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Joyce Y. Visitacion NCM 104 BSN-4AJ SY 2008-2009 MUSCULOSKELETAL SYSTEM Review of Anatomy & Physiology The musculoskeletal system consists of the: Muscles Tendons Ligaments Bones Joints Cartilages Bursae Primary function: to produce skeletal movements Functions of the musculoskeletal system: 1. Provides protection for the vital organs including the brain, heart and lungs. 2. Provides a sturdy framework to support body structures. 3. Makes mobility possible. 4. Joints hold the bones together and allow the body to move. 5. Muscles attached to the skeleton contract, moving the bones and producing heat that helps maintain body temperature. 6. Serves as reservoir for immature blood cells and essential minerals, including: Calcium – 98% of total body Calcium is present in bone. Phosphorus Magnesium Fluoride Hematopoiesis 1
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Page 1: Musculoskeletal System

Joyce Y. Visitacion NCM 104BSN-4AJ SY 2008-2009

MUSCULOSKELETAL SYSTEM

Review of Anatomy & Physiology The musculoskeletal system consists of the:

MusclesTendonsLigamentsBonesJointsCartilagesBursae

Primary function: to produce skeletal movements

Functions of the musculoskeletal system: 1. Provides protection for the vital organs including the brain,

heart and lungs.2. Provides a sturdy framework to support body structures.3. Makes mobility possible.4. Joints hold the bones together and allow the body to move.5. Muscles attached to the skeleton contract, moving the

bones and producing heat that helps maintain body temperature.

6. Serves as reservoir for immature blood cells and essential minerals, including:

Calcium – 98% of total body Calcium is present in bone.PhosphorusMagnesiumFluoride

Hematopoiesis A process in which the red bone marrow located within bone

cavities produces red blood cells, white blood cells, and platelets. The formation of blood cellular components.

MUSCLES

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Characteristic of Muscles: Muscles are made up of bundles of muscle fibers.

Functions: Provide the force to move bones.Assist in maintaining posture.Assist with heat production.

Process of contraction and relaxation: Muscle contraction and relaxation require large amounts of Adenosine Triphosphate.Contraction also requires Calcium, which functions as a catalyst.Acetylcholine released by the motor end plate of the motor neuron initiates an action potential.Acetylcholine then is destroyed by acetylcholinesterase.Calcium is required to contract muscle fibers and acts as catalyst for the enzyme needed for the sliding together action of actin and myosin.Following contraction, Adenosine Triphosphate transports Calcium out to allow actin and myosin to separate and allow the muscle to relax.

Three types of muscles exist in the body:1. Skeletal Muscles – voluntary and striated2. Cardiac Muscles – involuntary and striated3. Smooth / Visceral Muscles – involuntary and non-striated

TENDONS Bands of fibrous connective tissue that lie bones to muscles

LIGAMENTS Strong, dense and flexible bands of fibrous tissue connecting

bones to another bone. Ligaments hold bone and joint in the correct position.

BONES Variously classified according to shape, location and size. Bones are constructed cancellous (trabecular) or cortical

(compact) bone tissue.

Characteristics of Bones: Bones support and protect the structures of the body.

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Bones provide attachment for muscles, tendons and ligaments.Bones contain tissue in the central cavities, which aids in the formation of blood cells.Bones assist in regulating Calcium and Phosphate concentrations.

Bone Growth: The length of bone growth results from the ossification of the epiphyseal cartilage at the ends of the bones.Bone growth stops between the ages of 18 and 25 year.The width of the bone growth results from the activity of the osteoblasts (bone forming cell) and occurs throughout life but slows down with aging.As aging occurs, osteoclasts (bone resorption) accelerates, decreasing bone mass and predisposing the client to injury.

Functions: LocomotionProtectionSupport and leverBlood productionMineral deposition / storage

Bone is composed of: CellsProtein matrixMineral deposits

Three basic types of bone cell: 1. Osteoblasts

Bone forming cell.Function in the bone formation by secreting bone matrix.

Matrix consists of: a. Collagen fibersb. Ground substances (glycoprotein &

proteoglycans)Minerals deposited in the matrix are Calcium and Phosphorus.

