Musculo 2 Complete 2007

PERCEPTION & COORDINATION Musculoskelet al Disorders

FUNCTIONS S upport P rotection M ovement S torage of Minerals H ematopoiesis

See what happens when YOU have NO MUSCLES…….

Muscle Tissue • A specialized tissue that has the ability to shorten or “contract”.

Properties 1.Contractility 2.Excitability/Irritability 3.Elasticity 4.Extensibility

Functions • Movement • Posture • Joint Stability • Heat Production

• Strong , fibrous connective tissues that bind bones • Provide joint stability and allow restricted joint movement

• Strong, fibrous, non-elastic connective tissue extending from muscle sheath • Bind muscles to bones

• Nonvascular, supporting connective tissue composed of various cells and fibers. • Absorption of weight, shock, stress and strain • Protection of bones, joint, and joint tissue

• Elicit a description of the present illness and chief complaint

Cardinal Signs and Symptoms • • • •

Moderate to severe pain Inability to move body parts Localized edema Altered sensation to affected area • Contour deformity and asymmetry • Contusions

1. 2. 3. 4. 5.

Medical conditions / Medications Unsafe Environment Decreased Dietary intake Infrequent Exercise/Sedentary lifestyle Family history

Inspection • • • • • •

Body alignment Bone discrepancies Mobility Gait Joint alignment Muscle discrepancies

Palpation • Muscle mass • Muscle strength

•X-ray – detect structure, texture and density problem – evaluate the disease progression and treatment efficacy

•Bone Scan – detect skeletal trauma and disease – Pt. must void immediately before procedure

•Arthrography – identify acute or chronic tears of the joint capsule ( injection of radiopaque)

•Arthrocentesis – allows analysis of synovial fluid, blood or pus aspirated from

(+) RA if….. …….Synovial fluid is cloudy, milky, dark yellow and contains numerous inflammatory cells ……. Increased ESR (N: less than 15 mm/hr) ……. Decreased RBC ……..Decreased C4 Complement (N: 140-510 mg/L) …… (+) C-reactive protein (CRP) & Antinuclear antibody (ANA) …… X-ray: (+) bony erosion and narrowed joint spaces

• Myelography – detect herniation, tumor congenital/ degenerative condition – Keep pt. flat on bed @ least 12hrs post test

• Electromyography (EMG) – measures muscle electrical impulses

•Biopsy – studies bone, synovium, muscle tissue

•CT Scan – show soft tissue, bone and the spinal cord in threedimensional,

•MRI – allows study of soft tissue in multiple planes of the body

•CBC Analysis – identifies anemias,

• Alkaline phosphatase – identify increases in osteoblastic activity of the inflammatory condition.

• CPK-MB – elevation may identify skeletal muscle necrosis, atrophy or trauma.

• LDH – identify skeletal muscle damage.

• Serum Calcium – bone loss density

• C-reactive protein test – severity and course of inflammatory process

• Rheumatoid factor – measure the presence of

• Relief of pain • Maintenance of adequate tissue perfusion • Improved physical mobility

Neurovascular Assessment (6 P’s) ain ulses allor aresthesia aralysis olar

Pain – signals the beginning of muscle ischemia Pulses – pulselessness indicates disruption of arterial blood flow. Pallor – indicates disruption of arterial blood flow. Paresthesia – nerve function may be disrupted by nerve compression. Paralysis – increasing edema causes nerve compression Polar – indicates disrupted arterial blood flow

• Sprain – complete or incomplete tear in the supporting ligaments surrounding joints. • Strain – overstretching injury to a muscle or tendon.

• Sprain – commonly result from wrenching or twisting motion • Strain – typically result from excessively vigorous movement in understretched and overstretched muscles and tendons

• Sprain • Pain and discomfort • Edema • Decreased joint motion and function • Feeling of joint looseness

• Strain • Pain • Edema • Ecchymoses

1. Administer prescribed medication 2. Provide nursing care for the client who sustain sprain. 3. Provide nursing care for a client who suffer muscle or tendon strain. 4. Provide additional teaching

Displacement of a bone from its normal articulation with a joint

• May be congenital • May result from trauma or disease of surrounding joint tissue

• • • • • •

Pain Visible disruption of joint contour Edema Ecchymoses Impaired joint mobility Change in extremity length and in axis of dislocated bones

1. Administer prescribed medication 2. Prevent from further injury 3. Assist physician in reducing displaced parts as necessary 4. Provide teaching

Remember

• Rest • Ice • Compress • Elevate

• Disruption in the continuity of bone as a result of trauma or various disease process • Highest incidence in males 15-24 years and in elderly persons, women aged 65 years and older

• Direct blow • Crushing force • Sudden twisting motion • Extreme muscle contraction

Fractures • Complete fractureinvolves a break across the entire cross section of the bone and is frequently displaced from normal position • Incomplete fracture – break occurs through the only part of the cross section of the bone.

