Vincent B. Villaruz

MUSCULO-SKELETAL SYSTEM

By: Mr. Vincent B. Villaruz, RN

Review of Anatomy and Physiology  The

musculo-skeletal system consists of the muscles, tendons, bones and cartilage together with the joints  The primary function of which is to produce skeletal movements

Muscles Three types of muscles exist in the body  1. Skeletal Muscles muscle associated with bones  Voluntary

 2.

and striated

Cardiac muscles found only in the heart

 Involuntary

 3.

and striated

Smooth/Visceral muscles found in the walls of the viscera

3 types of muscles:  Non-striated

muscle  1. Smooth muscle - controlled by the autonomic nervous system; may either be generally inactive and then respond to neural stimulation or hormones or may be rhythmic.  Occurs in small groups or sheets of overlapping cells tightly bound together (ex. digestive tube, uterus, bladder, respiratory tract, vessels), can regenerate.

Striated muscle  2.

Cardiac muscle - found in the heart, acts like rhythmic smooth muscle, modulated by neural activity and hormones

 3.

Skeletal muscle - move us around and responsible for most of our behavior; most attached to bones at each end via tendons.

 Muscle

tissue composes 40-50% of total body weight.

Major functions of Muscles 

Movement - all 3 types of muscle

Maintain posture - skeletal muscle  Heat production - skeletal muscle 

Characteristics of muscle tissue  Excitability

- ability to respond to stimuli  Contractility - ability to shorten  Extensibility - ability to stretch  Elasticity - ability to return to original shape and length

TENDONS  Bands

of fibrous connective tissue that tie bones to muscles

LIGAMENTS  Strong,

dense and flexible bands of fibrous tissue connecting bones to another bone

BONES Variously classified according to shape, location and size  Functions 1. Locomotion 2. Protection 3. Support and lever 4. Blood production 5. Mineral deposition 

JOINTS  The

part of the Skeleton where two or more bones are connected

CARTILAGES A

dense connective tissue that consists of fibers embedded in a strong gel-like substance

BURSAE  Sac

containing fluid that are located around the joints to prevent friction

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM The

nurse usually evaluates this small part of the over-all assessment and concentrates on the patient’s posture, body symmetry, gait and muscle and joint function

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM  1.

HISTORY  2. Physical Examination  Perform

a head to toe assessment  Nurses need to inspect and palpate  The special procedure is the assessment of joint and muscle movement  Usually, a tape measure and a protractor are the only instruments

ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM  Gait  Posture  Muscular

palpation  Joint palpation  Range of motion  Muscle strength

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM LABORATORY PROCEDURES  1. BONE MARROW ASPIRATION 

   

Usually involves aspiration of the marrow to diagnose diseases like leukemia, aplastic anemia Usual site is the sternum and iliac crest Pre-test: Consent Intratest: Needle puncture may be painful Post-test: maintain pressure dressing and watch out for bleeding

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM LABORATORY PROCEDURES  2. Arthroscopy  A direct visualization of the joint cavity  Pre-test: consent, explanation of procedure, NPO  Intra-test: Sedative, Anesthesia, incision will be made  Post-test: maintain dressing, ambulation as soon as awake, mild soreness of joint for 2 days, joint rest for a few days, ice application to relieve discomfort

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM LABORATORY PROCEDURES 3. BONE SCAN  Imaging study with the use of a contrast radioactive material  Pre-test: Painless procedure, IV radioisotope is used, no special preparation, pregnancy is contraindicated  Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed, Supine position for scanning  Post-test: Increase fluid intake to flush out radioactive material

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM LABORATORY PROCEDURES 4. DXA- Dual-energy XRAY absorptiometry  Assesses bone density to diagnose osteoporosis  Uses LOW dose radiation to measure bone density  Painless procedure, non-invasive, no special preparation  Advise to remove jewelry

Common musculoskeletal problems The Nursing Management

Nursing Management of common musculoskeletal problems PAIN  These can be related to joint inflammation, traction, surgical intervention  1. Assess patient’s perception of pain  2. Instruct patient alternative pain management like meditation, heat and cold application, TENS and guided imagery

Nursing Management PAIN  3. Administer analgesics as prescribed  Usually

NSAIDS  Meperidine can be given for severe pain  4.

