musculo 2 complete 2007

8/14/2019 Musculo 2 Complete 2007

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PERCEPTIONPERCEPTION

&&

COORDINATIONCOORDINATION

Musculoskeletal Disorders


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Support

ProtectionMovement

Storage ofMinerals

H ematopoiesis

FUNCTIONSFUNCTIONS


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See what happensSee what happenswhen YOU havewhen YOU have

NO MUSCLES.NO MUSCLES.


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Muscle TissueMuscle Tissue

A specialized tissue thathas the ability to shortenor contract.


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PropertiesProperties1.Contractility

2.Excitability/Irritability3.Elasticity

4.Extensibility


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FunctionsFunctionsMMovementovementPPostureosture

JJoint Stabilityoint StabilityHHeat Productioneat Production


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Strong , fibrous connective tissues

that bind bones

Provide joint stability and allowrestricted joint movement


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Strong, fibrous, non-elastic

connective tissue extending from

muscle sheath Bind muscles to bones


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Nonvascular, supporting connective tissue

composed of various cells and fibers.

Absorption of weight, shock, stress and

strain

Protection of bones, joint, and joint tissue


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Elicit a description of

the present illness and

chief complaint


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Moderate to severe pain

Inability to move body parts

Localized edema

Altered sensation to affected

area

Contourdeformity and

asymmetry

Contusions

CardinalCardinal

Signs and Symptoms
http://www.walterschiropractic.com/images/back.jpg


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1. Medical conditions / Medications

2. Unsafe Environment

3. Decreased Dietary intake4. Infrequent Exercise/Sedentary lifestyle

5. Family history
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Inspection

Body alignment

Bone discrepancies

Mobility

Gait

Joint alignment

Muscle discrepancies


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PalpationPalpation Muscle mass

Muscle strength


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X-ray detect structure,

texture and densityproblem

evaluate the diseaseprogression and

treatment efficacy

Bone Scan detect skeletal

trauma and disease

Pt. must voidimmediately before

procedure


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Arthrography identify acute or

chronic tears of thejoint capsule( injection of

radiopaque)

Arthrocentesis allows analysis of

synovial fluid, blood

or pus aspirated from
http://uwcme.org/courses/rheumatology/knee/images/Knee5.jpg


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(+) RA if...Synovial fluid is cloudy, milky, dark yellow

and contains numerous inflammatory cells. Increased ESR (N: less than 15 mm/hr)

. Decreased RBC

..Decreased C4 Complement (N: 140-510mg/L)

(+) C-reactive protein (CRP) & Antinuclearantibody (ANA)

X-ray: (+) bony erosion and narrowed jointspaces
http://uwcme.org/courses/rheumatology/knee/images/Knee5.jpg


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Myelography detect herniation,

tumor congenital/degenerativecondition

Keep pt. flat on bed@ least 12hrs posttest

Electromyography(EMG) measures muscle

electrical impulses


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Biopsy studies bone,

synovium,muscle tissue

CT Scan

show soft tissue,bone and thespinal cord inthree-

dimensional,


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MRI allows study of

soft tissue inmultiple planes

of the body

CBCAnalysis identifies

anemias,


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Alkaline phosphatase identify increases in osteoblastic

activity of the inflammatory condition. CPK-MB

elevation may identify skeletal musclenecrosis, atrophy or trauma.

LDH identify skeletal muscle damage.

Serum Calcium bone loss density

C-reactive protein test severity and course of inflammatory

process

Rheumatoid factor measure the presence of


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Relief of pain

Maintenance of adequatetissue perfusion

Improved physical mobility


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Neurovascular Assessment

(6 Ps)ain

ulses

allor

aresthesia

aralysisolar


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Pain signals the beginning of muscle ischemia

Pulses pulselessness indicates disruption of

arterial blood flow.

Pallor indicates disruption of arterial blood flow.

Paresthesia nerve function may be disrupted bynerve compression.

Paralysis increasing edema causes nervecompression

Polar indicates disrupted arterial blood flow


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Sprain

complete or incomplete tearin the

supporting ligaments surrounding joints.

Strain

overstretching injury to a muscle or

tendon.


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Sprain

commonly result from wrenching or

twisting motion

Strain

typically result from excessivelyvigorous movement in understretchedand overstretched muscles and tendons


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Sprain

Pain and discomfort

Edema

Decreased joint

motion and function

Feeling of joint

looseness

Strain

Pain

Edema

Ecchymoses


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1. Administer prescribed medication

2. Provide nursing care for the client who

sustain sprain.

3. Provide nursing care for a client who

suffer muscle or tendon strain.

4. Provide additional teaching


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Displacement of a bone from its

normal articulation with a joint


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May be congenital

May result from trauma or disease

of surrounding joint tissue


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Pain

Visible disruption of joint contour

Edema

Ecchymoses

Impaired joint mobility

Change in extremity length and in axis

of dislocated bones


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2. Prevent from further injury

3. Assist physician in reducing displaced

parts as necessary

4. Provide teaching


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Remember

Rest

Ice Compress

Elevate


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http://rds.yahoo.com/S=96062883/K=Fractures/v=2/l=IVI/*-http://www.footcaredirect.com/stressfrac.jpg


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Disruption in the continuity of bone as a

result of trauma or various disease process

Highest incidence in males 15-24 years and

in elderly persons, women aged 65 yearsand older


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Direct blowCrushing force

Sudden twistingmotionExtreme muscle

contraction


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Fractures

Complete fracture-involves a break

across the entire cross

section of the bone

and is frequentlydisplaced from normal

position

Incomplete fracture break occurs through

the only part of the

cross section of the

bone.