• Closed fracture – does not produce a break in the skin. • Open fracture – presence of break in the skin. • Greenstick – bone bends w/out fracturing across completely, cortex on the covade side remain intact

Other fractures • Transverse – fracture that is straight across the bone, caused by a force applied to the site. • Spiral/ oblique – fracture twisting around the shaft of the bone, caused by violence forced through the limb. • Impacted- fracture where the fragment are

• Crush – occurs in cancellous bone as result of a compression force. • Burst – occurs in a short bone resulting from strong direct pressure. • Compression – fracture which the bone has been compressed • Pathologic – fracture through an area of diseased bone.

Other fractures • Avulsion – pulling away of a fragmet of bone by a ligament or tendon & its attachment. • Epiphyseal – fracture through the epiphysis

• Compound – fracture with a surface or open wound. Include more than one break in the bone. • Comminuted – fracture with more than one fragments

• Pain • Loss of function/sensation • Deformity • Shortening/lenghtening • Crepitus (grating sensation) • Swelling • Discoloration

• • • •

Excessive motion on site Soft tissue edema Warmth over injured area Paralysis distal to injury resulting from nerve entrapment • Signs of shock related to severe tissue injury

Fracture care • • • • • •

splinting of fracture preservation of body alignment elevation of body part to limit edema application of cold packs observe for changes in color, sensation, or temperature of injured part observe for signs of shock

• • • • • •

Fat embolism Compartment syndrome Nonunion Arterial damage Infection Hemorrhage/ Shock

Fat emboli - serious, potentially life-threatening complication S/Sx: Restlessness mental status changes tachycardia tachypnea hypotension Dyspnea Petechial rash over the upper chest and neck.

Compartment syndrome - increased pressure within a limited anatomic space compromising circulation, viability, and function of tissues within that space. • • • • • •

S/Sx: increased pain and swelling pain with passive motion inability to move joints loss of sensation pulselessness

Infection and osteomyelitis - caused by the interruption of the integrity of the skin; the infection invades bone tissue. • S/Sx: – – – – –

fever pain erythema in the affected area tachycardia elevated WBC count

Avascular necrosis- interruption in the blood supply to the bony tissue, which results in the death of the bone. • S/Sx: • pain • decreased sensation

Pulmonary Emboli- caused by immobility precipitated by a fracture • S/Sx: restlessness and apprehension • Dyspnea • Diaphoresis •

• ABG changes

Treatment •

Splinting- immobilization of the affected part to prevent soft tissue from being damaged by bony parts

•

Casting- provides rigid immobilization of affected body part for support and stability

Treatment •

• •

Internal fixation- use of metal screws, plates, nails and pins to stabilize reduced fractures Traction Reduction- restoration of the fracture fragments into anatomic alignment and rotation.

Nursing care plan/implementation for clients with Fracture Promote healing and prevent complications • diet: high protein, iron, vitamins (tissue repair), moderate carbohydrates (prevent weight gain) • increase fluid intake

Nursing care plan/implementation for clients with Fracture •

•

assess for complications of immobility (pneumonia, constipation, decubitus ulcers, osteoporosis) assess casted extremity for presence of foul odor, drainage, paleness or blueness, change in temperature, pulselessness, tingling, numbness

Nursing care plan/implementation for clients with Fracture Prevent injury or trauma • avoidance of high-risk activities (sky diving, high impact sports, rollerblading) • avoidance of safety hazards (throw rugs, untreated vision problems) • regular exercise

Nursing care plan/implementation for clients with Fracture • Provide care related to ambulation with crutches • Provide safety measures related to possible complications following fracture

Nursing Management • Administer prescribed medication • Provide care during transfer of the patient - immobilized the fractured extremity - support the affected side.

• Provide client and family teaching - explain prescribed activity restriction - Teach the proper use of assistive devices. - Provide additional teaching

Stages of Bone Healing • HEMATOMA AND INFLAMMATION • ANGIOGENESIS AND CARTILAGE FORMATION • CARTILAGE CALCIFICATION • CARTILAGE REMOVAL • BONE FORMATION • REMODELING

• Callus formation: 3 to 4 weeks • Ossification begins within 2 to 3 week up to 3 to 4 months • Progress should be monitored by serial x-rays – reveals complete bone union

Types of CASTS • Plaster Casts ( POP) – mold very smoothly to the body contour. • Non Plaster/ Synthetic Casts– fiberglass casts that are commonly used today

CASTS & MOLDS Short arm circular cast – wrist and finger Short arm posterior moldwrist and finger with compound affection Long arm circular castradius/ ulna Fuenster’s or munster’s cast- radius/ ulna with callus formation. Long arm posterior moldfx of radius & ulna w/ compound affection

CASTS & MOLDS Hanging cast shaft of humerus Functional arm cast – humerus (allows abduction & adduction) Shoulder spica – humerus and shoulder joint Airplane – humerus and shoulder compound affection