2. Osteocytes Mature bone cell.Involved in bone maintenance.

3. Osteoclasts

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Bone resorption cell.Involved in dissolving and resorbing bone.

Bone formation: Osteogenesis (bone formation) begins long before birth. Ossification is a process by which the bone matrix

(collagen fibers and ground substances) is formed and hard mineral crystals (Calcium and Phosphorus) are bound to the collagen fibers.

The Skeletal System The adult body has 206 bones.

Axial 1. Head - 22

Cranial bone – 8Facial bone - 14

2. Breastbone / sternum - 13. Ribs – 24

True ribs – 7 pairs (14); joined directly to the sternum.

False ribs – 3 pairs (9); joined to the sternum by cartilage.

Floating ribs – 2 pairs; not connected to the sternum at all, connected to the diaphragm.

4. Spine / Vertebrae - 33Cervical vertebrae – 7Thoracic vertebrae – 12Lumbar vertebrae – 5Sacrum – 5Coccyx – 4

Appendicular Upper extremities

1. Collar bone / clavicle – 22. Shoulder blade / scapula – 23. Humerus – 24. Radius, ulna / forearms – 45. Carpals (8): scaphoid, lunate, triquetrum, pisiform,

trapezium, trapezoid, capitate, hamate

Metacarpals (5)

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Phalanges (14) each handHands – 54

Lower extremities 1. Hip bone / Ilium – 22. Femur – 23. Kneecap / patella - 24. Tibia, fibula / legs – 45. Tarsals (7): calcaneus, talus, navicular bone, medial

cuneiform bone, intermediate cuneiform bone, lateral cuneiform bone, cuboidal bone

Metatarsals (5) Phalanges (14) each foot Feet - 52

Four categories of bones: 1. Long bones

Shaped like rods or shafts with rounded ends.Designed for weight bearing and movements.A typical long bone has a shaft (diaphysis) primarily cortical bone, proximal and distal diaphysis.Diaphysis is a hollow cylinder of compact bone that surrounds the medullary cavity.Epiphyses are the ends of long bones, are primarily cancellous bones.piphyseal plate separates the epiphyses from the diaphysis and is the center for longitudinal growth in children.Bone growth stops between the ages of 18 and 25 years.Articular cartilage covers the ends of long bones at the joints.

Humerus – “funny bone”; upper arm bone.Radius – outer and shorter bone of the forearm; aligned

to your thumb.Ulna – inner and longer bone of the forearm; aligned to

your pinky.Femur – “thigh bone”; strongest, largest and longest

bone in the body.Tibia – “shin bone”; inner and larger bone of the leg;

connects to the femur to form the knee joint and with the foot bone (talus) to allow the ankle to flex and extend.

Fibula – outer bone of the leg; serves as an area of muscle attachment.

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Metatarsals – bones of the feet.Metacarpals – bones of the palms or hands.Phalanges – finger and toes bones.

2. Short bones Consist of cancellous bone covered by a layer of compact bone.

Carpals – wrist bonesTarsals – ankle bones

3. Flat bones Are important sites of Hematopoiesis and frequently provide vital organ protection.Made of cancellous bone layered between compact bones.

Ribs – bones that form a protective cage around the organs of the upper body.

Sternum / Breastbone (manubrium, body, xiphoid process) – bones located in the middle of the chest.

Cranium (frontal, parietal, temporal, occipital, sphenoid, ethmoid) – bones protecting the brain.

Scapula – shoulder bladesPortions of the pelvic girdle / hip girdle

4. Irregular bones ave unique shapes related to their function.

Vertebrae of ear ossicles (hammer, anvil, stirrup)Facial bones (turbinate, lacrimal, mandible, maxilla,

nasal, palatine, vomer, zygomatic) Pelvis

JOINTS The part of the skeleton where 2 or more bones are connected.

Characteristics of the Joints: Joints allow the movement between bones.Joints are formed when 2 bones join.Joint surfaces are covered with cartilage.

