History ` Pain ` Numbness/Tingling ` Joint Stiffness ` Difficulty with movement Physical Examination ` Skeletal deformity ` Limited ROM ` Inflammation

` Edema ` erythema

Abduction is movement away from the center, as spreading the toes or fingers apart. Adduction is movement toward the midline of the body, as bringing the fingers and toes together. (Adduction and abduction always refer to movements of the appendicular skeleton). Angular motion is comprised of flexion, extension, adduction, and abduction. Each is based on reference to a certain anatomical position. Circumduction is a special type of angular motion, described as making circular movements as moving the arm in a loop. Dorsiflexion / Plantar flexion refers to movements of the foot. Dorsiflexion is the movement of the ankle while elevating the sole, as if digging in the heel. Plantar flexion is the opposite movement, extending the ankle and elevating the heel, as if standing on tiptoes. Elevation / Depression occurs when a structure moves in a superior or inferior direction, as the mandible is depressed when the mouth is opened and elevated when the mouth is closed. Extension occurs in the same plane as flexion, except that it increases the angle between articulating elements. Extension reverses the movement of flexion. Hyperextension is a continuation of movement past the anatomical position, which can cause injury.

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Flexion is movement in the anterior-posterior plane that reduces the angle between the articulating elements as in bringing the head toward the chest; that is, flexing the intervertebral joints of the neck. Gliding occurs when two opposing surfaces slide past each other as between articulating carpals and tarsals and between the clavicles and sternum. Opposition is a special movement of the thumb which enables it to grasp and hold an object. Pronation / Supination refers to the rotation of the distal end of the radius across the anterior surface of the ulna. This rotation moves the wrist and hand from palm-facing-front (supination) to palmfacing-back (pronation). Protraction entails moving a part of the body anteriorly in the horizontal plane, as in jutting the face forward to gain distance at a finish line. Retraction is the reverse movement of protraction as in pulling the jaw back towards the spine. Rotation involves turning the body or a limb around the longitudinal axis, as rotating the arm to screw in a lightbulb.

Electromyography -A test for muscle activity with graphical recording of the muscle at rest and during contraction Interventions: 1. Explain that the px muscle will asked to flex and relax muscles during the test 2. Explain that thismay cause minor discomfort but not painful 3. Administer analgesic as prescribed.

Arthroscopy -direct visualization of the joint (arthroscope) Intervention: Pre-test 1. Secure informed consent 2. Explain the procedure 3. Skin preparation 4. Use of local anesthesia 5. Administer analgesic and prophylactic antibiotic as prescribe. Post-test 1. Apply pressure/compact dressing at site 2. Monitor neurovascular status 3. Limit joint use 4. Administer analgesic as prescribed

Arthrocentesis -needle aspiration of synovial fluid from joint under local anesthesia Intervention Pre-test 1. Secure consent 2. Explain the procedure 3. Administer analgesic and prophylactic antibiotic as prescribe. Post-test 1. Apply pressure/compact dressing at site 2. Monitor neurovascular status 3. Limit joint use 4. Administer analgesic as prescribed

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Pain Pallor Paralysis Paresthesia Pulselessness

Bone Scan -visual imaging of bone metabolism after injection of IV radioisotope Intervention Pre-test 1. Explain the procedure 2. Determine the ability of px to lie down during the scan. 3. Advise that radioisotope will be injected 4. Explain that the px will drink several glasses of fluid to enhance excretion of isotope not absorbed by bone tissue.

Myelogram -Fluoroscopic procedure using an injection of radiopaque dye. Allows visualization of the subarachnois space,spinal cord and vertebral bodies. Intervention Pre-test 1. Explain the procedure 2. Note the px allergy to iodine, sea food and radiopaque dyes. Post-test 1.Bed rest on semi-fowlers position 2. Inspect site for bleeding 3. Monitor neurovascular status

X-ray Key Intervention 1.Check if the female px is not pregnant to avoid fetal damage from radiation exposure. Blood Chemistry Key Facts 1. Analyzes levels of potassium, calcium, BUN, protein, LE cell preparation test and anti-DNA 2. Monitor venipuncture site Hematologic Studies Key Facts 1. Analyzes substances for WBCs, RBCs, Hb and HCT 2. Note current drug therapy to anticipate possible interference with test result.