CASTS & MOLDS Rizzer’s jacket – scoliosis Minerva – upper dorsal cervical spine 1 & ½ hip spica – hip & femur Body cast – lower dorsolumbar spine Double hip spica – hip & femur Long leg cast- tibia, fibula Long leg posterior mold- fx of the tibia & fibula w/ compound affection Basket – severe leg trauma w/ open wound or inflammation

CASTS & MOLDS • Cylindrical leg cast- patella • Quadrilateral/ ischial weight bearing cast – shaft of femur w/ CF • Cast brace – fx of the femur distal 3rd • Short leg circular cast – ankle & foot • PTB- tibia/ fibula w/ CF • Delbit cast- Tibia & fibula • Short leg posterior mold – ankle & foot w/ compound affection • Boot leg cast for traction – hip & femoral fx • Internal rotator splint – post hip operation

CASTS & MOLDS Collar cast – cervical affection Pantalon cast – pelvic bone fracture Frog cast – congenital hip dislocation Single hip spica – hip & 1 femur 1 & ½ spica mold – hip & femur w/ compound affection Double hip spica- pelvic affection w/ CF +2 femur

CASTS & MOLDS

Single hip spica mold- pelvic bone fx w/ CF Night splint – post polio

• • • • •

immobilized a body part Exert uniform compression Provide for early mobilization Correct or prevent deformities Stabilize and support unstable joints

• • • • •

Prepare the client Assist during application of casts PRN After cast application, provide cast care Initiate pain relief measures as indicated Observe for signs of cast syndrome especially with client who are immobilized in large cast.

• • • • •

Provide nursing care for compartment syndrome, if indicated Notify the physician immediately if signs of other neurovascular complications occur Notify the physician if “hot-spots” occur Provide client teaching Ensure proper technique and procedure in cast removal.

• Support fresh cast with the palm of the hand to prevent indentations from tips of the fingers • Expose the cast to warm, circulating, dry air. • Plaster cast - 5-15 minutes up to 48 hours • Synthetic cast – 30 minutes Dry cast : white, odorless, close to room temperature and resonant to percussion. Wet Cast: gray, cool, musty smelling and dull to percussion.

Potential Pressure Areas/ Points

• Check neurovascular status • Alternate ambulation with periods of elevation to the cast when seated • Perform active ROM hourly when awake by wiggling fingers/ toes. • AVOID getting plaster cast wet, especially the padding under the cast • DO NOT cover cast with plastic or rubber boots.

Cast Care • NO weight bearing exercises for 24 hours after cast application • Clean plaster cast using slightly damp cloth, by rubbing soiled areas with scouring powder and by wiping off residual moisture • AVOID walking on wet floors or sidewalks to prevent falls • DO NOT place objects under the cast to pressure and skin injury.

• Neurovascular problems (Compartment Syndrome) – Pressure Ulcers/ Sores – severe initial pain over bony prominences, foul odor, purulent drainage & presence of “hot spots” • Immobility/ Disuse Syndrome – results to multi-system problems

Signs & Symptoms of COMPARTMENT SYNDROME 6 P’s • • • • • •

Pain – aggravated by moving or elevating affected extremity; usually not relieved by analgesics Pallor Pulselessness Paresthesia – occur early in the syndrome which progresses to…. Paralysis – late sign Puffiness – late sign

• An orthopedic treatment that involves placing tension on a limb, bone or muscle group using variety of weight and pulley systems

1. Decreased muscle spasm 2. Reduce, align, and immobilize fractures 3. Correct or prevent deformity 4. Increase space between joint surfaces.

• Straight or Running traction – involve straight pulling force in one plane. • Balanced suspension traction – involves exertion of a pull while the limb is supported by hammock or splint

• Skin traction – involves weight applied and held to the skin with a Velcro splint. • Skeletal traction – involves weight applied and attached to metal/pin inserted into bone

• Buck’s Extension Traction – femur & hip fracture • Overhead – fracture of humerus • Head halter – cervical spine affection • Pelvic girdle – lumbosacral affection, herniated nucleus pulposus

• Dunlop’s Traction – fractured elbow and humerus

• Halo pelvic – scoliosis • Halo femoral – severe scoliosis

Bryant’s traction – femoral fracture, Hip injuries among kids below 3 years old • Buttocks are slightly elevated and clear off the bed.

• Boot leg – hip and femoral affection

• Ninety degrees – fracture of the femur • Stove- in –chest – severe chest injury with multiple rib fracture

Hammock suspension – pelvic affection

Skin Traction • To control muscle spasm • To immobilize an area before surgery

Skeletal Traction • Uses wires, pins, or tongs placed through the bones • MOST frequently used in treating fractures of femur, humerus, tibia & cervical spine.