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Joints are enclosed in a capsule.Joint contains a cavity filled with synovial fluid.Ligaments hold the bone and joint in the correct position.Articulation is the meeting point of 2 or more bones.

Synovial fluid Is found in the joint capsule.Formed by a synovial membrane which lines the joint capsule.Lubricates the cartilage.Provides a cushion against shocks.

Different types of joints: 1. Amphiarthrosis

Cartilaginous and slightly movable joints.Ex. symphysis pubis

2. Condyloid Freely movable joints.They allow frictionless, painless movements.Ex. wrists

3. Diarthrosis Synovial jointsBall and socket jointsEx. hips, elbows

4. Synarthrosis Fibrous or fixed joints.No movement associated with these joints.

CARTILAGES A dense connective tissue that consists of fibers embedded in a

strong gel-like substance.

BURSAE A sac connecting fluid that is located around the joints to prevent

friction.

ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM

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The nurse usually evaluates this small part of the over-all assessment and concentrates on the:

patient’s posturebody symmetrygaitmuscle and joint function

NURSING ASSESSMENT1. Health History

PainBone – dull, deep ache “boring in nature.Function – sharp and piercing, relieved by immobility.Muscle - soreness

ParesthesiaBurning, tingling sensation or numbness

DietHigh purine diet

Family HistoryAllergy

2. Physical Examination Posture

Kyphosis – outward curvature of the spine.Lordosis – inward curvature of the spine.Scoliosis – lateral curvature of the spine.

GaitSmoothness and rhythm

Shuffling gait - characterized by short steps, with feet barely leaving the ground, producing an audible shuffling noise.Ataxic gait – unsteady, uncoordinated walk with a wide base of support and the feet thrown outward.Festinating gait - walks on the toes as if being pushed. Steps start slowly and increase in speed. The upper part of the body advances ahead of the lower part.Antalgic gait – consists of a limp adopted so as to avoid pain on weight-bearing structures (as in hip, knee, or ankle injuries)

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Bone integrityDeformities and alignment

Joint functionRange of motionEffusion – excess fluid in joint.Crepitus – grating or crackling sound or sensation. May occur with movement of ends of a broken bone or irregular joint surface.

Muscle strengthNeurovascualr function

LABORATORY PROCEDURES1. Bone Marrow Aspiration

Usually involes aspiration of the bone marrow to diagnose diseases like leukemia, aplastic anemia.

Usual site is the sternum and iliac crest. Pre-test:

1. Consent2. Explanation of the procedure.

Intratest: Needle puncture may be painful. Post-test:

1. Maintain pressure dressing.2. Watch out for bleeding.

2. Arthroscopy A direct visualization of the joint cavity.

Pre-test: 1. Consent2. Explanation of the procedure.3. NPO 8-12 hours

Intratest: 1. Sedative2. Anesthesia3. Incision will be made.

Post-test: 1. Maintain dressing.2. Ambulation as soon as awake.3. Mild soreness of joint for 2 days.4. Joint rest for a few days.5. Ice application to relieve discomfort.6. Administer pain medication as prescribed.7. An elastic wrap should be worn for 2-4 days as

prescribed.

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8. Instruct patient that walking without weight-bearing usually is permitted after sensation returns but to limit activity for 1-4 days as prescribed.

9. Elevate the extremity as often as possible for 2 days and place ice on the site to minimize swelling.

10. Reinforce instructions regarding the use of crutches, which may be used for 5-7 days post procedure for walking.

11. Notify the doctor if fever or increased knee pain occurs or if edema continues for more than 3 days.

3. Bone Scan Imaging study with the use of a contrast radioactive material.

Pre-test: 1. Painless procedure.2. IV radioisotope is used.3. No special preparation.4. Pregnancy is contraindicated.

Intratest: 1. IV injection.2. Waiting period for 2 hours before x-ray.3. Fluids allowed.4. Supine position for scanning.

Post-test: 1. Increase fluid intake to flush out radioactive material.

4. Dual-energy X-ray Absorptiometry (DXA) Assesses bone density to diagnose osteoporosis.Uses low dose radiation to measure bone density.

