remain seated while
washing. • Use pillow between legs for first 8 week after surgery when lying on the side
recommended by surgeon or when supine. • Keep hip in neutral, straight position when sitting,
walking, or lying. • Notify surgeon if severe pain, deformity, or loss of function occurs. • Inform
dentist of presence of prosthesis before dental work so that prophylactic antibiotics can be given
if indicated.
DO NOT - • Force hip into greater than 90 degrees of flexion (e.g., sitting in low chairs or on
low toilet seats). • Force hip into adduction. • Force hip into internal rotation. • Cross legs at
knees. • Put on own shoes or stockings without adaptive device (e.g., long-handled shoehorn or
stocking-helper) until 8 weeks after surgery. • Sit on chairs without arms. They are needed to aid
rising to a standing position.

d. Avoiding hip dislocation.

Towel rolls (i.e., trochanter rolls) or pillows placed on the lateral side of the leg are also used to
prevent external rotation. If a foam abduction pillow is used, it should be placed between the legs
to prevent dislocation of the new joint.
A carefully regulated rehabilitation program can prevent fracture instability and joint
dysfunction. Gentle range of motion (ROM) may be started if the joint is stable, and the affected
joint is well supported. An exercise program slowly restores the joint to its original ROM without
causing another dislocation. The patient should gradually return to normal activities. A patient
who has dislocated a joint may be at greater risk for repeated dislocations because of loose
ligaments. Activity restrictions of the affected joint may be imposed to decrease the risk for
repeated dislocation.

e. Assessment and treatment of a client with Lyme Disease.

The following instructions should be included when teaching patients and caregivers how to
prevent Lyme disease. • Avoid walking through tall grasses and low brush and sitting on logs. •
Mow grass. Remove brush around paths, buildings, and campsites to create “tick-safe zones.” •
Move woodpiles and bird feeders away from house. Discourage deer (main source of food for
adult ticks) from being in the area. • Wear long pants or nylon tights of tightly woven, light-
coloured fabric so that ticks can be easily seen. • Tuck pants into boots or long socks, tuck long-
sleeved shirts into pants, and wear closed shoes when hiking. • Check often for ticks crawling
from pant legs to open skin. • Thoroughly inspect and wash clothes. Placing clothing in dryer on
high heat effectively kills ticks. • Spray insect repellent containing DEET sparingly on skin or
apply permethrin to boots and clothes (especially on lower extremities) and camping gear. • Have
pets wear tick collars, inspect them often, and do not allow pets on furniture or beds. The
following instructions should be included when teaching patients and caregivers living in
endemic areas. • Remove attached ticks with tweezers (not fingers). Grasp tick's mouth parts as
close to skin as possible and gently pull straight out. Do not twist or jerk. Avoid folk solutions
such as painting the tick with nail polish or petroleum jelly. • Wash bitten area with soap and
water and apply antiseptic. Wash hands. • See a health care provider immediately if flulike
symptoms or a bull's eye rash appears within 3 to 30 days after removal of tick.

5. Complete the following chart for the selected drugs relevant to this module:

Drug & Mechanism of Indications & Adverse Nursing

Classificatio Action Contraindications Effects Considerations
n

Morphine Binds to opioid Alleviate Sedation, Monitor respiratory

(opioid pain receptors in moderate to respiratory status; if used in
agonist) the brain to cause severe post- depression, clients with head
an analgesic operative pain. hypotension, injury, may mask
response. Known drug palpitations, signs and symptoms
(Lilley, 2017) allergy, severe nausea, of increased ICP;
asthma. vomiting, perform regular
(Lilley, 2017) urinary pain assessments.
retention, (Lilley, 2017)
constipation.
(Lilley, 2017)

