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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 Three types of muscles exist in the body 1. Skeletal Muscles Voluntary and striated 2. Cardiac muscles Involuntary and striated 3. Smooth/Visceral muscles Involuntary and NON-striated 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 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 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 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 DXA- Dual-energy XRAY absorptiometry Assesses bone density to diagnose osteoporosis Uses LOW dose radiation to measure bone density. Painless procedure, noninvasive, no special preparation. Advise to remove jewelry PAIN These can be related to joint inflammation, traction, surgical intervention 1. Assess patients perception of pain 2. Instruct patient alternative pain management like meditation, heat and cold application, TENS and guided imagery 3. Administer analgesics as prescribed Usually NSAIDS Meperidine can be given for severe pain 4. Assess the effectiveness of pain measures 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 SELF-CARE DEFICITS

1. Assess functional levels of the patient 2. Provide support for feeding problems Place patient in Fowlers position Provide assistive device and supervise mealtime Offer finger foods that can be handled by patient Keep suction equipment ready 3. Assist patient with difficulty bathing and hygiene Assist with bath only when patient has difficulty Provide ample time for patient to finish activity 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 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 Traction: General principles 5. Observe and prevent foot drop Provide foot plate 6. Observe for DVT, skin irritation and breakdown 7. Provide pin care for clients in skeletal traction- use of hydrogen peroxide 8. 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 Use the trapeze

CAST Immobilizing tool made of plaster of Paris or fiberglass Provides immobilization of the fracture 1. CAST: types Long arm, Short arm, Short leg, Long leg, Spica , Body cast

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 Cast Application: 1. TO immobilize a body part in a specific position 2. TO exert uniform compression to the tissue 3. TO provide early mobilization of UNAFFECTED body part 4. TO correct deformities 5. TO stabilize and support unstable joints CAST: General Nursing Care 1. Allow the cast to air 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 Encourage mobility and range of motion exercises 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 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 CAST: General Nursing Care Hot spots occurring along the cast may indicate infection under the cast Osteoporosis

A disease of the bone characterized by a decrease in the bone mass and density with a change in bone structure 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 Osteoporosis: TYPES 1. Primary Osteoporosis- advanced age, post-menopausal 2. Secondary osteoporosis- Steroid overuse, Renal failure RISK factors for the development of Osteoporosis 1. Sedentary lifestyle 2. Age 3. Diet- caffeine, alcohol, low Ca and Vit D 4. Post-menopausal 5. Genetics- caucasian and asian 6. Immobility ASSESSMENT FINDINGS 1. Low stature 2. Fracture Femur 3. Bone pain LABORATORY FINDINGS 1. DEXA-scan Provides information about bone mineral density T-score is at least 2.5 SD below the young adult mean value 2. X-ray studies Medical management of Osteoporosis 1. Diet therapy with calcium and Vitamin D 2. Hormone replacement therapy 3. Biphosphonates- Alendronate, risedronate produce increased bone mass by inhibiting the OSTEOCLAST 4. Moderate weight bearing exercises 5. Management of fractures 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 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 back muscles. Heat application may provide comfort. Encourage good posture and body mechanics .Instruct to avoid twisting 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: AUTO-IMMUNE inflammatory joint disorder of UNKNOWN cause. 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 9-12 y.o. Systemic JRA: fever, salmon pink rash, five or more joints, anorexia, anemia, and fatigue. Pauci-articular: Mild joint pain and swelling, iridocyclyitis, less than 4 joints, very good prognosis POlyarthritis: Moming joint and stiffness and fever. Weight bearing joints, five or more joints, poor prognosis JRA: Symptoms may decrease as child enters adulthood. With periods of remissions and exacerbation. Medical Management: Aspirin and NSAIDS - mainstay treatment; slow acting anti rheumatic drugs, corticosteroids Nsg Management: Encourage normal