Pre-test: 1. Painless procedure.2. Non-invasive.3. No special preparation.4. Advise to remove jewelry.

5. Radiograph 6. Arthrocentesis 7. Arthrogram 8. Bone or Muscle Biopsy 9. Electromyography 10. Myelogram

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RISKS ASSOCIATED WITH MUSCULOSKELETAL DISORDERS:Autoimmune disordersCalcium deficiencyDegenerative conditionsFallsHyperuricemia (excess of uric acid in the blood)InfectionMedications Metabolic disorders (Ex. diabetes, malnutrition, obesity)Neoplastic disorders (Ex. tumors)ObesityPost-menopausal statesTrauma and injury

Nursing Management of Common Musculoskeletal Problems

1. Pain These can be related to joint inflammation, traction, surgical intervention.

a. Assess patient’s perception of pain.b. Instruct patient alternative pain management like

mediation, heat and cold application. Transcutaneous Electrical Nerve Stimulation (TENS) and guided imagery.

TENS - a technique used to relieve pain in an injured or diseased part of the body in which electrodes applied to the skin deliver intermittent stimulation to surface nerves and block the transmission of pain signals.

c. Administer analgesics as prescribed.Usually NSAIDS.Meperidine can be given for severe pain.

d. Assess the effectiveness of pain measures.

2. Impaired Physical Mobility a. Instruct patient to perform ROM exercises, either passive

or active.b. Provide support in ambulation with assistive devices.c. Turn and change position every 2 hours.

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d. Encourage mobility for a short period and provide positive reinforcements for small accomplishments.

3. Self-Care Deficits a. Assess functional levels of the patient.b. Provide support for feeding problems.

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

c. Assist patient with difficulty bathing and hygiene.d. Assist with bath only when patient has difficulty.e. Provide ample time for patient to finish activity.

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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.

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

Types of Osteoporosis:1. Primary Osteoporosis – advanced age, post-menopausal2. Secondary Osteoporosis – steroid overuse, renal failure

Risk Factors for the Development of Osteoporosis:1. Sedentary lifestyle2. Age – 50 years old and above3. Diet – caffeine, alcohol, low Ca and Vit D4. Post-menopausal – estrogen deficiency5. Genetics – Caucasian and Asian6. Immobility7. Female – due to lower peak bone mass8. Tobacco use

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9. Low body weight – less than 70 kgs.10. Medications – especially glucocorticoids

Assessment Findings:1. Low stature – decreasing height (10-15 cm) due to

collapsing vertebrae. 2. Bone pain – back pain (T5-L5)3. Dowager’s hump – curved upper back4. Fracture – femur

Laboratory Findings:1. DXA

Most commonly used bone mineral density (BMD) screening.

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

2. X-ray studies

Management of Osteoporosis:1. Diet therapy with Calcium and Vitamin D.2. Food supplementation – Phytoestrogen

BeansCabbageRiceBerriesSesame seedsGrains

3. Hormone replacement therapy.

4. Biphosphonates Alendronate, Residronate – increased bone mass

by inhibiting the osteoclast. These medications are best taken with full glass

of H2O after rising in the morning. The client should remain upright for 30 minutes

after taking the medication to prevent GI side effects especially esophageal irritation.

The client should not drink anything for 30 minutes following administration of the medication to increase absorption of the drug.

5. Moderate weight-bearing exercises.At least 30 minutes, 5 days a week, then work up to 60 minutes.This increases bone mass and total body Calcium.

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6. Management of fractures.7. Avoid use of tobacco and alcohol.

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.Take Calcium supplements with meals.Take Alendronate with an EMPTY stomach with full glass of water.Instruct on intake of hormonal replacement.

2. Relieve the pain. Instruct the patient to rest on a firm mattress.

Suggest that knee flexion will cause relaxation of the back muscle.Heat application may provide comfort.Encourage good posture and body mechanics.Instruct to avoid lifting and heavy lifting.

3. Improve bowel elimination.Constipation is a problem of Calcium supplements and immobility.Advise intake of HIGH fiber diet and increased fluids.

