The musculo-skeletal system consistsof the muscles, tendons, bones andcartilage together with the jointsThe primary function of which is toproduce skeletal movementsThree types of muscles exist in thebody1. Skeletal MusclesVoluntary and striated2. Cardiac musclesInvoluntary and striated3. Smooth/Visceral musclesInvoluntary and NON-striatedTendons: Bands of fibrous connectivetissue that tie bones to musclesLigaments: Strong, dense and flexiblebands of fibrous tissue connectingbones to another boneBones: Variously classified accordingto shape, location and sizeFunctions1. Locomotion2. Protection3. Support and lever 4. Blood production5. Mineral depositionJoints: The part of the Skeleton wheretwo or more bones are connectedCartilages: A dense connective tissuethat consists of fibers embedded in astrong gel-like substanceBursae: Sac containing fluid that arelocated around the joints to preventfriction1. BONE MARROW ASPIRATIONUsually involves aspiration of themarrow to diagnose diseases likeleukemia, aplastic anemia

Usual site is the sternum and iliac crest Pre-test

: Consent

Intratest

: Needle puncture may bepainful

Post-test

: maintain pressure dressingand watch out for bleeding2.

Arthroscopy

A direct visualization of the joint cavity

Pre-test

: consent, explanation of procedure, NPO

Intra-test

: Sedative, Anesthesia, incisionwill be made

Post-test

: maintain dressing, ambulationas soon as awake, mild soreness of jointfor 2 days, joint rest for a few days, iceapplication to relieve discomfortBONE SCANImaging study with the use of a contrastradioactive material

Pre-test

: Painless procedure, IVradioisotope is used, no specialpreparation,

pregnancy is contraindicated Intra-test

: IV injection, Waiting period of 2hours before X-ray, Fluids allowed, Supineposition for scanning

Post-test

: Increase fluid intake to flush outradioactive materialDXA- Dual-energy XRAY absorptiometryAssesses bone density to diagnoseosteoporosisUses

LOW dose radiation

to measurebone density. Painless procedure, non-invasive, no special preparation. Advise toremove jewelryPAINThese can be related to joint inflammation,traction, surgical intervention1. Assess patient’s perception of pain2. Instruct patient alternative painmanagement like meditation, heat andcold application, TENS and guidedimagery3. Administer analgesics as prescribedUsually NSAIDSMeperidine can be given for severe pain4. Assess the effectiveness of painmeasuresIMPAIRED PHYSICAL MOBILITY1. Instruct patient to perform range of motion exercises, either passive or active2. Provide support in ambulation withassistive devices3. Turn and change position every 2 hours4. Encourage mobility for a short periodand provide positive reinforcements for small accomplishmentsSELF-CARE DEFICITS1. Assess functional levels of the patient2. Provide support for feeding problemsPlace patient in Fowler’s positionProvide assistive device and supervisemealtimeOffer finger foods that can be handled bypatientKeep suction equipment ready3. Assist patient with difficulty bathing andhygieneAssist with bath only when patient hasdifficultyProvide ample time for patient to finish activityTractionA method of fracture immobilization byapplying equipments to align bone fragmentsUsed for immobilization, bone alignment andrelief of muscle spasmSkin traction- Buck, BryantSkeletal tractionBalanced Suspension tractionRunning/Straight tractionPulling force exerted on bones to reduce or immobilize fractures, reduce muscle spasm,correct or prevent deformitiesTO decrease muscle spasmsTO reduce, align and immobilize fracturesTo correct deformitiesTraction: General principles1.

ALWAYS ensure that the weights hang freely and do not touch the floor

NEVER remove the weights

3. Maintain proper body alignment4. Ensure that the pulleys and ropes areproperly functioning and fastened by tying

square knot

Traction: General principles5. Observe and prevent foot dropProvide foot plate6. Observe for DVT, skin irritation andbreakdown7. Provide pin care for clients in skeletaltraction- use of hydrogen peroxide8. Promote skin integrityUse special mattress if possibleProvide frequent skin careAssess pin entrance and cleanse the pin withhydrogen peroxide solutionTurn and reposition within the limits of tractionUse the trapezeCASTImmobilizing tool made of plaster of Paris or fiberglassProvides immobilization of the fractureCAST: types1.Long arm, Short arm, Short leg, Longleg, Spica , Body castPlaster of ParisDrying takes 1-3 daysIf dry, it is SHINY, WHITE, hard and resistantFiberglassLightweight and dries in 20-30 minutesWater resistantCast Application:1.TO immobilize a body part in aspecific position2.TO exert uniform compression to thetissue3.TO provide early mobilization of UNAFFECTED body part4.TO correct deformities5.TO stabilize and support unstable joints

AST: General Nursing Care1. Allow the cast to air dry (usually 24-72hours)

2. Handle a wet cast with the PALMS

not thefingertips3. Keep the casted extremity ELEVATEDusing a pillow4. Turn the extremity for equal drying.