Closed fracture doesnot produce a break in

the skin.

Open fracture

presence of break in

the skin.

Greenstick bone

bends w/out fracturingacross completely,

cortex on the covade

side remain intact

h f


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Other fractures Transverse fracture

that is straight acrossthe bone, caused by a

force applied to the

site.

Spiral/ oblique fracture twisting

around the shaft of the

bone, caused by

violence forced

through the limb.

Impacted- fracture

where the fragment are

Crush occurs incancellous bone asresult of acompression force.

Burst occurs in ashort bone resultingfrom strong direct

pressure.

Compression

fracture which thebone has beencompressed

Pathologic fracture

through an area ofdiseased bone.


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Other fractures

Avulsion pullingaway of a fragmet of

bone by a ligament or

tendon & itsattachment.

Epiphyseal fracture

through the epiphysis

Compound fracturewith a surface or

open wound. Include

more than one breakin the bone.

Comminuted

fracture with more

than one fragments


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Pain

Lossof function/sensation

Deformity

Shortening/lenghtening

Crepitus (grating sensation)

Swelling

Discoloration


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Excessive motion on site

Soft tissue edema

Warmth over injured area

Paralysis distal to injury resulting from

nerve entrapment

Signs of shock related to severe tissue

injury


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Fracture care

splinting of fracture

preservation of body alignment

elevation of body part to limit edema

application of cold packs

observe for changes in color, sensation,

or temperature of injured part

observe for signs of shock


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FatFat embolismembolism

Compartment syndrome

Nonunion

Arterial damage

Infection Hemorrhage/ Shock


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Fat emboli

- serious, potentially life-threateningcomplication

S/Sx:

Restlessness

mental status changes

tachycardia

tachypnea

hypotensionDyspnea

Petechial rash over the upper chest and neck.


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Compartment syndrome

- increased pressure within a limited anatomic

space compromising circulation, viability, andfunction of tissues within that space.

S/Sx: increased pain and swelling

pain with passive motion

inability to move joints loss of sensation

pulselessness


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Infection and osteomyelitis

- caused by the interruption of the

integrity of the skin; the infection invadesbone tissue.

S/Sx: fever

pain

erythema in the affected area

tachycardia

elevated WBC count


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Avascular necrosis- interruption in the bloodsupply to the bony tissue, which results in thedeath of the bone.

S/Sx: pain decreased sensation

Pulmonary Emboli- caused by immobilityprecipitated by a fracture

S/Sx: restlessness and apprehension

Dyspnea Diaphoresis

ABG changes


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Treatment

Splinting- immobilization of the

affected part to prevent soft tissue from

being damaged by bony parts

Casting- provides rigid immobilization

of affected body part for support andstability


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Treatment

Internal fixation- use of metal screws,

plates, nails and pins to stabilize

reduced fractures Traction

Reduction- restoration of the fracture

fragments into anatomic alignment androtation.


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Nursing care plan/implementation for

clients with FracturePromote healing and prevent complications

diet: high protein, iron, vitamins (tissue

repair), moderate carbohydrates(prevent weight gain)

increase fluid intake


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clients with Fracture

assess for complications of immobility

(pneumonia, constipation, decubitus

ulcers, osteoporosis) assess casted extremityfor presence of

foul odor, drainage, paleness or

blueness, change in temperature,pulselessness, tingling, numbness


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Prevent injury or trauma

avoidance of high-risk activities (sky

diving, high impact sports, rollerblading)

avoidance of safety hazards (throw rugs,

untreated vision problems)

regular exercise


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Provide care related to ambulation with

crutches

Provide safety measures related to

possible complications following fracture


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Nursing Management

Administer prescribed medication

Provide care during transfer of the patient

- immobilized the fractured extremity

- support the affected side.


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Provide client and family teaching

- explain prescribed activity restriction

- Teach the proper use of assistive

devices.

- Provide additional teaching


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Stages of Bone Healing

HEMATOMA AND INFLAMMATION

ANGIOGENESIS AND CARTILAGE

FORMATION

CARTILAGE CALCIFICATION

CARTILAGE REMOVAL

BONE FORMATION

REMODELING


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Callus formation: 3 to 4 weeks

Ossification begins within 2 to 3 weekup to 3 to 4

months

Progress should be monitored by serial x-rays reveals

complete bone union
http://www.healthclick.com/images/gait.gif


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Types of CASTS

Plaster Casts ( POP)

mold very smoothly to the

body contour.