Assess the effectiveness of pain measures

Nursing Management IMPAIRED PHYSICAL MOBILITY  1. Instruct patient to perform range of motion exercises, either passive or active  2. Provide support in ambulation with assistive devices  3. Turn and change position every 2 hours  4. Encourage mobility for a short period and provide positive reinforcements for small accomplishments

Nursing Management SELF-CARE DEFICITS  1. Assess functional levels of the patient  2. Provide support for feeding problems  Place

patient in Fowler’s position  Provide assistive device and supervise mealtime  Offer finger foods that can be handled by patient  Keep suction equipment ready

Nursing Management SELF-CARE DEFICITS  3. Assist patient with difficulty bathing and hygiene  Assist

with bath only when patient has difficulty  Provide ample time for patient to finish activity

Musculoskeletal Modalities Traction Cast

Nursing Management Traction  A method of fracture immobilization by applying equipments to align bone fragments  Used for immobilization, bone alignment and relief of muscle spasm

Traction  Skin

traction

 Skeletal

traction

Traction  Pulling

force exerted on bones to reduce or immobilize fractures, reduce muscle spasm, correct or prevent deformities

Nursing Management Traction: General principles  1. ALWAYS ensure that the weights hang freely and do not touch the floor  2. NEVER remove the weights  3. Maintain proper body alignment  4. Ensure that the pulleys and ropes are properly functioning and fastened by tying square knot

Nursing Management Traction: General principles  5. Observe and prevent foot drop  Provide

 6.

foot plate

Observe for DVT, skin irritation and breakdown  7. Provide pin care for clients in skeletal traction- use of hydrogen peroxide

Nursing Management CAST  Immobilizing tool made of plaster of Paris or fiberglass  Provides immobilization of the fracture

Nursing Management CAST: types 2. Long arm 3. Short arm 4. Spica

TYPES OF CASTS SHORT-ARM CAST LONG-ARM CAST SHORT-LEG CAST LONG-LEG CAST WALKING CAST BODY CAST SHOULDER SPICA CAST HIP SPICA CAST DOUBLE HIP SPICA CAST

Casting Materials  Plaster

of Paris

 Drying

takes 1-3 days  If dry, it is SHINY, WHITE, hard and resistant  Fiberglass  Lightweight

and dries in 20-30 minutes  Water resistant

Nursing Management CAST: General Nursing Care  1. Allow the cast to dry (usually 24-72 hours)  2. Handle a wet cast with the PALMS not the fingertips  3. Keep the casted extremity ELEVATED using a pillow  4. Turn the extremity for equal drying. DO NOT USE DRYER for plaster cast

Nursing Management CAST: General Nursing Care 5. Petal the edges of the cast to prevent crumbling of the edges 6. Examine the skin for pressure areas and Regularly check the pulses and skin

Nursing Management CAST: General Nursing Care 7. Instruct the patient not to place sticks or small objects inside the cast 8. Monitor for the following: pain, swelling, discoloration, coolness, tingling or lack of sensation and diminished pulses

• IN SKELETAL TRACTION, NEVER REMOVE THE WEIGHTS. • MAY REQUIRE MORE FREQUENT ANALGESIC ADMINISTRATION.

FREQUENT SKIN ASSESSMENTS SHOULD INCLUDE PIN CARE PER POLIC REPORT SIGNS OF INFECTION AT THE PIN SITES.

SKIN TRACTION, FREQUENTLY ASSESS SKIN FOR EVIDENCE OF PRESSUR SHEARING OR PENDING SKIN BREAKDOWN.

Common Musculoskeletal conditions Nursing management

METABOLIC BONE DISORDERS Osteoporosis  A disease of the bone characterized by a decrease in the bone mass and density with a change in bone structure

METABOLIC BONE DISORDERS Osteoporosis: Pathophysiology  Normal homeostatic bone turnover is altered rate of bone RESORPTION is greater than bone FORMATION reduction in total bone mass reduction in bone mineral density prone to FRACTURE

METABOLIC BONE DISORDERS Osteoporosis: TYPES  1. Primary Osteoporosis- advanced ageThere is a greater likelihood of developing osteoporosis as one gets older. About 15% of women in their 50s will have osteoporosis compared to about 50% of women in their 80s. There is increased bone loss and reduced calcium absorption associated with aging. post-menopausal- Estrogen protects women against bone loss. Early menopause (before age 45) occurring naturally or by surgical removal of both ovaries, increase a woman’s risk of osteoporosis. Amenorrhea or the abnormal absence of menstruation in women of childbearing age, indicate low estrogen levels. Amenorrhea can result from anorexia nervosa or excessive exercise. In men, low testosterone levels contribute to bone loss. 