Principles of Effective Traction • • • • • •

Countertraction must be maintained for effective traction Patient is on firm mattress and in good body alignment in the center of the bed. Line of pull must be continuous; never interrupted and in line with the long axis of the bone Weights must hang freely; should NOT be removed when repositioning unless prescribed intermittently Ropes must be unobstructed and aligned with pulleys Knots must not touch the pulley or foot of the bed and secured tightly

NURSING FOCUS • Weights must hang freely. • Line of pull is from the first pulley back to the point on the extremity. • Tie all knots securely. • Skin traction is usually intermittent and skeletal traction is usually continuous.]

1. Prevent complications of immobility 2. Promote skin integrity 3. Inspect for signs of skin breakdown, irritation or infection 4. Provide client teaching 5. Promote self-care within traction limitation

Care of Client with Skeletal Traction Maintain principles of effective traction

Watch for signs of infection especially around the pin site Check neurovascular status regularly especially immediately after application of traction. Assess sensorimotor function. Observe for pressure at traction

Avoiding infection at PIN SITE – The pin should be immobile in the bone and skin wound should be dry – Small amount of serous discharge oozing from pin site may occur – If infection is suspected, percuss gently over the tibia – (+) pain if infection is developing – Assess for other signs of infection: heat, redness, fever. – Clean pin tract with sterile applicators and prescribed solutions to prevent plugging at the pin site.

Buck’s extension • simplest form and provides for straight pull on the affected extremity • relieve muscle spasm • immobilize a limb temporarily • Heel is supported off bed to prevent pressure on heel, weight hangs free of the bed, and foot is well away from footboard of bed, and parallel to the bed.

Russel traction - permits the patient to move freely in the bed - permits flexion of the knee joint. • used in the treatment of intertrochanteric fracture of the femur when surgery is contraindicated • Hip is slightly flexed. Pillows may be used under lower leg to provide support and keep the heel free of the bed.

Russell’s Traction

Nursing Intervention of Patient’s with Traction  Monitor color, motion, and sensation of the affected extremity • Monitor the insertion sites for redness, swelling, or drainage • Patient education • Maintaining the traction • Skin care • Assist in toileting

• A. Open reduction – involves reduction and alignment of fractures through surgical opening • B. Internal Fixation – involves stabilization of reduced fracture with screws, or pins

• C. Bone graft – involves placement of bone tissue for healing, stabilization, or replacement • D. Arthroplasty – involves joint repair through small arthroscope

• E. Arthrodesis – involves immobilization of joint through fusion. • F. Joint replacement – involve replacement of joint surface with metal or plastic materials

Types of Joint Replacement • 1. Total hip replacement – involves replacement of the ball and socket of a severely damaged hip joint • 2. Total knee replacement – involves replacement to tibial, femoral, and patellar joints.

• G. Tendon transfer – involves movement of tendon insertion • H. Tenotomy – involves cutting tendons • I. Fasciotomy – involves removal of muscle fascia, relieving constriction

• J. Osteotomy – involves alignment of bone by removal of a wedge • Purpose of Orthopedic Surgery: – Reconstruct diseased or injured musculoskeletal structure

ASSESSMENT • 1. Preoperative assessment – Elicit the client’s medical history – Identify current medication and condition – Assess nutritional and hydration status – Assess skin integrity

• 2. Postoperative Assessment • Assess the cardiovascular ,respiratory , fluid and electrolyte. Nutritional status • Assess neurovascular status • Assess for joint dislocation • Assess for infection • Assess for thromboembolism • Assess and maintain safety and effectiveness of orthopedic apparatus

Total Hip Replacement

• a plastic surgery that involves removal of the head of the femur followed by placement of a prosthetic implant

Signs and symptoms necessitating Surgery • • • • •

Severe chronic pain Loss of joint mobility Excessive joint destruction Infection in the joint Contractures

Nursing Management • Teach client how to use crutches • Teach client mechanics of transferring. • Discuss importance of turning and positioning post-op. • Place affected leg in an abducted position and straight alignment following surgery • Prevent hip flexion of more than 90 degrees.

Nursing Management • Apply support stockings • Advise client to avoid external/internal rotation of affected extremity for 6 months to 1 year after surgery • Instruct client to avoid excessive bending, heavy lifting, jogging, jumping • Encourage intake of foods rich in Vitamin C, protein, and iron. • Administer prescribed medications.

Complications • • • • • •

Infection Hemorrhage Thrombophlebitis Pulmonary embolism Prosthesis dislocation Prosthesis loosening

• An implant procedure in which tibial, femoral and patellar joint surfaces are replaced.