performance of ADL; Assist child in ROM exercises; Administer Medications; encourage social and emotional development. Nsg Management: during acute attact: splint the joints. Neutral positioning, Warm or cold packs. Osteoarthritis: the most common form of degenerative joint disorder Osteoarthritis: Patho: Injury, genetic, obesity, advanced age--> stimulate the chondrocytes to release chemicals-> chemicals will cause cartilage degeneration reactive inflammation of the synovial lining and bone stiffening Risk factors: Increased age, obesity, repetitive use of joints with previous joint damage, anatomical deformity, genetic susceptibility Assessment Findings: joint pain, joint stiffness, functional joint impairment limitation. The joint involvement is assymetrical. This is not systemic, there is no fever, no severe swelling. Atrophy of unused muscles. Usual joint are the weight bearing joints. Joint Pain: caused by inflamed cartilage and synovium, stretching of the joint capsule. irritation of nerve endings. 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. Dx Findings: 1. X-ray: narrowing of the joint space, loss of cartilage, osteophytes. 2. Blood tests will show no evidence of systemic inflammation and are not useful. 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 to decrease inflammation Nsg Intervention: 1. Provide relief of Pain: Administer prescribed analgesics; Application of heat modalities. ICE packs may be used in the early acute stage. Plan daily activitites when pain is less severe. Pain meds before exercising. 2. Advise pt to reduce weight: aerobic exercise and walking. 3. Administer prescribed meds: NSAIDS. 4. Position the client to prevent flexion deformity: Use of foot board, splints, wedges, and pillows.

Rheumatoid Arthritis: A type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more women ages 3545 than men. Factors: Genetics: autoimmune connective tissue disorders. Fatigue, emotional stress, cold, infection. Patho: 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. Assessment: Pain; Joint Swelling and stiffness: symmetrical, bilateral; Warthm, erythema and lack of function; Fever, weight loss, anemia, fatigue; Palpation of joint reveals spongy tissues; hesitancy in joint movement. Assessment Findings: Joint involvement is symmetrical and bilateral: characteristically beginning in the hands, wrists, and feet. Joint stiffness occurs early morning last more than 30 minutes, not relieved by movement, dimishes as the day progresses. 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. Dx test: 1. xray shows bony erosion. Blood studies reveal positive rheumatoid factor, elevated ESR and CRP and anti nuclear antibody. Arthrocentesis shows synovial joint that is cloudy, milky, or dark yellow containing numerous WBC and inflammatory proteins. Medical ManagementL: Therapeutic dose of NSAIDS and Aspirin to reduce inflammation. Chemotherapy with methotrexate, antimalarials, gold therapy, and steroids. For advanced cases - arthroplasty, synovectomy. Nutritional therapy. Gold therapy: IM or Oral preparation. takes severals months 3-6 months before effects can be seen. Can damage the kidney and causes bone marrow depression. Nsg 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. 2. Decrease patient fatigue: schedule activity when pain is less severe, provide adequate periods of rests. Promote restorative sleep. Increase pt mobility: advise proper posture and body mechanics. support joint in function position. advise Active ROM.

caused by deposition of uric acid crystals in the joint and body tissues. Causes: 1. primary gout: disorder of purine metabolis. 2. Secondary gout: excessive uric acid in the blood like leukemia. Assessment" Fever low grade occasionaly. Pain on the knees, fingers, ankles, toes. Joints stiff and deformed, and tender to touch. SKIN appears red, shiny, swollen and hot skin over affected joints. Tophi deposits - urate leaking (advanced) Other: racing heart, chills, malaise, and tendon inflammation. Assessment: 1. Severe pain in the involved joints initially the big toel. 2. Swelling and inflammation of the joint. 3. TOPHI - yellowish-whitish irregular deposits in the skin that break open and reveal a gritty appearance. 4. PODAGRAa big toe. 5. Fever, malaise. 6. Body weakness and headache. 7. Renal stones. Dx tests: Elevated levels of uric acid in the blood. Uric acid stones in the kidneys. Positive urate crystals in the synovial fluid. Medical Management: 1. Allupurinol - take it with food. Rash signifies allergic reaction. 2. Colchicine: for acute attack. 3. Probenecid: for uric acid excretion in the kidney. Nsg Intervention. 1. Provide a diet with Low Purine: avoid organ meats, age and processed foods. Strict dietary restrictions is not necessary. 2. Encourage an increased fluid intake (2-3L/day) to prevent stone formation. 3. Instruct the pt to avoid alcohol. 4. Provide alkaline ash diet to increase urinary pH. 5. Provide bed rest during early attack of gout. 6. Position the affected extremity in mild flexion. 7. Administer anti gouty meds and analgesics. Fracture: a break in the continuity of the bone and is defined according to its type and extent. Severe mechanical stress to bone - - bone fracture. Direct blows. crushing forces. sudden twisting motion. extreme muscle contraction. Types: 1. Complete: involves a break across the entire cross section. 2. Incomplete fracture: the break occurs through only a part of the cross-section.