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:

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AUTO-IMMUNE inflammatory joint disorder of UNKNOWN disorder

SYSTEMIC chronic disorder of connective tissue Diagnosed BEFORE age 16 years old

PATHOPHYSIOLOGY- UNKNOWN

Affected by stress climate and genetics Common in girls 2-5 and 0-12 years old

JUVENILE RHEUMATOID ARTHRITIS

SYSTEMIC JRA PAUCI-ARTICULAR POLYARTICULAR FEVER Salmon-pink

rash Five or more

joins Anorexia,

anemia, fatigue

MILD joint pain and swelling

IRIDOCYCLITIS Less than 4 joints Very good

prognosis

Morning joint stiffness and fever

Weight bearing joints

Five or more points

Poor prognosis

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

Medical Management:1. ASPIRIN and NSAIDs- mainstay treatment2. Slow ating anti-rheumatic drugs3. Corticosteroids

Nursing Management:1. Encourage normal performance of daily activities2. Assist child in ROM exercises3. Administer medications4. Encourage social and emotional development

Nursing Management during acute attack: SPLINT the joints NEUTRAL positioning Warm or cold packs

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DEGENERATIVE JOINT DISEASEOSTEOARTHRITIS

o The most common form of degenerative joint disordero Chronic, NON-systemic disorder of jointso “Wear and fear Arthritis”\

Pathophysiology:o Injury; genetic, Previous joint damage, obesity, Advanced

age Stimulate the chondrocytes (cells in the joints) to release chemicals chemicals will cause cartilage degeneration, reactive inflammation of the synovial lining and bone stiffening

Risk Factors:3. Increased age 4. Obesity5. Repetitive use of joints with previous damage6. Anatomical deformity7. Genetic susceptibility

Assessment Findings:

1. Joint pain Caused by

o Inflamed cartilage and synoviumo Stretching of the joint capsuleo Irritation of nerve findings

2. Joint stiffness Commonly occurs in the morning after

awakening Lasts only for less than 30 minutes DECREASES with movement but worsens after

increased weight bearing activity Crepitation may be elicited

Diagnostic Findings:

PRESENT IN ALL FORMS

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1. X-Ray Narrowing of joint space Loss of cartilage Osteophytes (degeneration of cartilage)

2. Blood tests will show no evidence of systemic inflammation and are not useful

3. Functional joint impairment limitation

Joint Involvement:The joint involvement is ASSYEMTRICALThis is not systemic, there is no FEVER, no severe swellingAtrophy of unused musclesUsual joint are the WEIGHT bearing joints

Medical Management:1. Weight reduction2. Use of splinting devices to support joints3. Pharmacologic management:

Use of PARACETAMOL (ARCETAMI), NSAIDS Use of Glucosamine and chondroitin (retard the

destruction of cartilage) Topical analgesics Intra-articular steroids to decrease inflammation

Nursing Interventions:1. Provide relief of PAIN

Administer prescribed analgesics Application of heat modalities. ICE PACKS may be used

in the early acute stage III Plan daily activities when pain is less severe Pain meds before exercising

2. Advise patient to reduce weight Aerobic exercise Walking

3. Administer prescribed medications NSAIDS

4. Position the client to prevent flexion deformity Use of foot board, splints, wedges and pillows

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RHEUMATOID ARTHRITIS

Definition: A type of chronic systemic inflammatory arthritis and

connective tissue disorder affecting more women (ages 35-45) than men

An inflammatory disease

Factors: Genetic → Auto-immune connective tissue

disorders: Fatigue, emotional stress, cold, infection

Cause: Unknown

Pathophysiology: Immune reaction in the synovium → attracts neutrophils →

releases enzymes → brea kdown of collagen → irritates the synovial lining → causing synovial inflammation edema and pannus → formation and joint erosions and swelling

Assessment Findings: PAIN Joint swelling and stiffness- SYMETRICAL, Bilateral Warmth, erythema and lack of function → due to

inflammation SYSTEMIC MANIFESTATION: Fever, weight loss, anemia,

fatigue Palpation of joint reveals spongy tissue Hesitancy in joint movement

Joint Involvement: Joint involvement is SYMMETRICAL AND BILATERAL

characteristically beginning in the hands, wrist and feet Joint STIFFNESS occurs early morning; lasts more than 30

minutes bit relieved by movement diminished as the day progresses.