2. Secondary osteoporosis- Steroid overuse, Renal failure

METABOLIC BONE DISORDERS RISK factors for the development of Osteoporosis  1. Sedentary lifestyle  2. Age  3. Diet- caffeine, alcohol –(regular consumption of 2 to 3 ounces of alcohol everyday increases the risk of osteoporosis. Alcohol interferes with the absorption and use of calcium and vitamin D), low Ca and Vit D –(Calcium is required throughout life to build and maintain strong and healthy bones. Chronic low calcium intake increases the risk of osteoporosis. Inadequate Vitamin D intake reduces calcium absorption thereby increasing the risk of osteoporosis)

 4.

Post-menopausal  5. Genetics- caucasian and asiaCaucasians are more likely to develop osteoporosis more than those with African ancestry. This is attributed to the fact that Africans have 10-15% more bone mass than Asian and Caucasians. Hispanics are more at risk than Africans but considerably less than Asians and Caucasians.

 6.

Immobility -People with sedentary lifestyle, are bedridden or otherwise immobilized for a long period, are at high risk of developing osteoporosis.

METABOLIC BONE DISORDER ASSESSMENT FINDINGS  1. Low stature  2. Fracture  Femur

 3.

Bone pain

METABOLIC BONE DISORDER LABORATORY FINDINGS  1. DEXA-scan 

Provides information about bone mineral density





How does the procedure work? The DXA machine sends a thin, invisible beam of low-dose x-rays with two distinct energy peaks through the bones being examined. One peak is absorbed mainly by soft tissue and the other by bone. The soft tissue amount can be subtracted from the total and what remains is a patient's bone mineral density. DXA machines feature special software that compute and display the bone density measurements on a computer monitor.



T-score is at least 2.5 SD below the young adult mean value

    

 2.

X-ray studies

METABOLIC BONE DISORDER Medical management of Osteoporosis  1. Diet therapy with calcium(Good food sources of calcium include: dairy products such as milk, cheese yogurt and ice cream, canned sardines and salmon, tofu, brocolli, soybeans as well as calcium fortified foods. High-calcium milk and juices are also recommended)and Vitamin D(Vitamin D comes from the diet and the skin. Vitamin D production by the skin is dependent on exposure to sunlight.

2. Hormone replacement therapy  3. Biphosphonates- Alendronate, risedronate produce increased bone mass by inhibiting the OSTEOCLAST 



Medications that stop bone loss and increase bone strength, such as - Alendronate (Fosamax), - Risedronate (Actonel), - Raloxifen (Evista), - Ibandronate (Boniva), - Calcitonin (Calcimar), and - zoledronate (Reclast);

bisphosphonates are the most effective category or prescription medications for treating postmenopausal osteoporosis  4.

Moderate weight bearing exercises  5. Management of fractures

METABOLIC DISORDER Osteoporosis Nursing Interventions 1. Promote understanding of osteoporosis and the treatment regimen  Provide adequate dietary supplement of calcium and vitamin D  Instruct to employ a regular program of moderate exercises and physical activity  Manage the constipating side-effect of calcium supplements

METABOLIC DISORDER Osteoporosis Nursing Interventions  Take calcium supplements with meals  Take alendronate with an EMPTY stomach with water  Instruct on intake of Hormonal replacement

METABOLIC DISORDER Osteoporosis Nursing Interventions 2. Relieve the pain  Instruct the patient to rest on a firm mattress  Suggest that knee flexion will cause relaxation of back muscles  Heat application may provide comfort  Encourage good posture and body mechanics  Instruct to avoid twisting and heavy lifting

METABOLIC DISORDER Osteoporosis Nursing Interventions  3. Improve bowel elimination  Constipation is a problem of calcium supplements and immobility  Advise intake of HIGH fiber diet and increased fluids

METABOLIC DISORDER Osteoporosis Nursing Interventions  4. Prevent injury  Instruct to use isometric exercise to strengthen the trunk muscles  AVOID sudden jarring, bending and strenuous lifting  Provide a safe environment

Juvenile rheumatoid Arthritis  Definition:  AUTO-IMMUNE

inflammatory joint disorder of UNKNOWN cause  SYSTEMIC chronic disorder of connective tissue  Diagnosed

BEFORE age 16 years old

 We

all know that arthritis, inflammation of bone joints, is normally associated with an illness affecting people over the age of 50. Therefore it will come as a massive surprise to parents when their children are diagnosed with it. Even more surprising is the fact that approximately 300,000 children in the United States alone have some form of arthritis, and that we the public are totally unaware of this fact.