Non Plaster/ Synthetic

Casts fiberglass casts that

are commonly used today

CASTS & MOLDS
http://www.castroom.com/rr/other_casters/rr_hs9.jpg


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CASTS & MOLDS

Short arm circular cast wrist and finger

Short arm posterior mold-wrist and finger withcompound affection

Long arm circular cast-radius/ ulna

Fuensters or munsterscast- radius/ ulna with

callus formation.Long arm posterior mold-fx of radius & ulna w/compound affection

CASTS & MOLDS


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CASTS & MOLDS

Hanging cast shaft of

humerusFunctional arm cast

humerus (allows

abduction & adduction)Shoulder spica

humerus and shoulder

jointAirplane humerus and

shoulder compound

affection

CASTS & MOLDS


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Rizzers jacket scoliosis

Minerva upper dorsal

cervical spine1 & hip spica hip & femur

Body cast lower dorso-

lumbar spine

Double hip spica hip &femur

Long leg cast- tibia, fibula

Long leg posterior mold- fx of

the tibia & fibula w/compound affection

Basket severe leg trauma w/

open wound or inflammation

CASTS & MOLDS


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C S S & O S Cylindrical leg cast- patella

Quadrilateral/ ischial weightbearing cast shaft of femur w/CF

Cast brace fx of the femurdistal 3rd

Short leg circular cast ankle &

foot PTB- tibia/ fibula w/ CF

Delbit cast- Tibia & fibula

Short leg posterior mold ankle

& foot w/ compound affection Boot leg cast for traction hip

& femoral fx

Internal rotator splint post hipoperation

CASTS & MOLDS


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Collar cast cervical

affection

Pantalon cast pelvic bonefracture

Frog cast congenital hip

dislocationSingle hip spica hip & 1

femur

1 & spica mold hip &

femur w/ compound

affection

Double hip spica- pelvic

affection w/ CF +2 femur

CASTS & MOLDS


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CASTS & MOLDS

Single hip spica

mold- pelvic bone

fx w/ CF

Night splint post

polio


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immobilized a body part

Exert uniform compression

Provide for early mobilization

Correct or prevent deformities

Stabilize and support unstable joints


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Prepare the client

Assist during application of casts PRN

After cast application, provide cast care

Initiatepain relief measures as indicated

Observe forsigns of cast syndrome

especially with client who are

immobilized in large cast.


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Provide nursing care for compartment

syndrome, if indicated Notify the physician immediately if signs

of otherneurovascular complicationsoccur

Notify the physician ifhot-spots occur

Provide client teaching

Ensure proper technique and procedure incast removal.


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Support fresh cast with the palm of the hand toprevent indentations from tips of the fingers

Expose the cast to warm, circulating, dry air.

Plaster cast - 5-15 minutes up to 48 hours

Synthetic cast 30 minutes

Dry cast : white, odorless, close to room temperature

and resonant to percussion.

Wet Cast: gray, cool, musty smelling and dull topercussion.


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Potential Pressure

Areas/ Points
http://kidshealth.org/kid/feel_better/things/images_27471/cast_leg.gif


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Checkneurovascularstatus

Alternate ambulation with periods of elevation to

the cast when seated

Perform active ROM hourly when awake by

wiggling fingers/ toes.

AVOID getting plaster cast wet, especially the

padding under the cast DO NOT cover cast with plastic or rubber boots.
http://kidshealth.org/kid/feel_better/things/images_27471/cast_leg.gifhttp://kidshealth.org/kid/feel_better/things/images_27471/cast_leg.gif


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NO weight bearing exercises for 24 hours after

cast application

Cleanplaster cast using slightly damp cloth, by

rubbing soiled areas with scouring powder and by

wiping off residual moisture

AVOID walking on wet floors or sidewalks to

prevent falls DO NOT place objects under the cast to pressure

and skin injury.

Cast Care
http://kidshealth.org/kid/feel_better/things/images_27471/cast_leg.gif


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Neurovascular problems

(Compartment Syndrome)

Pressure Ulcers/ Sores severe initial painover bony prominences, foul odor, purulent

drainage & presence ofhot spots

Immobility/ Disuse Syndrome results tomulti-system problems


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6 Ps Pain aggravated by moving or elevating affected

extremity; usually not relieved by analgesics

Pallor

Pulselessness

Paresthesia occur early in the syndrome whichprogresses to.

Paralysis late sign Puffiness late sign

Signs & Symptoms of

COMPARTMENT SYNDROME
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An orthopedic treatment that involves

placing tension on a limb, bone or muscle

group using variety ofweight and pulley

systems


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1. Decreased muscle spasm

2. Reduce, align, and immobilize

fractures

3. Correct or prevent deformity

4. Increase space between jointsurfaces.


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Straight or Running traction

involve straight pulling force

in one plane.

Balanced suspension traction

involves exertion of a pull

while the limb is supported by

hammock or splint


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Skin traction

involves weight applied and held to the

skin with a Velcro splint.

Skeletal traction

involves weight applied and attached to

metal/pin inserted into bone


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Bucks Extension

Traction femur & hipfracture

Overhead fracture of

humerus

Head halter cervical

spine affection

Pelvic girdle lumbo-sacral affection,

herniated nucleus

pulposus

Dunlops Traction fractured elbow and

h


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humerus

Halo pelvic scoliosis


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Halo femoral severe scoliosis
http://www.jeromemedical.com/assets/images/halo.gif


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Bryants traction

femoral fracture,

Hip injuries amongkids below 3 years

old

Buttocks are slightlyelevated and clear off the

bed.

Boot leg hip and

femoral affection


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Ninety degrees

fracture of the

femur

Stove- in chest severe chest

injury with

multiple ribfracture

Hammock suspension pelvic affection


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Hammock suspension pelvic affection


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Skin Traction

To control muscle spasm

To immobilize an area before surgery


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Uses wires, pins, ortongs placed through

the bones MOST frequentlyused in treatingfractures of femur,

humerus, tibia &cervical spine.