Key Impact on: Development, economic, occupation and recreational and social.
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Decreased self-esteem Dependence Economic impact Restriction on body movement

Modifiable 1. Occupations that requires heavy lifting 2. Use of machinery 3. Repetitive motion 4. Vegetarian diet 5. Contact sports 6. Obesity

Non-modifiable 1. Aging 2. Menopause 3. Family history

1. 2. 3. 4.

Impaired physical mobility Ineffective tissue perfussion: Peripheral Impaired skin integrity Alteration in comfort: Pain

Arthrodesis surgical removal of cartillage from joint surfaces to fuse a joint into a functional position. Synovectomy removal of the synovial membrane from a joint using an arthroscope to reduce pain. Arthroplasty (total joint replacement) surgical replacement of a joint with a metal, plastic or prosthesis.

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Complete preoperative health teaching Complete preoperative checklist Administer preoperative drugs Document assessment data.

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3. 4.

5. 6. 7.

Assess pain level Administer analgesic as prescribed and evaluate response. Encourage turning, coughing, deep breathing. Maintain active and passive ROM for unaffected limbs and isometric exercises. Limit joint/area movement of affected limb. Elevate affected extremity Provide wound care.

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Infection Hemmorhage embolus

Fracture immobilization in which transfixing pins are inserted through the bone above and below the fracture site. Pins are attached to a rigid metal frame.

Pre-Operative 1. Apply the GIE 2. Monitor fracture complication 3. Maintain the position of the affected extremity with sandbags and pillows. 4. Maintain traction or splint. Post-operative 1. Assess pain level 2. Administer analgesic as prescribed and evaluate response. 3. Provide wound care 4. Maintain balanced suspension traction.

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Infection Hemorrhage Chronic pain

Surgical removal of all or part of a limb with two types: closed and open

Pre-operative 1. Complete px and family preoperative teaching with spiritual and cultural consideration. 2. Prepare the px for the possibility of phantom limb sensation or phantom pain. 3. Provide emotional support to allay the px and familys anxiety to surgery.

Post-operative 1. Assess cardiac and respiratory status 2. Assess pain level and administer pain medication (morphine, nubain) as prescribed 3. Provide wound care as directed. 4. Monitor vital signs, I/O, laboratory studies, neurovascular assessment and pulse oximetry. 5. Elevate the affected extremity as directed. 6. Inspect the stump for bleeding, infection and edema. 7. Maintain a rigid dressing for the stump prosthesis. 8. Provide trapeze. 9. Encourage the px to express feelings about changes in body image and phantom sensation and pain.

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Infection Skin breakdown Depression

Surgical reduction and stabilization of a fracture using orthopedic devices or hardware.

Pre-operative 1. Apply the GIE 2. Monitor fracture complication 3. Maintain the position of the affected extremity with sandbags and pillows. 4. Maintain traction or splint.

Post-operative 1. Assess cardiac and respiratory status 2. Assess pain level and administer pain medication (morphine, nubain) as prescribed 3. Provide wound care as directed. 4. Monitor vital signs, I/O, laboratory studies, neurovascular assessment and pulse oximetry. 5. Keep px in semi-fowlers position: no higher than 30 degrees. 6. Use abductor pillow and trochanter rolls. 7. Apply sequential compression or stockings. 8. Administer anticoagulants as prescribed. 9. Administer stool softeners as prescribed.