Juvenile rheumatoid arthritis is the most common type of arthritis affecting around 60,000 children. Unfortunately, doctors are not yet certain as to what causes juvenile rheumatoid arthritis, however, there are indications that it is associated with the autoimmune system, where white blood cells are unable to differentiate between normal and foreign cells.

Juvenile rheumatoid Arthritis  PATHOPHYSIOLOGY  Affected

: unknown

by stress, climate and genetics

 Common

in girls 2-5 and 9-12 y.o.



The Familiar Symptoms It is quite normal for kids to complain off and on about having sore joints and it is usually put down to growing pains. However, it may actually be more. If your child develops a limp and continually complains of sore joints associated with rashes and spikes in temperature, like fits of fever, this may indicate that juvenile rheumatoid arthritis is present. Under these conditions it is important to get him/her into the doctors surgery ASAP. The quicker a diagnosis is made the less damage will occur to cartilage and the joints affected by juvenile rheumatoid arthritis.

JRA  Symptoms

may decrease as child enters adulthood  With periods of remissions and exacerbations



Luckily, juvenile rheumatoid arthritis is easily diagnosed, there are a wide array of tests, available some of the more regular Diagnostic tools including blood tests, X-rays, and complete physical examinations are necessary. Other tests for other diseases known to be linked to juvenile rheumatoid arthritis may be performed, it is also likely that a referral to an orthopedic surgeon will be made to take samples of joint fluid for testing and further analysis. A diagnosis usually takes a number of days, upon receipt of the results of these tests, the pediatrician or doctor will work together with the orthopedic surgeon and any other medical professionals to develop a strategy to cure the child of juvenile rheumatoid arthritis.

JRA Medical Management  ASPIRIN and NSAIDs- mainstay treatment  Slow-acting anti-rheumatic drugs  Corticosteroids

JRA Nursing Management 2. Encourage normal performance of daily activities 3. Assist child in ROM exercises 4. Administer medications 5. Encourage social and emotional development

 Regular

exercise is vitally important to ensure that the child is protected against further arthritis by protecting bones and joints.

JRA Nursing Management During acute attack:  SPLINT the joints  NEUTRAL positioning  Warm or cold packs

 Treatment

actually serves two

purposes: 1. to protect and repair the joints from damage , and 2. reducing or eliminating the inflammation and pain.

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS  The most common form of degenerative joint disorder

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS  Chronic, NON-systemic disorder of joints

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Pathophysiology  Injury, genetic, Previous joint damage, Obesity, Advanced age  Stimulate the chondrocytes to release chemicals chemicals will cause cartilage degeneration, reactive inflammation of the synovial lining and bone stiffening

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Risk factors  1. Increased ageAging. As people age, cartilage normally is less able to repair itself. 

2. Obesity Obesity. Generally, the more weight a person carries, the greater the pressure on weight-bearing joints of the body



3. Repetitive use of joints with previous joint damageThere is an increased risk of developing OA in a joint that is not properly aligned or one that has been injured.

 4.

Anatomical deformity  5. genetic susceptibility- Other diseases and hereditary conditions that affect bones and connective tissues. Among the conditions are Ehlers-Danlos Syndrome, bone dysplasias, and Charcot joints.