Skeletal Traction

Principles of Effective Traction
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Countertractionmust be maintained for effective

traction Patient is on firm mattress and in good body

alignment in the center of the bed.

Line of pull must be continuous; never interrupted

and in line with the long axis of the bone

Weights must hangfreely; should NOT be removed

when repositioning unless prescribed intermittently

Ropes must be unobstructed and alignedwith

pulleys

Knots must not touch the pulley or foot of the bed

and secured tightly

Principles of Effective Traction


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NURSING FOCUSNURSING FOCUS

Weights must hang freely.Line of pull is from the first

pulley back to the point onthe extremity.

Tie all knots securely.

Skin traction is usuallyintermittent and skeletaltraction is usually

continuous.]


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1. Prevent complications of immobility

2. Promote skin integrity

3. Inspect for signs of skin breakdown,irritation or infection

4. Provide client teaching

5. Promote self-care within traction

limitation


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Care of Client with Skeletal Traction

Maintain principles of effective traction

Watch for signs ofinfection especially

around the pin site

Check neurovascularstatus regularly

especially immediately after application of

traction.

Assess sensorimotorfunction. Observe for

pressure at traction

Avoiding infection


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Avoiding infection

at PIN SITE

The pin should be immobile in the bone and skinwound should be dry

Small amount of serous discharge oozing from pinsite may occur

If infection is suspected, percuss gently over thetibia (+) pain if infection is developing

Assess for other signs of infection: heat, redness,

fever. Clean pin tract with sterile applicators and

prescribed solutions to prevent plugging at the pinsite.

Bucks extension


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simplest form and provides for straightpull on the affected extremity

relieve muscle spasm

immobilize a limb temporarily

Heel is supported offbed to preventpressure on heel, weight hangs free ofthe bed, and foot is well away fromfootboard of bed, and parallel to the

bed.

Russel traction


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Russel traction

- permits the patient to move freely in the

bed - permits flexion of the knee joint.

used in the treatment of intertrochanteric

fracture of the femur when surgery is

contraindicated

Hip is slightly flexed. Pillows may be

used under lower leg to provide supportand keep the heel free of the bed.

Russells Traction


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N i I t ti f P ti t


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Nursing Intervention of Patients

with Traction

Monitor color, motion, and sensation ofthe affected extremity

Monitor the insertion sites for redness,swelling, or drainage

Patient education

Maintaining the traction

Skin care

Assist in toileting


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A. Open reduction involves reduction

and alignment of fractures through surgical

opening

B. Internal Fixation involves

stabilization of reduced fracture withscrews, or pins


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C. Bone graft involves placement of bone

tissue for healing, stabilization, or

replacement

D. Arthroplasty involves joint repair

through small arthroscope


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E. Arthrodesis involves immobilization

of joint through fusion.

F. Joint replacement involve

replacement of joint surface with metal or

plastic materials


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Types of Joint Replacement

1. Total hip replacement involves

replacement of the ball and socket of a

severely damaged hip joint

2. Total knee replacement involves

replacement to tibial, femoral, and patellarjoints.


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G. Tendon transfer involves movement

of tendon insertion

H. Tenotomy involves cutting tendons

I. Fasciotomy involves removal ofmuscle fascia, relieving constriction


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J. Osteotomy involves alignment of bone

by removal of a wedge

Purpose of Orthopedic Surgery:

Reconstruct diseased or injured

musculoskeletal structure


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ASSESSMENT

1. Preoperative assessment

Elicit the clients medical history

Identify current medication and condition

Assess nutritional and hydration status

Assess skin integrity


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2. Postoperative Assessment

Assess the cardiovascular,respiratory , fluid and electrolyte.Nutritional status

Assess neurovascular status

Assess for joint dislocation

Assess for infection

Assess for thromboembolism

Assess and maintain safety andeffectiveness of orthopedic apparatus


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Total Hip Replacement

a plastic surgery that involves removal ofthe head of the femur followed by

placement of a prosthetic implant

Signs and symptoms necessitating


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Signs and symptoms necessitating

Surgery

Severe chronic pain

Loss of joint mobility

Excessive joint destruction

Infection in the joint

Contractures


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Nursing Management

Teach client how to use crutches

Teach client mechanics of transferring.

Discuss importance of turning andpositioning post-op.

Place affected leg in an abducted position

and straight alignment following surgery Prevent hip flexion of more than 90

degrees.


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Nursing Management

Apply support stockings

Advise client to avoid external/internal rotationof affected extremity for 6 months to 1 year

after surgery Instruct client to avoid excessive bending,

heavy lifting, jogging, jumping

Encourage intake of foods rich in Vitamin C,protein, and iron.

Administer prescribed medications.


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Complications

Infection

Hemorrhage

Thrombophlebitis

Pulmonary embolism

Prosthesis dislocation

Prosthesis loosening


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An implantprocedure in whichtibial, femoral andpatellar jointsurfaces are

replaced.


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Assess the neurovascular status of the leg

Immobilize knee in extension with a firmcompression dressing and an adjustable splint

or long leg cast Elevate on pillows

Apply ice to control edema and bleeding

Encourage active flexion of the foot every hourwhen patient is awake

Drainage: 1st 8 hrs. = 200 ml

After 48 hrs = less than 25 ml


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Types:Below the knee (BKA)


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Amputation of a Lower Extremity

surgical removal of a lower limb or part of the

limb.