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Joints are swollen and warm painful when moved Deformities are common in the hands and feet causing

misalignment Rheumatoid nodules may be found in subcutaneous tissues

Diagnostic Test:8. X-Ray

Shows bony erosion

9. Blood studies reveal (+) rheumatoid factor, elevated ESR and CRP and ANTI- nuclear anti body

10. Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing numerous WBC and inflammatory proteins

Medical Management:1. Therapeutic dose of NSAIDS and Aspirin to reduce

inflammation2. Chemotherapy with methotrexate (drug of choice

in rheumatoid arthritis) , antimalarials, gold therapy (aurothiglucose- given IM or oral) and steroid (suppress immune system)

3. For advanced cases arthropology, synovectomy (removal of synovial membrane)

4. Nutritional therapy

GOLD THERAPYo IM or Oral preparationo Takes several months (3-6) before effects can be

seeno Can damage the kidney and causes bone marrow

depression

Nursing Management:1. Relieve pain and discomfort

Use of splints to immobilize the affected extremity during acute stage of the disease and inflammation of REDUCE DEFORMITY

Administer prescribed medications Suggest application of COLD packs during the

acute phase of pain, then HEAT application as the inflammation subsides

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2. Decrease patient fatigue Schedule activity when pain is less severe Provide adequate periods of rests

3. Promote restorative sleep4. Increase patient mobility

Advise proper posture and body mechanics Support joint in functional position Advise ACTIVE ROME

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

6. Increase Mobility and Prevent deformity Lie FLAT on a firm mattress Lie PRONE several times to prevent HIP

FLEXION contractures 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 COLDUse to RELIEVE joint stiffness, pain and muscle spasm

Use to CONTROL inflammation and pain

AFTER acute attack ACUTE ATTACK

OA (Osteoarthritis Arthritis) VERSUS RA (Rheumatoid Arthritis)

OA RAOnset is EARLY Onset is LATE (over 60)

CHRONIC SYSTEMIC DISEASE DEGENERATIVE DISEASE

Involves the SYNOVIUM Involves the CARTILAGE

Involved joints are Involved joints are UNILATERAL-

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SYMMETRICAL-FINGERS, CERVICAL SPINE

WEIGHT BEARING KNEE, HIPS AND SPINE

Malaise, fever, anemia (systemic manifestations)

No other S/SX systemic

Joint TENDERNESS, SWELLING, WARMTH AND REDNESS (stiffness in the morning for 30 minutes but disappear during movement)

CREPITUS, stiffness in the morning decreases after activity

Subcutaneous nodules

Stiffness that diminishes

Rest the joint, cold and head modalities, ASA, NSAIDS, DMARDS (Disease Modifying Anti-rheumatic Drugs)

Rest the joints, Avoid over activity, Weight reduction, cold and warm modalities, ASA

Normal color of synovial fluid is yellow in color

GOUTY ARTHRITIS

Definition: A systemic disease cased by deposition of uric acid crystals

in the joint and body tissues “BIG TOE” is usually affected MAIN PROBLEM: ABNORMAL PURINE METABOLISM THAT

RESULTS TO HYPERURICEMIA

CAUSES:11. Primary gout- disorder of Purine

metabolism12. Secondary gout- excessive uric acid in the

blood like leukemia; side effects of medications such as diuretics, salicylates

Assessment Findings:

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1. Severe pain in the involved joints, initially the big toe

2. Swelling and inflammation of the joint3. TOPHI- yellowish-whittish, irregular deposits in

the skin that break open and reveals a gritty appearance

4. PODAGRA- big toe5. Fever, malaise6. Body weakness and headache7. Renal stones

Diagnostic Test: Elevated levels of uric acid in the blood Uric acid stones in the kidney (+) Urate crystals in the synovial fluid

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 (2-3L/day) to prevent stone formation