• Assess the neurovascular status of the leg • Immobilize knee in extension with a firm compression dressing and an adjustable splint or long leg cast • Elevate on pillows • Apply ice to control edema and bleeding • Encourage active flexion of the foot every hour when patient is awake • Drainage: 1st 8 hrs. = 200 ml • After 48 hrs = less than 25 ml

 

Types: •Below the knee (BKA)

Amputation of a Lower Extremity • surgical removal of a lower limb or part of the limb. - 10% of patients experience uncomfortable sensations- phantom limb pain. - Phantom limb pain described as a cramp or uncomfortable sensation - disappears with time - the pain is a real sensation and should not be dismissed as illusionary.

• Monitor for bleeding. • Elevate the foot of the bed if hemorrhage is suspected. • Apply pressure directly over the area of bleeding. • Notify surgeon ASAP. • Have clamps available at bedside.

Complications of Amputation –

Infection

–

Wound necrosis

–

Phantom limb pain

–

Contractures

–

Skin breakdown

• Monitor vital signs q 15 min until stable, then q 2 hours for 1st 24 hours, then q 4 hours. • Keep the stump elevated for 1st 24 hours to prevent edema • After 48 hours DO NOT elevate with pillows BUT rather elevate the foot of the bed.

To prevent contractures: • Place patient in a prone position for 15 minutes, four times per day. (especially AKA) after 24-48 hrs to stretch the muscles and prevent flexion contracture of hip • Have patient lie in a supine position with the knee in extension (especially BKA). • Encourage to do active ROM of extremity to strengthen muscles and inhibit contractures. • Maintain on low-Fowler’s or flat position after AKA

• In prone position, place a pillow under the abdomen and stump and keep the legs close together to prevent abduction • Support stump with pillow for first 24 hours; place rolled bath blanket along outer aspect to prevent outward rotation. • Encourage exercises to prevent thromboembolism • Encourage patient to ambulate using correct crutchwalking techniques

• Crutch • Cane • Walker

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Crutch Walking Crutches – artificial supports – assist patients – aid in walking Preparation: – strengthen muscles of the shoulder girdle and upper extremities

Measurement: – Lying down: from anterior fold of axilla to the sole of the foot, then add 2 inches OR subtract 16 inches from patient’s height – Standing: two-finger-width insertion between axillary fold and underarm piece grip with tip of the crutch placed 6 to 8 inches lateral to the floor.

Basic stance: TRIPOD POSITION • Crutches rest approx. 8 to 10 inches in front of and to the side of patient’s toes • TALLER = WIDER • NO Weight bearing on axilla; should be on HANDS

NURSING ALERT Three-point gait is used for non-weight bearing person with a fracture of the leg or hip.

NURSING ALERT Four-point gait is used for patients affected by polio and cerebral palsy.

NURSING ALERT Swing-through gait is used by the paraplegic with leg braces.

Stair Climbing Using Crutches

 

• Going up stairs: proceed with unaffected (good) leg first, then advance crutches and affected (bad) leg.  

• Going down stair: proceed with both crutches and affected (bad) leg first, then advance unaffected (good) leg.

NURSING ALERT Remember: the GOOD GO TO HEAVEN (move good leg first when going up); THE BAD GO TO HELL (move crutches and bad leg first when going down).

Using a Cane •

•

Hold the cane on unaffected (good) side. Move the cane and the affected (bad) leg at the same time first (simultaneously), then advance the good leg; or advance the cane first, then affected leg, then unaffected leg. The cane handle should be held, with the elbow flexed at 30 degrees, it should be at the level of the femur.

Using a Walker • The top of the walker should be at the same level as the cane (head at femur level) with elbow flexed at 30 degrees. • When using a walker, advance it 6 inches and then move into it.

Caring for Patient with

•A disease characterized by exaggerated loss of bone mass and changes in microarchitecture of the bone tissue that compromise bone quality. •Bones become fragile and prone to fracture.

Characteristics of Osteoporosis

“Silent": most patients are unaware of osteoporosis until the first bone fracture occurs.

It is more common in females than males: in women, hormone secretion drops drastically during menopause and this accelerates bone loss.

These factors increase your risk of developing osteoporosis: 1. 2. 3. 4. 5. 6. 7.

Heredity factors Early menopause in women Drinking too much coffee and strong tea Cigarette smoking and alcoholism Low calcium intake Lack of exercise Some diseases, such as rheumatoid arthritis, hyperthyroidism or some reproductive disorders. 8. Prolonged use of certain medications, such as steroids and thyroid hormone

Aging

CALCITONIN

ESTROGEN

BONE RESORPTION

BONE FORMATION

Loss of BONE MASS

PTH

Health history includes questions concerning: • • • • • • • •

Occurrence of osteoporosis Family history Previous Fractures Dietary consumption of calcium Exercise patterns Onset of menopause Use of corticosteroids Alcohol, smoking & caffeine intake

BACK PAIN CONSTIPATION

FRACTURE

IMPAIRED MOBILITY

SHORTENED STATURE & SPINAL DEFORMITY

BREATHING PROBLEMS

1. Reviewing and evaluating a patient's: •

physical condition,

•

lifestyle &

•

daily living habits

2. Measuring Bone Density

• • • •

Balance diet rich in CALCIUM & VITAMIN D Regular weight-bearing EXERCISES Hormone replacement therapy (HRT) with ESTROGEN & PROGESTERONE Other medications: • Alendronate • Calcitonin

Prevention of osteoporosis begins from childhood as it is important that you maximize your peak bone mass before the age of 35 years.