Baclofen The effects of Muscle relaxants The primary Toxicity and

muscle relaxants are used primarily adverse management of
are relaxation of for the relief of effects of overdose.
striated muscles, painful muscle An adequate airway
mild weakness of musculoskeletal relaxants are must be maintained
skeletal muscles, conditions, such an extension and means of
decreased force of as muscle spasms, of their effects artificial respiration
muscle often following on the CNS should be readily
contraction, and injuries such as and skeletal available.
muscle stiffness. low back strain. muscles. Electrocardiographi
Other effects They are most Euphoria, c monitoring needs
include effective when light- to be instituted and
generalized CNS used in headedness, large quantities of
depression conjunction with dizziness, intravenous fluids
manifested as physiotherapy. drowsiness, are administered to
sedation, fatigue, avoid crystalluria.
somnolence, The only usual confusion,
ataxia, and contraindication and muscle
respiratory and to the use of weakness are
cardiovascular muscle relaxants often
depression. is known drug experienced
 Baclofen is one of allergy, but early in
the more effective contraindications treatment.
drugs in this class for some of these
and is a derivative drugs may
of GABA. It is include severe
believed to work renal impairment.
by depressing
nerve transmission
in the spinal cord.

Enoxaparin Binds to Prevention of Fever, Monitor for any

antithrombin III DVT, PE. Acute confusion, signs of
inactivating factors MI, coronary nausea, bleeding/hematoma.
Xa/IIa, thereby heart thrombosis. bleeding at Monitor blood
resulting in a site, studies, renal
higher ratio of Sensitivities and ecchymosis, studies, and
anti-factor Xa to major bleeding angio-edema, anaphylaxis. Assess
IIa. osteoporosis. neurological status.

Heparin Prevents Prevention Fever, chills, Assess for bleeding,

conversion of treatment of headaches, blood studies,
fibrinogen to fibrin DVT, PE, MI, hematuria, hypersensitivity.
and prothrombin to open heart hemorrhage, Evaluate aPTT &
thrombin by surgery, rash, injection PTT.
enhancing anticlotting of site reaction,
inhibitory effects indwelling hyperkalemia,
of antithrombin III. venipuncture anaphylaxis
devices.

Hypersensitivities
and bleeding.

Warfarin Interferes with Antiphospholipid Fever, Assess blood

blood clotting by antibody dizziness, studies, bleeding,
indirect means; syndrome, arterial fatigue, fever, skin rash or
depresses hepatic thromboembolis headache, hematoma.
synthesis of vit K- m prophylaxis, lethargy,
dependent DVT, MI angina,
coagulation factors prophylaxis, after edema,
(II, VII, IX, X) MI, stroke syncope,
prophylaxis, N/V/D,
thrombosis hepatitis,
 prophylaxis, PE hematuria,
hemorrhage,
rash,
epistaxis,
dyspnea,
anaphylaxis.

ASA Blocks pain Mild to moderate Drowsiness, Assess for pain,

impulses by fevers, confusion, fever, hepatic
blocking COX-1 in rheumatoid intracranial studies, renal
CNS, reduces arthritis, hemorrhage, studies, blood
inflammation by thromboembolic dysrhythmias, studies,
inhibition of disorders, TIA, tinnitus, hepatotoxicity,
prostaglandin rheumatic fever, hypoglycemia allergic reactions,
synthesis; post-MI, , hypoglycemia,
antipyretic action prophylaxis of hyponatremia, salicylate level.
results from MI, ischemic hypokalemia,
vasodilation of stroke, acute MI, N/V/D, GI
peripheral vessels; angina, Kawasaki bleeds, ulcers,
decreases platelet disease. increased PT,
aggregation aPTT
Pregnancy, bleeding time,
breastfeeding, bronchospasm
sensitivities, , anaphylaxis.
children <12y.o.,
GI bleeds, ulcers,
bleeding
disorders, ICP,
nasal polyps,
alcoholism,
intracranial
bleeding.

Ibuprofen Inhibits COX-1, Use for Headache, Assess hepatic,

COX-2 by rheumatoid N/V/D, GI renal, blood studies,
blocking arthritis, OA, bleed (long electrolytes, and
arachidonate, dental pain, use), evaluate pain level.
analgesic, anti- musculoskeletal
inflammatory, disorders, fever,
antipyretic migraine.