3. Instruct the patient to avoid alcohol4. Provide alkaline ash diet to increase urinary pH 5. Provide bed rest during early attack of gout6. Position the affected extremity in mild flexion7. Administer anti-gout medication and analgesics

GOUT

FEVER- low grade occasionally

PAIN- fingers/knees/ankles/toe (main)

JOINTS- stiffened deformed (chronic); joints tender to touch

SKIN- red, shiny, swollen, and hot skin over affected joints; tophi deposits ≈urate leaking (advanced)

OTHER- racing heart (occasionally), chills (occasionally), malaise; tendon inflammation

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Medical Management (MAIN PHARMACOLOGICAL TREATMENT OF GOUTY ARTHRITIS):1. Allupurinol- take it WITH FOOD

Rash signifies allergic reaction

2. ColchicineFor acute attack (usually first 24 hours)

3. ProbenecidFor uric acid excretion in the kidney

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

type and extentSevere mechanical stress to bone bone fractureDirect blowsCrushing forcesSudden twisting motionExtreme muscle contraction

Types of Fracture:13. Complete Fracture

Involves a break across the entire cross-section

14. Incomplete FractureThe break occurs through only a part of the cross section

INCOMPLETE FRACTURE IN CHILDREN- GREENSTICK

1. Comminuted FractureA fracture that involves production of several bone fragments

2. Simple FractureA fracture that involves the break of a bone into 2 parts or one

Assessment Findings:1. Pain or tenderness over the involved area

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2. Loss of function3. Deformity4. Shortening5. Crepitus6. Swelling and discoloration

PAINo Continuous and increases in severityo Muscle spasm accompanies the fracture is a reaction of

the body to immobilize the fractured bone

LOSS OF FUNCTIONoAbnormal movement and pain can result to this

manifestation

DEFORMITYoDisplacement, angulations or rotation of the fragments

causes deformity

CREPITUSoA grating sensation produced when the bone fragments

rub each other

Diagnostic Test: X-Ray

Emergency Management of Fracture:1. Immobilize any suspected fracture 2. Support the extremity above and below when moving the

affected part from a vehicle3. Suggested temporary splints- hard board, stick, rolled sheets4. Apply sling if forearm fracture is suspected or the suspected

fractured arm maybe bandaged to the chest5. Open fracture is managed by covering a clean/sterile gauze to

prevent contamination6. DO NOT attempt to reduce the fracture

Medical Management:1. Reduction of fracture either open or closed, immobilization

and Restoration of function2. Antibiotics; muscle relaxants and pain medications

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General Nursing Management For CLOSED FRACTURE:1. Assist in reduction and immobilization2. Administer pain medication and muscle relaxants3. Teach patient to care for the cast4. Teach patient about potential complication of fracture

and to report infection, poor and continuous pain

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 extremity to prevent edema formation3. Administer care of traction and cast

Fracture Complications:EARLY

1. Shock2. Fat embolism

Occurs usually in fractures of the long bones Fat globes 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

Onset is rapid, within 24-72 hours

3. Compartment syndrome4. Infection5. DVT

LATE1. Delayed union2. Avascular necrosis3. Delayed reaction to fixation devices4. Complex regional syndrome

Assessment Findings:1. Sudden Dyspnea and respiratory distress 2. Tachycardia

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3. Chest pain4. Crackles, wheezes and cough5. Petechial rashes over the chest, axilla, and hard palate

Nursing Management:1. Support the respiratory function

Respiratory failure is the most common cause of death

Administer oxygen in high concentration Prepare for possible intubation and ventilator support

2. Administer drugs Corticosteroids Dopamine Morphine

3. Institute preventive measures Immediate immobilization of fracture Minimal fracture manipulation Adequate support for fractures bone during turning and

positioning Maintain adequate hydration and electrolyte balance

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 t increased mass in the compartment by

edema, swelling or hemorrhage

2. Paresthesia- burning or tingling sensation3. Numbness4. Motor weakness5. Pulselessness, impaired capillary refill time and cyanotic

skin

Medical and Nursing Management: Assess frequently the neurovascular status if the casted

extremity Elevate the extremity above the level of the heart

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Assist in cast removal and FASCIOTOMY