Sufficient intake of calcium

Adequate weight-bearing exercises.

Maintain a healthy lifestyle.

Home safety to prevent falls and fractures.

To maintain bone mass, postmenopausal women may need adequate hormone replacement therapy according to a doctor's advice.

ETIOLOGY • Result from trauma or secondary infection. • Blood-borne (hematogenic) osteomyelitis is common children • Chronic illness • Long term corticosteroid therapy

Clinical Manifestations • • • • • • •

Localized bone pain Tenderness, heat, and edema Guarding of the affected area Restricted movement Systemic symptom Purulent drainage malaise

Lab/ Dx Findings • WBC count reveals leukocytosis • ESR is elevated • Blood cultures identifies the causative agent (Staph. Aureus) • Radiograph and bone scan

Nursing Management 1. Administer prescribed medication 2. Protect the affected extremity from further injury and pain 3. Promote healing and tissue growth 4. Prepare client for surgical treatment 5. Provide additional teaching 6. May apply warm, wet soaks 20 min several times a day

-a slowly progressive, degenerative joint disease characterized by variable changes in weight-bearing joint. -Also known as Degenerative Joint Disease/ Hyperthropic Arthritis

• Associated with • Obesity • Aging (>50yr) • Trauma • Genetic predisposition • Congenital abnormalities

• Pain and muscle spasm, aggravated by use relieved by rest • Limited motion • Joint grating with movement • Flexion contractures • Joint tenderness • Presence of Heberden’s nodes or Bouchard’s nodes • Weight loss • Cold intolerance

• Radiographs may reveal a narrowing of joint space

1. Administer prescribed medication 2. Provide nonpharmacologic comfort measures 3. Position the client to prevent flexion deformity 4.Plan activities that promote optimal function and independence

5. Refer to physical and occupational therapy 6. Prepare the client fro surgical treatment as indicated 7. Provide referrals

Medication Aspirin • inhibits cyclooxygenase enzyme, it diminishes the formation of prostaglandins • anti-inflammatory, analgesic, antipyretic action • inhibit platelet aggregation in cardiac disorders

Adverse effects: • GI: Epigastric distress, nausea, and vomiting • Blood: inhibition of platelet aggregation and a prolonged bleeding time • Respiratory: In toxic doses, can cause respiratory depression

• Hypersensitivity • Reye’s syndrome: Acute encephalopathy following a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver

Toxicity: (mild or severe) • Mild salicylism: nausea, vomiting, marked hyperventilation, headache, mental confusion, dizziness, and tinnitus • Severe salicylism: restlessness, delirium, hallucinations, convulsions, coma, respiratory and metabolic acidosis and death from respiratory failure.

Ibuprofen • anti-inflammatory, analgesic,and antipyretic acitivity • use for chronic treatment of rheumatoid and osteoarthritis • less GI effects than aspirin • reversible inhibitors of the cyclooxygenases and inhibit the synthesis of prostaglandins

Adverse effects: • GI: dyspepsia to bleeding • CNS: headache, tinnitus and dizziness

Indomethacin • anti-inflammatory, analgesic and antipyretic acitivity • inhibits cyclooxygenase enzyme • more potent than aspirin as an antiinflammatory agent

Adverse effects: • *dose-related • GI: nausea, vomiting, anorexia, diarrhea and abdominal pain • CNS: frontal headache, dizziness, vertigo, light-headedness, and mental confusion • Hypersensitivity reaction

Nursing Management Promote comfort: reduce pain, spasms, inflammation, swelling • medications as prescribed. • Heat to reduce muscle spasm • Cold to reduce swelling and pain

•

Prevent contractures: exercise, bed rest on firm mattress, splints to maintain proper alignment

•

Position: elevate extremity to reduce swelling

•

Promote independence

 

    Pain       Joints         General

 Rheumatoid   Early morning stiffness which gets better as the day progresses. May be exacerbated by exercise.   Typical deformity is symmetrical (bilateral) with swelling.   Ulnar deviation  

Weight loss, fatigue, and fever.

Osteoart hritis    

Stiffness worsens during the day. Feels better after exercise.     May be localized to a single joint or more, may not be swollen, but may be painful. Finger joints may become affected.  

