Nurse Licensure Examination Review

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

Bands of fibrous connective tissue that tie bones to muscles

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

Variously classified according to shape, location and size

Functions1. Locomotion2. Protection3. Support and lever4. Blood production5. Mineral deposition

The part of the Skeleton where two or more bones are connected

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

Sac containing fluid that are located around the joints to prevent friction

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

1. HISTORY 2. Physical Examination

◦ Perform a head to toe assessment◦ Nurses need to inspect and palpate ◦ The special procedure is the assessment of

joint and muscle movement◦ Usually, a tape measure and a protractor

are the only instruments

Gait Posture Muscular palpation Joint palpation Range of motion Muscle strength

LABORATORY PROCEDURES 1. BONE MARROW ASPIRATION

◦Usually involves aspiration of the marrow to diagnose diseases like leukemia, aplastic anemia

◦Usual site is the sternum and iliac crest◦Pre-test: Consent◦ Intratest: Needle puncture may be painful◦Post-test: maintain pressure dressing and

watch out for bleeding

LABORATORY PROCEDURES 2. Arthroscopy

◦ A direct visualization of the joint cavity◦ Pre-test: consent, explanation of

procedure, NPO◦ Intra-test: Sedative, Anesthesia, incision

will be made◦ Post-test: maintain dressing, ambulation

as soon as awake, mild soreness of joint for 2 days, joint rest for a few days, ice application to relieve discomfort

LABORATORY PROCEDURES3. 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

LABORATORY PROCEDURES4. DXA- Dual-energy XRAY absorptiometry

Assesses bone density to diagnose osteoporosis

Uses LOW dose radiation to measure bone density

Painless procedure, non-invasive, no special preparation

Advise to remove jewelry

The Nursing Management

PAIN These can be related to joint

inflammation, traction, surgical intervention

1. Assess patient’s perception of pain 2. Instruct patient alternative pain

management like meditation, heat and cold application, TENS and guided imagery

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

SELF-CARE DEFICITS 3. Assist patient with difficulty bathing and

hygiene◦ Assist with bath only when patient has difficulty◦ Provide ample time for patient to finish activity

TractionCast

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

Skeletal traction

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

CAST Immobilizing tool made of plaster of Paris or

fiberglass Provides immobilization of the fracture

CAST: types1. Long arm2. Short arm3. Spica

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: General Nursing Care 1. Allow the cast to dry (usually 24-

72 hours) 2. Handle a wet cast with the

PALMS not the fingertips 3. Keep the casted extremity

ELEVATED using a pillow 4. Turn the extremity for equal

drying. DO NOT USE DRYER for plaster cast

CAST: General Nursing Care5. 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

CAST: General Nursing Care7. 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

Nursing management

Osteoporosis A disease of the bone characterized by a

decrease in the bone mass and density with a change in bone structure

Osteoporosis: Pathophysiology Normal homeostatic bone turnover is

altered rate of bone RESORPTION is greater than bone FORMATION reduction in total bone mass reduction in bone mineral density prone to FRACTURE

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 Interventions1. 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

Osteoporosis Nursing Interventions Take calcium supplements with meals Take alendronate with an EMPTY stomach

with water Instruct on intake of Hormonal replacement

Osteoporosis Nursing Interventions2. 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

Osteoporosis Nursing Interventions 3. Improve bowel elimination Constipation is a problem of calcium

supplements and immobility Advise intake of HIGH fiber diet and

increased fluids

Osteoporosis Nursing Interventions 4. Prevent injury Instruct to use isometric exercise to

strengthen the trunk muscles AVOID sudden jarring, bending and

strenuous lifting Provide a safe environment

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 Pauci-articular Polyarticular

FEVER MILD joint pain and swelling

Morning joint stiffness and fever

Salmon-pink rash

IRIDOCYCLITIS Weight Bearing joints

Five or more joints

Less than 4 joints

Five or more joints

Anorexia, anemia, fatigue

Very Good prognosis

Poor prognosis

Symptoms may decrease as child enters adulthood

With periods of remissions and exacerbations

Medical Management1. ASPIRIN and NSAIDs- mainstay

treatment2. Slow-acting anti-rheumatic drugs3. Corticosteroids

Nursing Management1. Encourage normal performance of daily

activities2. Assist child in ROM exercises3. Administer medications4. Encourage social and emotional

development

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

OSTEOARTHRITIS The most common form of degenerative

joint disorder

OSTEOARTHRITIS Chronic, NON-systemic disorder of joints

OSTEOARTHRITIS: Pathophysiology Injury, genetic, Previous joint

damage, Obesity, Advanced age Stimulate the chondrocytes to release chemicals chemicals will cause cartilage degeneration, reactive inflammation of the synovial lining and bone stiffening

OSTEOARTHRITIS: Risk factors 1. Increased age 2. Obesity 3. Repetitive use of joints with previous joint

damage 4. Anatomical deformity 5. genetic susceptibility

OSTEOARTHRITIS: Assessment findings 1. Joint pain 2. Joint stiffness 3. Functional joint impairment

limitation The joint involvement is ASYMMETRICAL This is not systemic, there is no FEVER,

no severe swelling Atrophy of unused muscles Usual joint are the WEIGHT bearing joints