Musculoskeletal Modalities Traction Cast

Traction A method of fracture immobilization by applying equipments

to align bone fragments Used for immobilization, bone alignment and relief of muscle

spasm Skin traction: Buck, Bryant Skeletal traction Balanced suspension traction Running/straight traction Pulling force exerted on bones to reduce or immobilize

fractures, reduce muscle spasm, correct or prevent deformities

To decrease muscle spasms To reduce align and immobilize fractures To correct 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 alignment4. Ensure that the pulleys and ropes are properly functioning

and fastened by tying a square knot5. Observe and prevent foot drop ≈ Provide FOOT PLATE6. Observe for DVT, skin irritation and breakdown7. Provide pin care for clients in skeletal traction- use of

hydrogen peroxide8. Promote skin integrity

Use special mattress if possible Provide frequent skin care Assess pin entrance and cleanse the pin with hydrogen

peroxide solution Turn and reposition within the limits of traction

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Use the trapeze

Cast Immobilizing tool made of plaster of Paris or fiberglass Provides immobilization of the fracture

Cast Types:1. Long arm2. Short arm3. Short leg4. Long leg5. Spica6. Body Cast

Casting Materials:1. Plaster of Paris

Drying takes 1-3 days If dry it is SHINY, WHITE, hard and resistant

2. Fiberglass Lightweight and dries in 20-30 minutes Water resistant

Cast Application:1. TO immobilize a body part in a specific position2. TO exert uniform compression to the tissue3. TO provide early mobilization of UNAFFECTED body part4. TO correct deformities5. To stabilize and support unstable joints

Nursing Management:CAST: General Nursing Care

1. Allow the cast to air dry (usually 24-72 hours)2. Handle a wet cast with PALMS not fingertips3. Keep the cast extremity ELEVATED using a pillow4. Turn the extremity for equal drying. DO NOT USE DRYER for

plaster cast Encourage mobility and range of motion exercises

5. Petal the edges of the cast to prevent crumbling of the edges6. Examine the skin for pressure areas and regularly check the

pulses and skin

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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

Strains: Excessive stretching of a muscle or tendon Nursing Management:

1. Immobilize affected part2. Apply cold packs initially, then heat packs3. Limit joint activity4. Administer NSAIDS and muscle relaxants

Sprains: Excessive stretching of LIGAMENTS Nursing Management:

1. Immobilize extremity and advise rest2. Apply cold packs initially, then heat packs3. Compression bandage may be applied to relieve edema4. Assist in cast application5. Administer NSAIDS

Amputation: Removal of body part Peripheral vascular disease, fulminating gas gangrene,

trauma, congenital deformities, chronic osteomyelitis, malignant tumor

Purpose is to relieve symptom and improve function Staged amputation- gangrene and infection Complication are hemorrhage, infection, skin breakdown,

phantom limb pain, joint contractures

Assessment: Neurovascular evaluation Functional status of the extremity Diet- balance with adequate protein and vitamins Psychological status

o Grief response

Nursing diagnosis: Acute pain

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Disturbed body image Infection risk Ineffective coping Risk for disturbed sensory perception Self care deficit

Goals: Relief of Pain

o Evaluation of paino Opioid analgesicso Place a light sandbag on the rosidual limb to

counteract muscle spasm

Absence of altered sensor perceptiono Phantom paino Acknowledge the feeling and help the patient modify

the perceptiono Keep the patient activeo Early rehab and stump desensitization with kneading

massage brings relief

Wound healingo Change the wound dressingo Wrap the residual limb with elastic dressing

Acceptance of body image Restoration of physical mobility

o Avoid abduction, external rotation and flexion of the lower extremity amputated

o Elevate the foot area of the bedo Turn side to sideo Post-op rehab ROM exerciseo Discourage sitting for prolong periods

Absence of complicationo Massive hemorrhage-most threateningo Infection- most frequento Socket of prosthesis is wash with mild detergents

and dried thoroughly with a clean cloth

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