Rheumatoid arthritis • chronic systemic inflammatory disease • destruction of connective tissue and synovial membrane within the joints • weakens and leads to dislocation of the joint and permanent deformity

Risk Factors: • exposure to infectious agents • fatigue • stress

Diagnostic tests • Elevated ESR • Mild leukocytosis • Anemia • Positive RF

Signs and Symptoms • inflammation, tenderness, and stiffness of the joints • moderate to severe pain and morning stiffness lasting longer than 30 minutes • joint deformities, muscle atrophy, and decreased range of motion • spongy, soft feeling in the joints • low grade fever, fatigue and weakness

Signs and Symptoms • anorexia, weight loss, and anemia • elevated ESR, and positive RF – – –

•

Nonreactive: 0-39 IU/ml (CRP) Weakly reactive: 40-79 IU/ml (CRP) Reactive: greater than 80 IU/ml (CRP)

X-ray showing joint deterioration

Rheumatoid Arthritis

Rheumatoid Arthritis

Medication • Salicylates (acetylsalicylic acid ) • NSAIDs • Corticosteroids- anti-inflammatory • Gold salts

Gold salts •

slow-acting, anti-inflammatory agents

•

Gold sodium thiomalate, Aurothioglucose, Auranofin

•

- these drugs cannot repair existing damage, rather they can only prevent further injury

•

- use in the treatment of RA that does not respond to salicylates or other NSAID therapy

• Adverse effects: • dermatitis of the skin or of the mucous membranes • proteinuria and nephrosis

• Gold salts should be avoided in patients suffering from hepatic or renal disease, pregnancy. • Serious Toxicity: Dimercaprol

Treatment • Hot and Cold packs to affected joints • Surgical Procedures: synovectomy, arthrotomy, arthrodesis, arthroplasty

Nursing Management Prevent or correct deformities • • • •

bed rest daily ROM exercises heat and/or pain medication increase oral fluid intake at least 1500 mL to prevent renal calculi

A metabolic disease marked by urate crystal deposits in joints throughout the body.

- Linked to a genetic deficit in purine metabolism - Age (>50yr) - Higher incidence in men

Signs and Symptoms • • • • •

extreme pain swelling erythema of the involved joints fever tophi

• sudden attacks, usually at night • Pain, joint swelling and inflammation • Intolerance to the weight of bed linen over the affected joint • Pruritus or skin ulceration • Signs of renal involvement

• 1. Arthrocentesis reveals urate crystal in synovial fluid • 2. Serum uric acid level is increased • 3. Radiographs may show joint damage in advanced disease.

Treatment • Allopurinol - a purine analog - reduces the production of uric acid by competitively inhibiting uric acid biosynthesis which are catalyzed by xanthine oxidase.

Allopurinol - Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies). • Adverse effects: hypersensitivity reactions, nausea and diarrhea

Colchicine • Effective for acute attacks of gouty arthritis pain • Reduces inflammation in the joint. • Does not prevent the progression of gout but have a suppressive, prophylactic effect reducing the frequency of acute attacks and relieves pain. • Anti-inflammatory activity alleviating pain within 12 hours

Colchicine • Adverse effects: nausea, vomiting, abdominal pain, diarrhea, agranulocytosis, aplastic anemia, alopecia

1. Administer prescribed medication 2. Promote measures to prevent exacerbations. 3. Provide measures to promote comfort and reduce pain 4. Provide client teaching

Caring for Patient with

What is • Osteomalacia involves softening of the bones caused by a deficiency of vitamin D or problems with the metabolism of this vitamin.

?

• In children, the condition is called rickets and is usually caused by a deficiency of vitamin D .

•

In adult, the condition is usually caused by: 1. Inadequate dietary intake of vitamin D 2. Inadequate exposure to sunlight (ultraviolet radiation) 3. Malabsorption of vitamin D

• Other conditions: • Hereditary or acquired disorders of vitamin D metabolism • Kidney failure and acidosis , • PO4 depletion associated with low dietary intake or kidney disease • Side effects of medications used to treat seizures .

• Risk factors are related to the causes. – In the elderly, there is an increased risk for those who tend to remain indoors and who avoid milk because of

lactose intolerance • The incidence is 1 in 1000 people.

• diffuse bone pain , especially in the hips • muscle weakness • symptoms associated with low calcium – numbness around the mouth & of extremities – Carpopedal spasms – Bowing of legs – Waddling or limping GAIT – Decrease in height/ Spinal Deformities (i.e. KYPHOSIS)

• In children, symptoms of rickets include: – delayed sitting, crawling, and walking; pain when walking; and the development of bowlegs or knock-knees.

• • • • • •

Bone biopsy: (+) increase in osteoid Bone X-ray or CT scan of lumbosacral spine shows demineralization. Studies of the vertebrae: (+) compression fx Low serum vitamin D level Low serum calcium & phosphate levels Elevated ALP (Alkaline Phosphatase)

•

Adequate dietary intake of dairy products that are fortified with

vitamin D •

Adequate exposure of the body to

sunlight

• Oral supplements of vitamin D , calcium, and phosphorus

• Large doses of Vitamin D with exposure to sunlight may be indicated in people with intestinal malabsorption .