Systemic inflammatory disease that affects the synovial lining of joints. Basic Pathophysiological process of RA 1. Inflammation of synovium 2. Pannus formation 3. Pannus replacement by fibrotic tissue and calcifies. 4. Destruction of cartillage, bone and ligaments.

Etiology: 1. Idiophatic 2. Autoimmune disease Top 4 signs and symptoms: 1. Painful, swollen joint 2. Symmetrical joint swelling 3. Morning stiffness (stiffness from rest to movement) 4. Crepitus

Diagnostics: 1. Rheumatoid factor: (+) 2. Latex fixation test: (+) rheumatoid factor 3. ANA test 4. Synovial fluid analysis 5. Increased ESR Management: 1. Anti-rheumatic drugs as prescribed 2. NSAIDs 3. Glucocorticoids 4. Heat andcold therapy 5. Joint replacement

Intervention: 1. Assess neuromuscular status 2. Assess pain level for tolerance 3. Administer prescribed medication 4. Keep joint extended; provide passive ROM 5. Provide heat and cold therapy Complications: 1. Deppression 2. Peripheral neuropathy 3. Keratoconjunctivitis Surgical Intervention: 1. Synovectomy 2. Joint replacement

-Degeneration of articular cartillage. -Affects weight bearing joints -Degenerated cartillage enters synovium which fibroses and limits joint movement. -Primarily affects the knee, spine and hip joints.

Etiology 1. Aging 2. Obesity 3. Joint trauma 4. Congenital abnormalities Tops 3 signs and symptoms 1. Enlarged; edematous joints 2. Joint stiffness 3. Heberdens and Bouchards nodes

Diagnostics 1. X-ray: joint deformities or bone spur 2. Hematology: increased ESR Management 1. NSAIDs 2. Heat and cold therapy 3. Exercise as tolerated 4. Analgesic: aspirin 5. Weight reduction

Intervention: 1. Assess neuromuscular status 2. Assess pain level for tolerance 3. Administer prescribed medication 4. Provide heat and cold therapy Complications: 1. Contractures 2. Injury Surgical Management 1. Synovectomy 2. Arthrodesis 3. Joint replacement

Inflammatory joint disease caused by deposits of uric acid crystals

Etiology: 1. Genetics 2. Decreased uric acid excretion 3. Chronic renal failure Signs and symptoms: 1. Joint pain 2. Redness and swelling 3. Tophi or great toe, ankle and outer ear

Pathophysiology Purine metabolism (uric acid) Abnormal purine metabolism Decreased excretion of urates Increased blood levels of urates Precipitation of urates in areas with slow blood circulation Accumulation in synovium cavity Damage to adjacent tissues

Signs and symptoms: 1. Joint pain 2. Redness and swelling in joint 3. Tophi formation Diagnostics: 1. hematology: increased ESR 2. Blood chemistry: increased uric acid 3. Synovial fluid analysis: (+) crystals

Intervention: 1. Patient health education: diet 2. Uricosuric agents: probenicid 3. Xanthine-oxidase inhibitor: allopurinol 4. Analgesic 5. Increase fluid intake for excretion Surgical Intervention: 1. Joint replacement 2. Arthoplasty 3. Evacuation of uric crystals Complication: Renal calculi

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Bacterial infection of the bone and soft tissue Infection that causes bone destruction Bone fragments necroses New bone cells form; causing nonunion

Etiology ` Staphylococcus aureus ` Hemolytic streptococcus Risk Factors ` Infection near bone ` Open wound

Signs and symptoms ` Bone pain ` Localized edema ` Increased pain with movement Diagnostics: 1. Blood culture: (+) bone organism 2. Hematology: increased WBC, ESR 3. Bone scan: (+) 4. Bone biopsy: (+)

Management: 1. Specific antibiotic 2. Analgesic 3. Wound care 4. IV therapy 5. Cast or splint Intervention: 1. Monitor v/s and I/O 2. Provide wound care 3. Maintain cast 4. Assess level of pain 5. Administer drugs as prescribed