- 10% of patients experience uncomfortable

sensations- phantom limb pain.

- Phantom limb pain described as a cramp or

uncomfortable sensation

- disappears with time- the pain is a real sensation and should not be

dismissed as illusionary.


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Monitor for bleeding.

Elevate the foot of the bed ifhemorrhage is suspected.

Apply pressure directly over thearea of bleeding.

Notify surgeon ASAP.

Have clamps available at bedside.


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Complications of Amputation

Infection

Wound necrosis

Phantom limb pain

Contractures

Skin breakdown


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Monitor vital signs q 15 min until stable, then q

2 hours for 1st 24 hours, then q 4 hours.

Keep the stump elevatedfor 1st 24 hours toprevent edema

After48 hoursDO NOTelevatewith pillows

BUT rather elevate the foot of the bed.


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To prevent contractures:

Place patient in a prone position for15 minutes, four

times per day. (especially AKA) after 24-48 hrs to

stretch the muscles and prevent flexion contracture of

hip Have patient lie in a supine position with the knee in

extension (especially BKA).

Encourage to do active ROM of extremity to strengthen

muscles and inhibit contractures.

Maintain on low-Fowlers or flat position after AKA

In prone position, place a pillow under the abdomen


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In prone position, place a pillow under the abdomenand stump and keep the legs close together to prevent

abduction

Support stump with pillow for first 24 hours; placerolled bath blanket along outer aspect to prevent

outward rotation.

Encourage exercises to prevent thromboembolism

Encourage patient to ambulate using correct crutch-walking techniques


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Crutch Cane

Walker

37

C t h W lki
http://www.prescottmedical.com/images/crutches.jpg


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Crutch Walking

Crutches

artificial supports

assist patients aid in walking

Preparation:

strengthen muscles ofthe shoulder girdle andupper extremities
http://www.elrodmobility.com/images/rubbermaid.crutches.jpghttp://www.elrodmobility.com/images/rubbermaid.crutches.jpghttp://www.prescottmedical.com/images/crutches.jpg


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Measurement:

Lying down: from anterior fold ofaxilla to the sole of the foot, then add2 inches OR subtract 16 inches from

patients height Standing:two-finger-width insertion

between axillary fold and underarmpiece grip with tip of the crutchplaced 6 to 8 inches lateral to thefloor.

Basic stance:


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Basic stance:

TRIPOD POSITION

Crutches rest approx.8 to 10 inches in front

of and to the side ofpatients toes

TALLER = WIDER

NO Weight bearing on

axilla; should be onHANDS


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NURSINGALERT

Three-point gait is used fornon-weight bearing person

with a fracture of the leg orhip.


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NURSINGALERT

Four-point gait is used forpatients affected by polio andcerebral palsy.


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NURSING

ALERTSwing-through gait is used bythe paraplegic with leg braces.

Stair Climbing


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g

Using Crutches

Going up stairs: proceed with unaffected

(good) leg first, then advance crutches andaffected (bad) leg.

Going down stair: proceed with both

crutches and affected (bad) leg first, thenadvance unaffected (good) leg.


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NURSING ALERT

Remember: the GOOD GO TO HEAVEN(move good leg first when going up); THEBAD GO TO HELL (move crutches andbad leg first when going down).


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Using a Cane Hold the cane on unaffected (good) side. Move

the cane and the affected (bad) leg at the same

time first (simultaneously), then advance the

good leg; or advance the cane first, then affected

leg, then unaffected leg. The cane handle should be held, with the elbow

flexed at 30 degrees, it should be at the level of

the femur.


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Using a Walker

The top of the walker should be at thesame level as the cane (head at femur

level) with elbow flexed at 30 degrees. When using a walker, advance it 6

inches and then move into it.


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Caring for Patient with


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A disease characterized by

exaggeratedloss of bone massand changes in microarchitectureof the bone tissue thatcompromise bone quality.

Bones become fragile andprone to fracture.

Characteristics of OsteoporosisCharacteristics of Osteoporosis


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Silent": most patients are

unaware of osteoporosis until

the first bone fracture

occurs.

It is more common in females than

males: in women, hormone secretiondrops drastically during menopause and this

accelerates bone loss.


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These factors increase your risk ofdeveloping osteoporosis:

1. Heredity factors

2. Early menopause in women

3. Drinking too much coffee and strong tea4. Cigarette smoking and alcoholism

5. Low calcium intake

6. Lack of exercise

7. Some diseases, such as rheumatoid arthritis,

hyperthyroidism or some reproductivedisorders.

8. Prolonged use of certain medications, such as

steroids and thyroid hormone


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Loss of BONE MASS

Aging

CALCITONIN ESTROGEN PTH

BONE RESORPTION BONE FORMATION


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Health history includes questions concerning:

Occurrence of osteoporosis

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


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IMPAIRED MOBILITY

BACK PAIN

CONSTIPATIONSHORTENED STATURE &

SPINAL DEFORMITY

FRACTURE BREATHING PROBLEMS


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1. Reviewing and evaluating apatient's:

physical condition,

lifestyle & daily living habits

2. Measuring Bone Density


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Balance diet rich in CALCIUM & VITAMIN D Regular weight-bearing EXERCISES Hormone replacement therapy (HRT) with

ESTROGEN & PROGESTERONE Other medications:

Alendronate Calcitonin
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Prevention of osteoporosis begins fromchildhood as it is important that you maximizeyour peak bone mass before the age of 35years.
http://www.healthnet.com/healthy_woman/_images/calcium_foods.jpg


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Sufficient intake ofcalcium

Adequate weight-bearing exercises.
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Maintain a healthy lifestyle.