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Assessment findings  1. Joint pain  2. Joint stiffness  3. Functional joint impairment limitation  The joint involvement is ASYMMETRICAL  This is not systemic, there is no FEVER, no severe swelling  Atrophy of unused muscles  Usual joint are the WEIGHT bearing joints

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Assessment findings 1. Joint pain  Caused by  Inflamed

synovium  Stretching of the joint capsule  Irritation of nerve endings

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Assessment findings 2. Stiffness  commonly occurs in the morning after awakening  Lasts only for less than 30 minutes  DECREASES with movement  Crepitation may be elicited

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Diagnostic findings 1. X-ray  Narrowing of joint space  Loss of cartilage  Osteophytes- a bony projection associated with the degenerationof cartilage @ joints 2. Blood tests will show no evidence of systemic inflammation and are not useful

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Medical management  1. Weight reduction  2. Use of splinting devices to support joints  3. Occupational and physical therapy  4. Pharmacologic management  Use of PARACETAMOL, NSAIDS  Use of Glucosamine and chondroitin  Topical analgesics  Intra-articular steroids to decrease inflam

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Nursing Interventions  1. Provide relief of PAIN  Administer

prescribed analgesics  Application of heat modalities. ICE PACKS may be used in the early acute stage!!!  Plan daily activities when pain is less severe  Pain meds before exercising

DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Nursing Interventions  2. Advise patient to reduce weight  Aerobic

exercise

 Walking

 3.

Administer prescribed medications

 NSAIDS

Rheumatoid arthritis A

type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more women (ages 35-45) than men

 Rheumatoid

arthritis is an inflammatory form of arthritis that causes joint pain and damage. Rheumatoid arthritis attacks the lining of your joints (synovium) causing swelling that can result in aching and throbbing and eventually deformity. Sometimes  rheumatoid arthritis symptoms make even the simplest activities — such as opening a jar or taking a walk — difficult to manage.  Rheumatoid arthritis is two to three times more common in women than in men and generally occurs between the ages of 40 and 60. But rheumatoid arthritis can also affect young children and older adults.

 There's

no cure for rheumatoid arthritis. With proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with rheumatoid arthritis.

Rheumatoid arthritis FACTORS: Genetic Auto-immune connective tissue disorders Fatigue, emotional stress, cold, infection

Rheumatoid arthritis Pathophysiology  Immune reaction in the synovium  attracts neutrophils  releases enzymes  breakdown of collagen  irritates the synovial liningcausing synovial inflammation edema and pannus formation and joint erosions and swelling

Rheumatoid arthritis ASSESSMENT FINDINGS  1. PAIN  2. Joint swelling and stiffnessSYMMETRICAL, Bilateral  3. Warmth, erythema and lack of function  4. Fever, weight loss, anemia, fatigue  5. Palpation of join reveals spongy tissue  6. Hesitancy in joint movement

Rheumatoid arthritis ASSESSMENT FINDINGS  Joint involvement is SYMMETRICAL and BILATERAL  Characteristically beginning in the hands, wrist and feet  Joint STIFFNESS occurs early morning, lasts MORE than 30 minutes, not relieved by movement, diminishes as the day progresses

Rheumatoid arthritis ASSESSMENT FINDINGS  Joints are swollen and warm  Painful when moved  Deformities are common in the hands and feet causing misalignment  Rheumatoid nodules may be found in the subcutaneous tissues

Rheumatoid arthritis Diagnostic test  1. X-ray 

Shows bony erosion



2. Blood studies reveal (+) rheumatoid factor, elevated ESR and CRP and ANTInuclear antibody



Elevated erythrocyte sedimentation rate (ESR, or sed rate), which indicates the presence of an inflammatory process in the body.

 3.

Arthrocentesis (draw fluid from your joint using a Needle) shows synovial fluid that is cloudy, milky or dark yellow containing numerous WBC and inflammatory proteins

Rheumatoid arthritis MEDICAL MANAGEMENT  1. Therapeutic dose of NSAIDS and Aspirin to reduce inflammation (Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). Stronger versions of these NSAIDs and others are available by prescription.

2. Chemotherapy with methotrexate, antimalarials, gold therapy and steroid. Corticosteroid medications, such as prednisone and methylprednisolone (Medrol).  3. For advanced cases- arthroplasty(Total joint replacement - During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a metal and plastic prosthesis) ,synovectomy(Removal of the joint lining). If the lining around your joint (synovium) is inflamed and causing pain, your surgeon may recommend removing the lining of the joint. 

 4.

Nutritional therapy

Eat a healthy diet. A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health. However, there's no special diet that can be used to treat rheumatoid arthritis. It hasn't been proved that eating any particular food will make your joint pain or inflammation better or worse.