Contraindications
: pregnancy,
hypersensitivity,
 severe
hepatic/renal
disease, GI
disorders, HTN

Celecoxib Inhibits Use for chronic Fatigue, Assess pain, beers

prostaglandin rheumatoid anxiety, (in older adults),
synthesis by arthritis, acute dysuria, CBC during
selectively pain, arthritis. nervousness therapy, GI toxicity
inhibiting
cyclooxygenase-2 Contraindicated
(cox-2) in pregnancy,
hypersensitivity,
for perioperative
pain in CABG,
hypertension,

Methotrexate Inhibits an enzyme Use for acute Nausea, Ensure medication

(high alert) that reduces folic lymphocytic vomiting, is taken as directed.
acid, which is leukemia, in anorexia, Prone to infections.
needed nucleic combination for diarrhea, Immunosuppressive
acid synthesis in breast, lung, head, ulcerative – blood studies.
all cells; specific to neck carcinoma, stomatitis, Monitor vital signs,
S phase of cell lymphoma, rash, alopecia signs of N/V/D and
cycle; sarcoma. administer meds if
immunosuppressiv provided. Monitor
e Anemia, signs of toxicity.
hypersensitivity,
thrombocytopenia
, renal disease,
hepatic disease,
AIDS, pregnancy

Etanercept Binds tumor Use for Headache, inj- Assess for pain in
necrosis factor, rheumatoid site reaction, RA, ROM, swelling
which is involved arthritis, pharyngitis, of joints during
in immune and ankylosing cough, treatment. Inj-site
inflammatory spondylitis, rhinitis. reactions,
reactions. plaque psoriasis. hypersensitivity.
Evaluate
Contraindicated therapeutic
in sepsis, response.
pregnancy,
 breastfeeding,
HF, MS,
malignancies,
hypersensitivity.

Apply (A)- Part B

Online Learning Activities:
The course instructor/ professor will provide the learning activities to apply and critically
analyze the module theory, concepts, and relevant best practice guidelines.

Reflect (R)- Part B

A. Independent Reflection Activity:
As the nurse manager you are planning to implement a new fall prevention program at your
workplace. What information would you include in the program based on the Registered Nurses’
Association of Ontario (RNAO, 2017) best practice guidelines?

B. Review the sample NCLEX-style questions:

A patient is receiving an opioid via a PCA pump as part of his postoperative pain management
program. During rounds, the nurse finds him unresponsive, with respirations of 8 breaths/min
and blood pressure of 102/58 mmHg. After stopping the opioid infusion, what should the nurse
do next?
a) Notify the charge nurse.
b) Draw arterial blood gases.
c) Administer an opiate antagonist per standing orders.
d) Perform a thorough assessment, including mental status.

IV morphine is prescribed for a patient who has had surgery. The nurse informs the patient that
which common adverse effects can occur with this medication? Select all that apply.
a) Diarrhea
b) Constipation
c) Pruritis
d) Urinary frequency
e) Nausea

The nurse is administering a dose of morphine to a 48-year-old postoperative patient. The dose
orders is 3 mg every 3 hours as needed for pain. The medication is supplied in vials of 4 mg/mL.
How much will be drawn into the syringe for this dose? 0.75mL

A patient is receiving instructions for warfarin therapy and asks the nurse about what
medications she can take for headaches. The nurse will tell her to avoid which type of
medication?
a) Opioids
b) Acetaminophen
c) NSAIDs
 d) There are no restrictions when taking warfarin

The nurse is teaching a patient about self-administration of enoxaparin (Lovenox). Which

statement should be included in this teaching session?
a) “We will need to teach a family member how to give this drug in your arm.”
b) “This drug is given in the folds of your abdomen, but at least 5 centimetres away from
your navel.”
c) “This drug needs to be taken at the same time every day with a full glass of water.”
d) “Be sure to massage the injection site thoroughly after receiving the drug.”