Home safety to prevent falls and fractures.
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To maintain bone mass, postmenopausal women

may need adequate hormone replacement therapy

according to a doctor's advice.
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ETIOLOGY
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ETIOLOGY

Result from trauma or secondary

infection.

Blood-borne (hematogenic)osteomyelitis is common children

Chronic illness

Long term corticosteroid therapy
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Clinical Manifestations
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Localized bone pain

Tenderness, heat, and edema

Guarding of the affected area Restricted movement

Systemic symptom

Purulent drainage

malaise

Lab/ Dx Findings


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Lab/ Dx Findings

WBC count reveals leukocytosis

ESR is elevated

Blood cultures identifies the causative agent(Staph. Aureus)

Radiograph and bone scan

Nursing Management


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Nursing Management


2. Protect the affected extremity from furtherinjury and pain

3. Promote healing and tissue growth

4. Prepare client for surgical treatment

5. Provide additional teaching

6. May apply warm, wet soaks 20 minseveral times a day


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-a slowly progressive, degenerative joint diseasecharacterized by variable changes in weight-bearingjoint.

-Also known as Degenerative Joint Disease/Hyperthropic Arthritis


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Associated with

Obesity

Aging (>50yr) Trauma

Genetic predisposition

Congenital abnormalities
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Pain and muscle spasm, aggravated by userelieved by rest

Limited motion

Joint grating with movement Flexion contractures Joint tenderness Presence of Heberdens nodes or Bouchards

nodes Weight loss Cold intolerance


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Radiographs may reveal a narrowing of

joint space


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2. Provide nonpharmacologic comfort

measures3. Position the client to prevent flexion

deformity

4.Plan activities that promote optimal functionand independence


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5. Refer to physical and occupational therapy

6. Prepare the client fro surgical treatment as

indicated7. Provide referrals

Medication


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Medication

Aspirin

inhibits cyclooxygenase enzyme, it

diminishes the formation ofprostaglandins

anti-inflammatory, analgesic, antipyretic

action inhibit platelet aggregation in cardiac

disorders

Adverse effects:

GI E i t i di t d


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GI: Epigastric distress, nausea, and

vomiting

Blood: inhibition of platelet aggregation

and a prolonged bleeding time

Respiratory: In toxic doses, can cause

respiratory depression


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Hypersensitivity

Reyes syndrome: Acute encephalopathy

following a viral illness and ischaracterized pathologically by cerebral

edema and fatty changes in the liver

Toxicity: (mild or severe)


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Toxicity: (mild or severe)

Mild salicylism: nausea, vomiting, markedhyperventilation, headache, mental

confusion, dizziness, and tinnitus

Severe salicylism: restlessness, delirium,hallucinations, convulsions, coma,

respiratory and metabolic acidosis and

death from respiratory failure.

Ibuprofen


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p

anti-inflammatory, analgesic,and

antipyretic acitivity

use for chronic treatment of rheumatoidand osteoarthritis

less GI effects than aspirin

reversible inhibitors of thecyclooxygenases and inhibit the synthesis

of prostaglandins


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Adverse effects:

GI: dyspepsia to bleeding

CNS: headache, tinnitus and dizziness

Indomethacin


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anti-inflammatory, analgesic and

antipyretic acitivity

inhibits cyclooxygenase enzyme more potent than aspirin as an anti-

inflammatory agent

Adverse effects:


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*dose-related

GI: nausea, vomiting, anorexia, diarrhea

and abdominal pain

CNS: frontal headache, dizziness,vertigo, light-headedness, and mental

confusion

Hypersensitivity reaction

Nursing Management


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g g

Promote comfort: reduce pain, spasms,

inflammation, swelling

medications as prescribed.

Heat to reduce muscle spasm

Cold to reduce swelling and pain


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Prevent contractures: exercise, bed reston firm mattress, splints to maintainproper alignment

Position: elevate extremity to reduceswelling

Promote independence

Pain

RheumatoidEarly morning stiffness

Osteoarthritis


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Joints

General

Early morning stiffnesswhich gets better as theday progresses. May beexacerbated by exercise.Typical deformity issymmetrical (bilateral)

with swelling.Ulnar deviation

Weight loss, fatigue, andfever.

Stiffness worsensduringthe day.Feels better afterexercise.

May be localized toa single joint ormore, may not beswollen, but may bepainful.Finger joints maybecome affected.