• Monitoring of blood levels of phosphorus and calcium may be indicated with some underlying conditions. • Braces or surgery to correct deformities

•

• •

Protrusion of the nucleus of the disk into the fibrous ring of the disk with subsequent nerve compression May occur in any portion of the vertebral column Signs & Symptoms 1. 2. 3. 4.

Pain Sensory changes Loss of reflex Muscle weakness

1. Cervical   

Pain/ Stiffness – head, neck & upper extremities Paresthesia, numbness Weakness

2. Lumbar     

Low back pain radiating to the buttocks and leg Postural deformity of the spine (+) Straight-Leg Raise test Weakness & Asymmetric reflexes Sensory loss

Nursing Alert: Perform repeated assessments of sensorimotor functions/ reflexes to determine progression of condition

Alleviating pain – Anti-inflammatory drugs, muscle relaxants, and narcotic analgesics – Use of bed boards under the mattress – Bed rest – supine or low fowler’s or side lying position with slight knee flexion and pillows between knees. – Moist heat application – Relaxation techniques

Signs & Symptoms: • • • •

Abnormal lateral deviation of spine Unleveled shoulder Asymmetric waistline Prominent scapula

Complications: • Related to respiratory problems due to decreased lung expansion as a result of severe curvature of the spine

Nursing Implementation 1. Monitor progression of the curvature 2. Prepare the child and parents for the use of a brace if prescribed – usually worn from 16 to 23 hours a day – inspect the skin for signs of redness or breakdown – keep the skin clean and dry, avoiding lotions and powders – advise the child to wear soft nonirritating clothing under the brace

Nursing Implementation Prepare the child and parents for surgery if prescribed. Postoperative: • maintain proper alignment; avoid twisting movements • logroll the child when turning, to maintain alignment • instruct in activity restrictions • instruct the child to roll from a side-lying position to a sitting position, and assist with ambulation

Paget's Disease of Bone • Localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones and vertebrae • Primary bone resorption followed by bone formation • Diseased bone is highly vascularized but structurally weak • More common in the adult (>50 y/o) • Male > female

Clinical Manifestations • • • • • •

bowing of femur and tibia enlargement of the skull cranial nerve compression respiration distress pain high cardiac output failure

Diagnostics • • • •

X-rays Serum alkaline phosphatase- elevated Serum calcium- elevated Bone scan

Nursing Management • Prevent pathological fractures • Control pain • Administer drugs as prescribed

Bone Tumors Osteosarcoma • Most common primary bone tumor • Occurs between 10-25 years of age, with Paget's disease and exposure to radiation • Exhibits a moth-eaten pattern of bone destruction. • Most common sites: metaphysis of long bones especially the distal femur, proximal tibia and proximal humerus

Osteosarcoma

Clinical Manifestations • local signs – pain ( dull, aching and intermittent in nature), swelling, limitation of motion • systemic symptoms: malaise, anorexia, and weight loss

Diagnostics • • • •

Biopsy- confirms the diagnosis X-ray MRI Bone Scan

Medical Management • Radiation • Chemotherapy • Surgical management – amputation – limb salvage procedures

Nursing Management • Promote understanding of the disease process and treatment regimen • Promote pain relief • Prevent pathologic fracture. • Promote coping skills and self esteem • Assess for potential complications (infection, complications of immobility).

Nursing Management • • • •

Provide care for client with amputation Observe for signs of bleeding Elevate stump on pillow for 24-40 hrs Turn patient to prone position for short time first post-op day then 2-3x daily

Nursing Management • Encourage exercise as soon as possible (1st or 2nd post-op day) • Dangle and transfer patient to wheelchair and back within 1st or 2nd day post-op; crutch walking started as soon as patient feels sufficiently strong • Apply lanolin to dry skin

Other Musculoskeletal Disorders Dysplasia of the Hip • condition in which the head of the femur is improperly seated in the acetabulum, or hip socket, of the pelvis. • Congenital or develop after birth

Assessment Neonates: laxity of the ligaments around the hip, which allows the femoral head to be displaced from the acetabulum upon manipulation. Implementation: • Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation (neonatal period)

Assessment Infants beyond the newborn period: a. Asymmetry of the gluteal and thigh skinfolds when the child is placed prone and the legs are extended against the examining table. b. Limited range of motion in the affected hip. c. Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed. d. apparent short femur on the affected side (Galleazzi sign, Allis sign)

Spica Cast

CARPAL TUNNEL SYNDROME: • It occurs when the median nerve at the wrist is compressed • ASSESSMENT: • Pain • Numbness • Paresthesia • Thumb, 1st & 2nd fingers affected=Tinel Sign( tingling sensation when inner wrist is percussed)

Management: • • • •

Wrist splinting Avoid repetitive wrist movement Carpal canal cortisone injection Surgical release of tendon sheat