OSTEOARTHRITIS: Assessment findings1. Joint pain Caused by

◦ Inflamed synovium◦ Stretching of the joint capsule◦ Irritation of nerve endings

OSTEOARTHRITIS: Assessment findings2. Stiffness commonly occurs in the morning after commonly occurs in the morning after

awakeningawakening Lasts only for less than 30 minutes DECREASES with movementCrepitation may be elicited

OSTEOARTHRITIS: Diagnostic findings1. X-ray Narrowing of joint space Loss of cartilage Osteophytes2. Blood tests will show no evidenceno evidence of

systemic inflammation and are not useful

OSTEOARTHRITIS: Medical management 1. Weight reduction 2. Use of splinting devices to support

joints 3. Occupational and physical therapy 4. Pharmacologic management

◦ Use of PARACETAMOL, NSAIDS◦ Use of Glucosamine and chondroitin◦ Topical analgesics◦ Intra-articular steroids to decrease inflam

OSTEOARTHRITIS: Nursing Interventions 1. Provide relief of PAIN

◦ Administer prescribed analgesics◦ Application of heat modalities. ICE PACKS

may be used in the early acute stage!!!◦ Plan daily activities when pain is less

severe◦ Pain meds before exercising

OSTEOARTHRITIS: Nursing Interventions 2. Advise patient to reduce weight

◦ Aerobic exercise◦ Walking

3. Administer prescribed medications◦ NSAIDS

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

FACTORS:GeneticAuto-immune connective tissue disordersFatigue, emotional stress, cold, infection

Pathophysiology Immune reaction in the synovium

attracts neutrophils releases enzymes breakdown of collagen irritates the synovial liningcausing synovial inflammation edema and pannus formation and joint erosions and swelling

ASSESSMENT FINDINGS 1. PAIN 2. Joint swelling and stiffness-SYMMETRICAL, Bilateral

3. Warmth, erythema and lack of function

4. Fever, weight loss, anemia, fatigue 5. Palpation of join reveals spongy tissue 6. Hesitancy in joint movement

ASSESSMENT FINDINGS Joint involvement is SYMMETRICAL and

BILATERAL Characteristically beginning in the hands,

wrist and feet Joint STIFFNESS occurs early morning,

lasts MORE than 30 minutes, not relieved by movement, diminishes as the day progresses

ASSESSMENT FINDINGS Joints are swollen and warm Painful when moved Deformities are common in the hands

and feet causing misalignment Rheumatoid nodules may be found in

the subcutaneous tissues

Diagnostic test 1. X-ray

◦ Shows bony erosion 2. Blood studies reveal (+)

rheumatoid factor, elevated ESR and CRP and ANTI-nuclear antibody

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

MEDICAL MANAGEMENT 1. Therapeutic dose of NSAIDS and

Aspirin to reduce inflammation 2. Chemotherapy with methotrexate,

antimalarials, gold therapy and steroid 3. For advanced cases- arthroplasty,

synovectomy 4. Nutritional therapy

MEDICAL MANAGEMENTGOLD THERAPY: IM or Oral preparation Takes several months (3-6) before

effects can be seen Can damage the kidney and causes bone

marrow depression

Nursing MANAGEMENT1. 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

Nursing MANAGEMENT2. Decrease patient fatigueSchedule activity when pain is less severe

Provide adequate periods of rests

3. Promote restorative sleep

Nursing Management4. Increase patient mobilityAdvise proper posture and body mechanics

Support joint in functional position

Advise ACTIVE ROME

Nursing Management5. Provide Diet therapyPatients experience anorexia, nausea and weight loss

Regular diet with caloric restrictions because steroids may increase appetite

Supplements of vitamins, iron and PROTEIN

6. Increase Mobility and prevent deformity:

Lie FLAT on a firm mattressLie PRONE several times to prevent HIP FLEXION contracture

Use one pillow under the head because of risk of dorsal kyphosis

NO Pillow under the joints because this promotes flexion contractures

HOT Cold

Use to RELIEVE joint stiffness, pain and muscle spasm

Use to control inflammation and pain

After acute attack ACUTE ATTACK

A systemic disease caused by deposition of uric acid crystals in the joint and body tissues

CAUSES: 1. Primary gout- disorder of Purine

metabolism 2. Secondary gout- excessive uric

acid in the blood like leukemia

ASSESSMENT FINDINGS 1. Severe pain in the involved joints,

initially the big toe 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. PODAGRA

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

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

Medical management 1. Allupurinol- take it WITH FOOD

Rash signifies allergic reaction

2. Colchicine For acute attack

Nursing Intervention1. Provide a diet with LOW purine Avoid Organ meats, aged and processed

foods STRICT dietary restriction is NOT

necessary2. Encourage an increased fluid intake (2-

3L/day) to prevent stone formation3. Instruct the patient to avoid alcohol4. Provide alkaline ash diet to increase

urinary pH5. Provide bed rest during early attack of gout

Nursing Intervention6. Position the affected extremity in mild

flexion7. Administer anti-gout medication and

analgesics

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 OF FRACTURE 1. Complete fracture