Rheumatoid arthritis


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chronic systemic inflammatory disease

destruction of connective tissue and

synovial membrane within the joints

weakens and leads to dislocation of the

joint and permanent deformity

Ri k F t


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Risk Factors:

exposure to infectious agents

fatigue

stress

Diagnostic tests


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g

Elevated ESR

Mild leukocytosis

Anemia

Positive RF

Signs and Symptoms

inflammation, tenderness, and stiffness of


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the joints

moderate to severe pain and morning

stiffness lasting longer than 30 minutes

joint deformities, muscle atrophy, anddecreased range of motion

spongy, soft feeling in the joints

low grade fever, fatigue and weakness

Signs and Symptoms

i i ht l d i


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anorexia, weight loss, and anemia

elevated ESR, and positive RF

Nonreactive: 0-39 IU/ml (CRP)

Weakly reactive: 40-79 IU/ml (CRP)

Reactive: greater than 80 IU/ml (CRP)

X-ray showing joint deterioration

Rheumatoid Arthritis
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Rheumatoid Arthritis
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Medication


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Salicylates (acetylsalicylic acid )

NSAIDs

Corticosteroids- anti-inflammatory

Gold salts

Gold salts


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slow-acting, anti-inflammatory agents

Gold sodium thiomalate, Aurothioglucose,

Auranofin

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

- use in the treatment of RA that does notrespond to salicylates or other NSAIDtherapy

Adverse effects: dermatitis of the skin or of the mucous


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membranes

proteinuria and nephrosis

Gold salts should be avoided in patients

suffering from hepatic or renal disease,

pregnancy.

Serious Toxicity: Dimercaprol

Treatment


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Hot and Cold packs to affected joints

Surgical Procedures: synovectomy,

arthrotomy, arthrodesis, arthroplasty

Nursing Management


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Prevent or correct deformities

bed rest

daily ROM exercises

heat and/or pain medication

increase oral fluid intake at least 1500 mLto prevent renal calculi


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A metabolic disease marked by

urate crystal deposits in joints

throughout the body.


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- Linked to a genetic deficitin purine metabolism

- Age (>50yr)

- Higher incidence in men

Signs and Symptoms


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extreme pain

swelling

erythema of the involved joints fever

tophi
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sudden attacks, usually at night

Pain, joint swelling and inflammation

Intolerance to the weight of bed linenover the affected joint

Pruritus or skin ulceration

Signs of renal involvement


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1. Arthrocentesis reveals urate crystal in

synovial fluid

2. Serum uric acid level is increased

3. Radiographs may show joint damage

in advanced disease.

Treatment


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Allopurinol

- a purine analog

- reduces the production of uric acid bycompetitively inhibiting uric acid

biosynthesis which are catalyzed by

xanthine oxidase.

Allopurinol


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- Effective in the treatment of primary

hyperuricemia of gout and

hyperuricemia secondary to other

conditions (malignancies).

Adverse effects: hypersensitivity

reactions, nausea and diarrhea

Colchicine

Eff ti f t tt k f t th iti i


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Effective for acute attacks of gouty arthritis pain

Reduces inflammation in the joint.

Does not prevent the progression of gout but have

a suppressive, prophylactic effect reducing the

frequency of acute attacks and relieves pain.

Anti-inflammatory activity alleviating pain within

12 hours

Colchicine


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Adverse effects: nausea, vomiting,

abdominal pain, diarrhea,

agranulocytosis, aplastic anemia,

alopecia


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2. Promote measures to prevent

exacerbations.

3. Provide measures to promote comfort

and reduce pain

4. Provide client teaching


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Caring forPatient with

What is ?
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Osteomalacia

involves softeningof the bones caused

by a deficiencyof vitamin D orproblems with the

metabolism of thisvitamin.
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In children, thecondition is

called ricketsand is usuallycaused by a

deficiency ofvitamin D .


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In adult, the conditionis usually caused by:

1. Inadequate dietary

intake of vitamin D2. Inadequate exposure

to sunlight (ultravioletradiation)

3. Malabsorption ofvitamin D
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Other conditions: Hereditary or acquired disorders

of vitamin D metabolism

Kidney failure and acidosis ,

PO4 depletion associated withlow dietary intake or kidneydisease

Side effects ofmedications usedto treat seizures .


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Risk factors are related tothe causes. In the elderly, there is an

increased risk for those whotend to remain indoors andwho avoid milk because oflactose intolerance

The incidence is 1 in 1000people.
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diffuse bone pain , especially in the hips

muscle weakness

symptoms associated with low calcium

numbness around the mouth & ofextremities

Carpopedal spasms

Bowing of legs

Waddling or limping GAIT Decrease in height/ Spinal Deformities

(i.e. KYPHOSIS)

In children, symptoms ofricketsinclude:


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delayed sitting, crawling, and walking;pain when walking; and the development

ofbowlegs orknock-knees.


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Bone biopsy: (+) increase in osteoid

Bone X-ray or CT scan of lumbosacral spineshows demineralization.

Studies of the vertebrae: (+) compression fx Low serum vitamin D level

Low serum calcium &phosphate levels

Elevated ALP (Alkaline Phosphatase)


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Adequate dietaryintake of dairyproducts that are

fortified withvitamin D

Adequate exposureof the body to

sunlight


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Oral supplementsof vitamin D ,calcium, and

phosphorus
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Large doses of Vitamin D

with exposure tosunlight may beindicated in people withintestinal malabsorption .
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Monitoring of blood levels

ofphosphorus andcalcium may be indicatedwith some underlyingconditions.