Comp[lication: 1. Bone necrosis 2. Amputation 3. Chronic osteomyelitis 4. Pathologic fractures 5. Sepsis Surgical Intervention: 1. I and D of bone abcess 2. Bone graft 3. Bone segment transfer

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Metabolic bone dysfunction; reduced bone mass and density and porosity Illness and medications increases the risk of skeletal fractures

Etiology 1. Calcium deficiency 2. Bone marrow disorders 3. Vitamin D deficiency 4. Cushings syndrome 5. hyperthyrodism

Risk Factors 1. Age 2. Post menopausal 3. Immobility 4. Corticosteroid use Signs and symptoms 1. Dowagers hump 2. Thoracic and lumbar pain 3. Decrease in height 4. Joint pain 5. Pathologic fracture

Diagnostics: 1. X-ray: porous bone 2. DEXA scan: decreased bone mineral density 3. Bones scan: decreased bone mineral density Treatment 1. Calcium supplementation 2. Exercise program with weight bearing Intervention 1. Assess musculoskeletal status 2. Assist with planning exercises 3. Prevent fall 4. Administer medication as prescribed Complication pathologic fracture

Chronic compression neuropathy of the median nerve at the wristmedian nerve supplies motor innervention (function) of the wrist and fingers.

Etiology 1. Streneous and repetitive use of the hand 2. Fractures of the wrist 3. Tenosynovitis 4. Obesity

Signs and symptoms 1. Nocturnal pain and paresthesia 2. Burning and tingling of the hand 3. Weakness 4. Tinels sign: (+) 5. Phalens test: (+) Diagnostic: ` Motor nerve velocity (MNV) studies: (+) delayed conduction of the nerve at the wrist

Intervention: 1. Health teaching: avoid wrist flexion 2. Carpal tunnel release 3. Hand splint 4. NSAID 5. Instruct the patient to avoid manual activity that includes dorsiflexion and volar flexion of the wrist. Complication 1. Chronic hand pain 2. Loss of thumb abduction 3. Trophic changes of the hand and fingers

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Rupture of the intervertebral disk Lumbo sacral (L4,L5) Cervical (C5,C6,C7)

Etiology 1. Back and neck strain 2. Degeneration of the disk 3. Weakness of ligaments 4. Heavy lifting 5. trauma

Primarily caused by nerve root compression due to herniation.

Sensory Impairment r/t Spinal Cord Injury

Signs and symptoms: 1. Pain in the back radiating across the buttock and down to the leg 2. Weakness, numbness and tingling of the foot and leg. 3. Cervical affection: neck pain that radiates down the arm and hand. Diagnostics: 1. CT scan: disk displacement 2. MRI: disk protrusion 3. X-ray: narrowing of disk space

Interventions: 1. Assess neuromuscular status 2. Maintain traction: braces and cervical collar 3. Assess level of pain 4. Administer pain medication as prescribed 5. Reposition patient every 2 hours using log rolling technique. Complications: 1. Thrombophlebitis 2. Chronic pain 3. Muscle arthropy 4. Progressive paralysis Surgical Interventions: 1. Laminectomy 2. Spinal fusion 3. Microdisktectomy

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Break in the continuity of the bone Occurs when the stress in the bone is greater than the bone can withstand. Results in muscle spasm, edema, hemmorhage,compressed nerve and ecchymosis.

Etiology: 1. Trauma 2. Force on a bone

Risk Factors: 1. Aging: demineralization of the bone 2. Osteoporosis: decreased bone density 3. Contact sports 4. Increased stress in the bone. 5. History of fracture. Signs and symptoms: 1. Pain aggravated by motion 2. Loss of motor function 3. Deformity 4. Edema 5. Ecchymosis Diagnosis- X-ray: (+) deformity

Management: 1. Abductor pillow (fractured hip) 2. Analgesics 3. Skin traction: Bucks, Bryants and Russel traction 4. Skeletal traction 5. Casting 6. Closed reduction 7. ORIF 8. External fixation

Intervention: 1. Assess neuromuscular status 2. Keep legs abducted (hip fracture) 3. Monitor and record v/s, I and O. 4. Provide skin, pin and cast care. 5. Provide a trapeze. 6. Encourage turning, coughing, deep breathing and passive ROM

1. 2. 3.