Which cast care instructions should the nurse provide to a client who just had a plaster cast
applied to the right forearm? Select all that apply.
a) Keep the cast clean and dry.
b) Allow the cast 24 to 72 hours to dry.
c) Keep the cast and extremity elevated.
d) Expect tingling and numbness in the extremity.
e) Use a hair dryer set on warm to hot setting to dry the cast.
f) Use a soft, padded object that will fit under the cast to scratch the skin under the cast.

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The
client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and
administers an analgesic, with little relief. Which problem may be causing this pain?
a) Infection under the cast.
b) The anxiety of the client.
c) Impaired tissue perfusion.
d) The recent occurrence of the fracture.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of
compartment syndrome. The nurse determines that the client understands the information if the
client states that he or she should report which early symptom of compartment syndrome?
a) Cold, bluish-coloured fingers.
b) Numbness and tingling in the fingers.
c) Pain that increases when the arm is dependent.
d) Pain that is out of proportion to the severity of the fracture.

The nurse is administering methotrexate as part of the treatment for rheumatoid arthritis and will
monitor for which sign of bone marrow suppression?
a) Edema.
b) Tinnitus.
c) Increased bleeding tendencies.
d) Tingling in the extremities.

The nurse is preparing discharge instructions for a client receiving baclofen. Which instructions
should be included in the teaching plan?
a) Restrict fluid intake.
b) Avoid the use of alcohol.
 c) Stop the medication if diarrhea occurs.
d) Notify the health care provider if fatigue occurs.

In monitoring a client’s response to disease-modifying antirheumatic drugs (DMARDs), which

assessment findings would the nurse consider acceptable responses? Select all that apply.
a) Control of symptoms during periods of emotional stress.
b) Normal white blood cell, platelet, and neutrophil counts.
c) Radiological findings that show no progression of joint degeneration.
d) An increased range of motion in the affected joints 3 months into therapy.
e) Inflammation and irritation at the injection site 3 days after the injection is given.
f) A low-grade temperature on rising in the morning that remains throughout the day.

Extend (E)- Part B

Ali, P., Santy-Tomlinson, J., & Watson, R. (2014). Assessment and diagnosis of acute limb
compartment syndrome: A literature review. International Journal of Orthopaedic & Trauma
Nursing, 18, 180-190. doi: 10.1016/j.ijotn.2014.01.002

Centers for Disease Control and Prevention. (CDC, 2018). Lyme disease. Retrieved
from https://www.cdc.gov/lyme/

Jarvis, C. (2017). Physical examination and health assessment (3rd Canadian ed.). Toronto, ON:
Elsevier Canada.

Regan, E. N., Phillips, F., & Magri, T. (2013). Get a leg (or two) up on total knee
arthroplasty. Nursing 2013, 43(7), 32-37. doi: 10.1097/01.NURSE.0000431156.83425.1a

Registered Nurses’ Association of Ontario. (2017). Clinical best practice guidelines: Preventing
falls and reducing injury from falls (4th ed.). Retrieved
from https://rnao.ca/sites/rnao-ca/files/bpg/FALL_PREVENTION_WEB_1207-17.pdf

Registered Nurses’ Association of Ontario. (2013). Clinical best practice guidelines: Assessment
and management of pain (3rd ed.). Retrieved
from http://rnao.ca/sites/rnao-ca/files/AssessAndManagementOfPain_15_WEB-
_FINAL_DEC_2.pdf

Sawhney, M. (2012). Epidural analgesia: What nurses need to know. Nursing 2012, 42(8), 36-
41. doi: 10.1097/01.NURSE.0000415833.28619.a1
Sendir, M., Buyukyilmaz, F., & Musovi, D. (2013). Patients’ discharge information needs after
total hip and knee arthroplasty: A quasi-qualitative pilot study. Rehabilitation Nursing 2013,
38(2), 264-271. doi: 10.1002/mj.103