Rheumatoid arthritis MEDICAL MANAGEMENT GOLD THERAPY:  IM or Oral preparation  Takes several months (3-6) before effects can be seen  Can damage the kidney and causes bone marrow depression

Rheumatoid arthritis Nursing MANAGEMENT 1. Relieve pain and discomfort  USE splints to immobilize the affected extremity during acute stage of the disease and inflammation to REDUCE DEFORMITY  Administer prescribed medications  Suggest application of COLD packs during the acute phase of pain, then HEAT application as the inflammation subsides

Rheumatoid arthritis Nursing MANAGEMENT 2. Decrease patient fatigue Schedule activity when pain is less severe Provide adequate periods of rests 3. Promote restorative sleep

Rheumatoid arthritis Nursing Management 4. Increase patient mobility  Advise proper posture and body mechanics  Support joint in functional position  Advise ACTIVE ROME

Rheumatoid arthritis Nursing Management 5. Provide Diet therapy  Patients experience anorexia, nausea and weight loss  Regular diet with caloric restrictions because steroids may increase appetite  Supplements of vitamins, iron and PROTEIN

Rheumatoid arthritis 6. Increase Mobility and prevent deformity:  Lie FLAT on a firm mattress  Lie PRONE several times to prevent HIP FLEXION contracture  Use one pillow under the head because of risk of dorsal kyphosis  NO Pillow under the joints because this promotes flexion contractures

Hot versus Cold HOT

Cold

Use to RELIEVE joint stiffness, pain and muscle spasm After acute attack

Use to control inflammation and pain ACUTE ATTACK

Gouty arthritis A

systemic disease caused by deposition of uric acid crystals in the joint and body tissues  CAUSES:  1. Primary gout- disorder of Purine metabolism  2. Secondary gout- excessive uric acid in the blood like leukemia

Gouty arthritis  ASSESSMENT

FINDINGS  1. Severe pain in the involved joints, initially the big toe  2. Swelling and inflammation of the joint  3. TOPHI(TOPHUS)- yellowishwhitish, irregular deposits in the skin that break open and reveal a gritty appearance  4. PODAGRA

Gouty arthritis ASSESSMENT FINDINGS  5. Fever, malaise  6. Body weakness and headache  7. Renal stones

Gouty arthritis DIAGNOSTIC TEST  Elevated levels of uric acid in the blood  Uric acid stones in the kidney

Gouty arthritis  Medical

management  1. Allupurinol- take it WITH FOOD 

 2.

Rash signifies allergic reaction

Colchicine 

For acute attack

Gouty arthritis Nursing Intervention 1. Provide a diet with LOW purine  Avoid Organ meats, aged and processed foods  STRICT dietary restriction is NOT necessary 2. Encourage an increased fluid intake (23L/day) to prevent stone formation 3. Instruct the patient to avoid alcohol 4. Provide alkaline ash diet to increase urinary pH 5. Provide bed rest during early attack of gout

Gouty arthritis Nursing Intervention 6. Position the affected extremity in mild flexion 7. Administer anti-gout medication and analgesics 

Anti-Gout Meds:     

Allopurinol Colchicine Indomethacin Probenecid Sulfinpyrazone

Fracture A

break in the continuity of the bone and is defined according to its type and extent

Fracture  Severe

mechanical Stress to bone  bone fracture  Direct Blows  Crushing forces  Sudden twisting motion  Extreme muscle contraction

Fracture TYPES OF FRACTURE  1. Complete fracture  Involves

a break across the entire cross-

section  2.

Incomplete fracture

 The

break occurs through only a part of the cross-section

Fracture TYPES OF FRACTURE  1. Closed or Simple fracture  The

fracture that does not cause a break in the skin

 2.

Open or Compound fracture

 The

skin

fracture that involves a break in the

Fracture TYPES OF FRACTURE  1. Comminuted fracture A

fracture that involves production of several bone fragments

 2.