Braces or surgery tocorrect deformities
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Protrusion of the nucleus of the disk into the

fibrous ring of the disk with subsequent nerve

compression

May occur in any portion of the vertebral column

Signs & Symptoms

1. Pain

2. Sensory changes

3. Loss of reflex

4. Muscle weakness


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1. Cervical Pain/ Stiffness head, neck & upper extremities Paresthesia, numbness

Weakness

2. Lumbar Low back pain radiating to the buttocks and leg Postural deformity of the spine

(+) Straight-Leg Raise test

Weakness & Asymmetric reflexes

Sensory loss

Nursing Alert:Perform repeated assessments ofsensorimotor

functions/ reflexes to determine progression of condition


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Alleviating pain

Anti-inflammatory drugs, muscle relaxants, and

narcotic analgesics

Use ofbed boards under the mattress

Bed rest supine or low fowlers or side lying

position with slight knee flexion and pillows

between knees.

Moist heat application Relaxation techniques
http://www.chiropractic-care.com.sg/scoliosis.jpg


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Signs & Symptoms: Abnormal lateral deviation of spine

Unleveled shoulder

Asymmetric waistline Prominent scapula

Complications:

Related to respiratory problems dueto decreased lung expansion as aresult of severe curvature of thespine

Nursing Implementation
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1. Monitor progression of the curvature

2. Prepare the child and parents for the use of abrace if prescribed

usually worn from 16 to 23 hours a day inspect the skin for signs of redness or breakdown

keep the skin clean and dry, avoiding lotions andpowders

advise the child to wear soft nonirritating clothingunder the brace


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Nursing Implementation


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Prepare the child and parents for surgery if prescribed.

Postoperative:

maintain proper alignment; avoid twisting movements

logroll the child when turning, to maintain alignment

instruct in activity restrictions

instruct the child to roll from a side-lying position to asitting position, and assist with ambulation

Paget's Disease of Bone


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Localized rapid bone turnover, most commonlyaffecting the skull, femur, tibia, pelvic bonesand vertebrae

Primary bone resorption followed by boneformation

Diseased bone is highly vascularized butstructurally weak

More common in the adult (>50 y/o) Male > female



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bowing of femur and tibia

enlargement of the skull

cranial nerve compression

respiration distress

pain

high cardiac outputfailure


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Nursing Management


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Prevent pathological fractures

Control pain

Administer drugs as prescribed

Bone Tumors


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Osteosarcoma

Most common primary bone tumor

Occurs between 10-25 years of age, with Paget's

disease and exposure to radiation

Exhibits a moth-eaten pattern of bone destruction.

Most common sites: metaphysis of long bones

especially the distal femur, proximal tibia andproximal humerus

Osteosarcoma


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local signs pain ( dull, aching and

intermittent in nature), swelling,

limitation of motion

systemic symptoms: malaise, anorexia,

and weight loss


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Diagnostics


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Biopsy- confirms the diagnosis

X-ray

MRI Bone Scan

Medical Management


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Radiation

Chemotherapy Surgical management

amputation

limb salvage procedures

Nursing Management


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Promote understanding of the disease

process and treatment regimen

Promote pain relief

Prevent pathologic fracture.

Promote coping skills and self esteem

Assess for potential complications(infection, complications of immobility).

Nursing Management


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Provide care for client with amputation

Observe for signs of bleeding

Elevate stump on pillow for 24-40 hrs Turn patient to prone position for short

time first post-op day then 2-3x daily

Nursing Management


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Encourage exercise as soon as possible

(1st or 2nd post-op day)

Dangle and transfer patient to

wheelchair and back within 1st or 2nd

day post-op; crutch walking started as

soon as patient feels sufficiently strong

Apply lanolin to dry skin

Other Musculoskeletal Disorders


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Dysplasia of the Hip

condition in which the head of the femur

is improperly seated in the acetabulum,

or hip socket, of the pelvis.

Congenital or develop after birth


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Assessment


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Neonates: laxity of the ligaments around the hip,

which allows the femoral head to be displaced

from the acetabulum upon manipulation.

Implementation:

Splinting of the hips with Pavlik harness to

maintain flexion and abduction and externalrotation (neonatal period)
http://images.google.com/imgres?imgurl=www.musckids.com/health_library/orthopaedics/images/1harnessff.gif&imgrefurl=http://www.musckids.com/health_library/orthopaedics/ddh.htm&h=500&w=530&prev=/images%3Fq%3DDysplasia%2Bof%2BHip%26start%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8%26sa%3DNhttp://images.google.com/imgres?imgurl=www.orthoweb.be/brochures/pediatric/images/pavlik.jpg&imgrefurl=http://www.orthoweb.be/brochures/pediatric/pavlik_uk.htm&h=244&w=163&prev=/images%3Fq%3DDysplasia%2Bof%2BHip%26start%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8%26sa%3DN


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Assessment
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Infants beyond the newborn period:

a. Asymmetry of the gluteal and thigh skinfoldswhen the child is placed prone and the legs areextended against the examining table.

b. Limited range of motion in the affected hip.c. Asymmetric abduction of the affected hipwhen the child is placed supine with the kneesand hips flexed.

d. apparent short femur on the affected side(Galleazzi sign, Allis sign)

Spica Cast


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CARPAL TUNNEL SYNDROME: It occurs when the median nerve at the wrist is

compressed
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ASSESSMENT:

Pain

Numbness

Paresthesia

Thumb, 1st & 2nd fingers affected=Tinel Sign(

tingling sensation when inner wrist is

percussed)

Management:

Wrist splinting


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Avoid repetitive wrist movement

Carpal canal cortisone injection

Surgical release of tendon sheat


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musculo 2 complete 2007

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