Check ropes, pulleys, freedom of movement

This helps to ensure that traction is functioning properly

Check traction set up, pin site and suspensions.

This helps to ensure that traction is functioning properly

Check weights and avoid unnecessary movement

This ensures that proper amount of weight is suspended and prevent additional pain upon movement

4.

Check all skin surfaces for signs of tolerance or pressure areas

This helps uncover signs of pressure that will lead to pressure sores.

Complication: 1. DVT 2. Fat embolism 3. Pulmonary embolism 4. Pneumonia 5. Compartment syndrome 6. Osteomyelitis

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Chronic inflammatory autoimmune disorder that affects the connective tissue Deposits of antigen/antibody complexes affect the connective tissue cells Normally, the immune system helps protect the body from harmful substances. But in patients with an autoimmune disease, the immune system cannot tell the difference between harmful substances and healthy ones. The result is an overactive immune response that attacks otherwise healthy cells and tissue. This leads to long-term (chronic) inflammation.

Etiology Idiopathic Signs and symptoms: Almost all people with SLE have joint pain and swelling. Some develop arthritis. Frequently affected joints are the fingers, hands, wrists, and knees.
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Other common symptoms include: Chest pain when taking a deep breath Fatigue Fever with no other cause General discomfort, uneasiness, or ill feeling (malaise) Hair loss Mouth sores Sensitivity to sunlight Skin rash -- a "butterfly" rash over the cheeks and bridge of the nose affects about half of people with SLE. The rash gets worse in sunlight. The rash may also be widespread. Swollen lymph nodes

Other symptoms depend on what part of the body is affected: ` Brain and nervous system:
Headaches Mild cognitive impairment Numbness, tingling, or pain in the arms or legs Personality change Psychosis Risk of stroke Seizures Vision problems
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Digestive tract: abdominal pain, nausea, and vomiting Heart: abnormal heart rhythms (arrhythmias) Kidney: blood in the urine Lung: coughing up blood and difficulty breathing Skin: patchy skin color, fingers that change color when cold (Raynaud's phenomenon)

Diagnostics: 1. LE cell preparation test: (+) 2. ANA test: (+) 3. Rheumatoid factor: (+) 4. Urine chemistry: proteinuria, hematuria 5. Antibody tests, including:
Antinuclear antibody (ANA) panel Anti-double strand (ds) DNA Antiphospholipid antibodies Anti-Smith antibodies
6. 7. 8.

CBC to show low white blood cells, hemoglobin, or platelets Chest x-ray showing pleuritis or pericarditis Kidney biopsy

Intervention: 1. Assess musculoskeletal and renal status 2. Provide adequate rest period 3. Prevent infection 4. Minimize environmental stress 5. Avoid exposing patient to sunlight 6. Patient should wear protective clothing, sunglasses, and sunscreen when in the sun.

Treatment ` Nonsteroidal anti-inflammatory medications (NSAIDs) are used to treat arthritis and pleurisy. ` Corticosteroid creams are used to treat skin rashes. ` An antimalaria drug (hydroxychloroquine) and lowdose corticosteroids are sometimes used for skin and arthritis symptoms. ` Immunosuppressant ` Plasmapharesis Complication: 1. Pleural effusion 2. Renal failure 3. Coronary atherosclerosis, pericarditis, myocarditis, endocarditis 4. Systemic infection 5. deppression

Thank you very much for listening and active participation!

Prepared and discussed by: MELVIN NIZEL M. ALARCA