Simple fracture

A

fracture that involves break of bone into two parts or one

Fracture ASSESSMENT FINDINGS  1. Pain or tenderness over the involved area  2. Loss of function  3. Deformity  4. Shortening  5. Crepitus  6. Swelling and discoloration

Fracture ASSESSMENT FINDINGS 1. Pain  Continuous and increases in severity  Muscles spasm accompanies the fracture is a reaction of the body to immobilize the fractured bone

Fracture ASSESSMENT FINDINGS 2. Loss of function  Abnormal movement and pain can result to this manifestation

Fracture ASSESSMENT FINDINGS 3. Deformity  Displacement, angulations or rotation of the fragments Causes deformity

Fracture ASSESSMENT FINDINGS 4. Crepitus  A grating sensation produced when the bone fragments rub each other

Fracture  DIAGNOSTIC  X-ray

TEST

Fracture EMERGENCY MANAGEMENT OF FRACTURE  1. Immobilize any suspected fracture  2. Support the extremity above and below when moving the affected part from a vehicle  3. Suggested temporary splints- hard board, stick, rolled sheets  4. Apply sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged to the chest

Fracture EMERGENCY MANAGEMENT OF FRACTURE  5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination  6. DO NOT attempt to reduce the facture

Fracture MEDICAL MANAGEMENT  1. Reduction of fracture either open or closed, Immobilization and Restoration of function  2. Antibiotics, Muscle relaxants and Pain medications

Fracture General Nursing MANAGEMENT  For CLOSED FRACTURE  1. Assist in reduction and immobilization  2. Administer pain medication and muscle relaxants  3. teach patient to care for the cast  4. Teach patient about potential complication of fracture and to report infection, poor alignment and continuous pain

Fracture General Nursing MANAGEMENT  For OPEN FRACTURE  1. Prevent wound and bone infection  Administer prescribed antibiotics  Administer tetanus prophylaxis  Assist in serial wound debridement  2. Elevate the extremity to prevent edema formation  3. Administer care of traction and cast

Fracture

 FRACTURE

COMPLICATIONS

 Early  1.

Shock  2. Fat embolism  3. Compartment syndrome  4. Infection  5. DVT

Fracture

 FRACTURE

COMPLICATIONS

 Late  1.

Delayed union  2. Avascular necrosis  3. Delayed reaction to fixation devices  4. Complex regional syndrome

Fracture

 FRACTURE

COMPLICATIONS: Fat

Embolism  Occurs usually in fractures of the long bones  Fat globules may move into the blood stream because the marrow pressure is greater than capillary pressure  Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs

Fracture

 FRACTURE

COMPLICATIONS: Fat

Embolism  Onset is rapid, within 24-72 hours  ASSESSMENT FINDINGS  1. Sudden dyspnea and respiratory distress  2. tachycardia  3. Chest pain  4. Crackles, wheezes and cough  5. Petechial rashes over the chest, axilla and hard palate

Fracture

 FRACTURE

COMPLICATIONS: Fat

Embolism  Nursing Management  1. Support the respiratory function  Respiratory failure is the most common cause of death  Administer O2 in high concentration  Prepare for possible intubation and ventilator support

Fracture

 FRACTURE

COMPLICATIONS: Fat

Embolism  Nursing Management  2. Administer drugs  Corticosteroids  Dopamine  Morphine

Fracture

FRACTURE COMPLICATIONS: Fat Embolism  Nursing Management  3. Institute preventive measures  Immediate immobilization of fracture  Minimal fracture manipulation  Adequate support for fractured bone during turning and positioning  Maintain adequate hydration and electrolyte balance 

Fracture  Early

complication: Compartment syndrome  A complication that develops when tissue perfusion in the muscles is less than required for tissue viability

Fracture  Early

complication: Compartment syndrome  ASSESSMENT FINDINGS  1. Pain- Deep, throbbing and UNRELIEVED pain by opiods  Pain is due to reduction in the size of the muscle compartment by tight cast  Pain is due to increased mass in the compartment by edema, swelling or hemorrhage

Fracture  Early

complication: Compartment syndrome  ASSESSMENT FINDINGS  2. Paresthesia- burning or tingling sensation  3. Numbness  4. Motor weakness  5. Pulselessness, impaired capillary refill time and cyanotic skin

Fracture  Early

complication: Compartment syndrome  Medical and Nursing management  1. Assess frequently the neurovascular status of the casted extremity  2. Elevate the extremity above the level of the heart  3. Assist in cast removal

Strains Excessive stretching of a muscle or tendon  Nursing management  1. Immobilize affected part  2. Apply cold packs initially, then heat packs  3. Limit joint activity  4. Administer NSAIDs and muscle relaxants 

Sprains Excessive stretching of the LIGAMENTS  Nursing management  1. Immobilize extremity and advise rest  2. Apply cold packs initially then heat packs  3. Compression bandage may be applied to relieve edema  4. Assist in cast application  5. Administer NSAIDS 