1. Comminuted: a fracture that involves production of several bone fragments. 2. Simple fracture: a fracture that involves break of bone into two parts or one. Assessment: Pain or tenderness over the involved area, loss of function, deformity, shortening, crepitus, swelling, and discoloration. PAIN: continuous and increases in severity. Muscle spasm accompanies the fracture is a reaction of the body to immobilize the fractured bone. 2. Loss of function: abnormal movement and pain can result to this manifestation. 3. Deformity: displacement, angulation or rotation of fragments causes deformity. 4. Crepitus: a grating sensation produced when the bone fragments rub each other. 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. 5. Open fracture is managed by covering a clean / sterile gauze to prevent contamination. 6. Do not attempt to reduce the fracture. \ Medical Management: 1. Reduction of fracture either open or closed, immobilization and Restoration of function. 2. Antibiotics, muscle relaxants and pain medications. 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 pt about potential complication of fracture and to report infection, poor alignment and continuous pain. 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. Early complication: shock, fat embolism, compartment syndrome, infection, dvt. Late complication: 1. Delayed union, avascular necrosis, delayed reaction to fixation devices, complex regional syndrome. 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. Onset is rapid, within 24-72 hours Assessment findings: sudden dyspnea and respiratory distress, tachycardia, chest pain, crackles, wheezes and cough, petechial rashes over the chest, axilla, and hard palate. Nsg management: 1. Support the respiratoty function. Respiratory failure is the most common cause of death. Admister o2 in high concentration. Prepare for possible intubation and ventilator support. 2. Administer drugs: corticosteroids, dopamine. and morphine. 3, Institue preventive measures: immediate immobilization of fracture, minimal fracture manipulation. adequate support for fractured bone during turning and positioning. Maintain adequate hydration and electrolyte balance. Compartment Syndrome: A complication that develops when tissue perfusion in the muscles is less than required for tissue variability. Assessment: 1. Pain: deep, throbbing and unrelieved by pain by opoiod. 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, swelliung or hemorrhage. Medical and Nsg 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 and fasciotomy. Strains: excessive stretching of a muscles or tendon. Nsg Management: immobilize the affected part. Apply cold packs initially then heat packs. Limit joint activity. administer NSAIDS and muscle relaxants. Sprains: excessive stretching of the ligaments nsg management: immobilize extremity and advise rest. Apply cold packs initialy and heat packs. Compression bandage may be applied to relieve edema. Assist in cast application. Administer NSAIDS.

3. 4.


Provide Diet therapy: pts

experiences anorexia, nausea and weight loss. Regular diet with caloric restrictions because steroids may decrease appetite. Supplements of vitamins, iron, and proteins. Increase Mobility and prevent deformity: lie flat on a firm mattress. Lie prone several times to prevent HIp flexion contractures. Use on pillow under the head because of risk of dorsal kyphosis. No pillow under the joints because this promotes flexion contractures.

Hot application: use to relieve joint stiffness, pain and muscle spasm. after acute attacks. COld: use to control inflammation and pain. Acute attacks. RA: onset is early, chronic systemic disease, involves the synovium, involved joints are symmetricalfingers, cervical spine; malaise, fever, anemia. OA: onset is late. degenerative disease. involves the cartilages. involved joints are unilateral-weight bearing knee, hips, spine. no other systemic s/sx Gouty arthritis: A systemic disease

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