◦ Involves a break across the entire cross-section 2. Incomplete fracture

◦ The break occurs through only a part of the cross-section

TYPES OF FRACTURE 1. Closed fracture

◦ The fracture that does not cause a break in the skin

2. Open fracture◦ The fracture that involves a break in the skin

TYPES OF FRACTURE 1. Comminuted fracture

◦ A fracture that involves production of several bone fragments

2. Simple fracture◦ A fracture that involves break of bone into two

parts or one

ASSESSMENT FINDINGS 1. Pain or tenderness over the involved

area 2. Loss of function 3. Deformity 4. Shortening 5. Crepitus 6. Swelling and discoloration

ASSESSMENT FINDINGS1. Pain Continuous and increases in severity Muscles spasm accompanies the fracture is

a reaction of the body to immobilize the fractured bone

ASSESSMENT FINDINGS2. Loss of function Abnormal movement and pain can result to

this manifestation

ASSESSMENT FINDINGS3. Deformity Displacement, angulations or rotation of the

fragments Causes deformity

ASSESSMENT FINDINGS4. Crepitus A grating sensation produced when the

bone fragments rub each other

DIAGNOSTIC TEST X-ray

EMERGENCY MANAGEMENT OF FRACTURE 1. Immobilize any suspected fracture 2. Support the extremity above and

below when moving the affected part from a 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

EMERGENCY MANAGEMENT OF FRACTURE 5. Open fracture is managed by covering a

clean/sterile gauze to prevent contamination

6. DO NOT attempt to reduce the facture

MEDICAL MANAGEMENT 1. Reduction of fracture either open or

closed, Immobilization and Restoration of function

2. Antibiotics, Muscle relaxants and Pain medications

General Nursing MANAGEMENT For CLOSED FRACTURE 1. Assist in reduction and immobilization 2. Administer pain medication and muscle

relaxants 3. teach patient to care for the cast 4. Teach patient about potential

complication of fracture and to report infection, poor alignment and continuous pain

General Nursing MANAGEMENT For OPEN FRACTURE 1. Prevent wound and bone infection Administer prescribed antibiotics Administer tetanus prophylaxis Assist in serial wound debridement 2. Elevate the extremity to prevent edema

formation 3. Administer care of traction and cast

FRACTURE COMPLICATIONS Early 1. Shock 2. Fat embolism 3. Compartment syndrome 4. Infection 5. DVT

FRACTURE COMPLICATIONS Late 1. Delayed union 2. Avascular necrosis 3. Delayed reaction to fixation devices 4. Complex regional syndrome

FRACTURE COMPLICATIONS: Fat Embolism Occurs usually in fractures of the long

bones Fat globules may move into the blood

stream because the marrow pressure is greater than capillary pressure

Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs

FRACTURE COMPLICATIONS: Fat Embolism Onset is rapid, within 24-72 hours ASSESSMENT FINDINGS 1. Sudden dyspnea and respiratory

distress 2. tachycardia 3. Chest pain 4. Crackles, wheezes and cough 5. Petechial rashes over the chest, axilla

and hard palate

FRACTURE COMPLICATIONS: Fat Embolism Nursing Management 1. Support the respiratory function Respiratory failure is the most common

cause of death Administer O2 in high concentration Prepare for possible intubation and

ventilator support

FRACTURE COMPLICATIONS: Fat Embolism Nursing Management 2. Administer drugs Corticosteroids Dopamine Morphine

FRACTURE COMPLICATIONS: Fat Embolism Nursing Management 3. Institute preventive measures Immediate immobilization of fracture Minimal fracture manipulation Adequate support for fractured bone

during turning and positioning Maintain adequate hydration and

electrolyte balance

Early complication: Compartment syndrome

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

Early complication: Compartment syndrome ASSESSMENT FINDINGS 1. Pain- Deep, throbbing and UNRELIEVED

pain by opiods Pain is due to reduction in the size of the

muscle compartment by tight cast Pain is due to increased mass in the

compartment by edema, swelling or hemorrhage

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

time and cyanotic skin

Early complication: Compartment syndrome

Medical and Nursing management 1. Assess frequently the neurovascular

status of the casted extremity 2. Elevate the extremity above the

level of the heart 3. Assist in cast removal and

FASCIOTOMY

Excessive stretching of a muscle or tendon

Nursing management 1. Immobilize affected part 2. Apply cold packs initially, then

heat packs 3. Limit joint activity 4. Administer NSAIDs and muscle

relaxants

Excessive stretching of the LIGAMENTS Nursing management 1. Immobilize extremity and advise rest 2. Apply cold packs initially then heat

packs 3. Compression bandage may be

applied to relieve edema 4. Assist in cast application 5. Administer NSAIDS