DONOT USE DRYER

for plaster castEncourage mobility and range of motionexercises5. Petal the edges of the cast to preventcrumbling of the edges6. Examine the skin for pressure areas andRegularly check the pulses and skin7. Instruct the patient not to place sticks or small objects inside the cast8. Monitor for the following:

pain, swelling,discoloration, coolness, tingling or lack of sensation and diminished pulses

CAST: General Nursing CareHot spots occurring along the cast mayindicate infection under the cast

Osteoporosis

A disease of the bone characterizedby a decrease in the bone mass anddensity with a change in bonestructureNormal homeostatic bone turnover isaltered rate of bone

RESORPTION is greater than bone FORMATION

reduction in total bone massreduction in bone mineral densityprone to

FRACTURE

Osteoporosis: TYPES1. Primary Osteoporosis- advancedage, post-menopausal2. Secondary osteoporosis- Steroidoveruse, Renal failureRISK factors for the development of Osteoporosis1.

Sedentary lifestyle

2. Age3. Diet- caffeine, alcohol, low Ca andVit D4. Post-menopausal5. Genetics-

caucasian and asian

Immobility

ASSESSMENT FINDINGS1. Low stature2.

Fracture Femur

3. Bone painLABORATORY FINDINGS1. DEXA-scanProvides information about bonemineral density

T-score is at least 2.5 SD below theyoung adult mean value

2. X-ray studiesMedical management of Osteoporosis1. Diet therapy with calcium andVitamin D2. Hormone replacement therapy3. Biphosphonates- Alendronate,risedronate produce increased bonemass by inhibiting the OSTEOCLAST4. Moderate weight bearing exercises5. Management of fracturesOsteoporosis Nursing Interventions1. Promote understanding of osteoporosis and the treatmentregimenProvide adequate dietary supplementof calcium and vitamin DInstruct to employ a regular program of moderate exercises and physical activityManage the constipating side-effect of calcium supplementsTake calcium supplements with mealsTake alendronate with an EMPTY stomachwith water Instruct on intake of Hormonalreplacement2. Relieve the pain: Instruct the patient torest on a firm mattress. Suggest that kneeflexion will cause relaxation of backmuscles. Heat application may providecomfort. Encourage good posture andbody mechanics .Instruct to avoid twistingand heavy lifting3. Improve bowel elimination. Constipationis a problem of calcium supplements andimmobility. Advise intake of HIGH fiber dietand increased fluids4. Prevent injury. Instruct to use isometricexercise to strengthen the trunk muscles.AVOID sudden jarring, bending andstrenuous lifting. Provide a safeenvironmentJuvenile Rheumatoid Arthritis: Definition:AUTO-IMMUNE inflammatory jointdisorder of UNKNOWN cause. SYSTEMICchronic disorder of connective tissueDiagnosed BEFORE age 16 years oldPATHOPHYSIOLOGY : unknown Affectedby stress, climate and genetics. Commonin girls 2-5 and 9-12 y.o.Systemic JRA: fever, salmon pink rash,five or more joints, anorexia, anemia, andfatigue.Pauci-articular: Mild joint pain andswelling, iridocyclyitis, less than 4 joints,very good prognosisPOlyarthritis: Moming joint and stiffnessand fever. Weight bearing joints, five or more joints, poor prognosisJRA: Symptoms may decrease as childenters adulthood. With periods of remissions and exacerbation.Medical Management: Aspirin andNSAIDS - mainstay treatment; slow actinganti rheumatic drugs, corticosteroidsNsg Management: Encourage normalperformance of ADL; Assist child in ROMexercises; Administer Medications; encouragesocial and emotional development.Nsg Management: during acute attact: splintthe joints. Neutral positioning, Warm or coldpacks.Osteoarthritis: the most common form of degenerative joint disorder Osteoarthritis: Patho: Injury, genetic, obesity,advanced age--> stimulate the chondrocytesto release chemicals-> chemicals will causecartilage degeneration reactive inflammationof the synovial lining and bone stiffeningRisk factors: Increased age, obesity, repetitiveuse of joints with previous joint damage,anatomical deformity, genetic susceptibilityAssessment Findings: joint pain, jointstiffness, functional joint impairment limitation.The joint involvement is assymetrical. This isnot systemic, there is no fever, no severeswelling. Atrophy of unused muscles. Usual joint are the weight bearing joints.Joint Pain: caused by inflamed cartilage andsynovium, stretching of the joint capsule.irritation of nerve endings.Stiffness. Commonly occurs in the morningafter awakening. Lasts only for less than 30minutes. Decreases with movement, butworsens after increased weight bearingactivity. Crepitation may be elicited.Dx Findings: 1. X-ray: narrowing of the jointspace, loss of cartilage, osteophytes. 2. Bloodtests will show no evidence of systemicinflammation and are not useful.Medical Management: 1. Weight reduction. 2.Use of splinting devices to support joints. 3.Occupational and physical therapy. 4.Pharmacologic management: use of paracetamol, nsaids, use of glucosamine andchondroitin; topical analgesics, intra-articular to decrease inflammationNsg Intervention: 1. Provide relief of Pain:Administer prescribed analgesics; Applicationof heat modalities. ICE packs may be used inthe early acute stage. Plan daily activititeswhen pain is less severe. Pain meds beforeexercising. 2. Advise pt to reduce weight:aerobic exercise and walking. 3. Administer prescribed meds: NSAIDS. 4. Position theclient to prevent flexion deformity: Use of footboard, splints, wedges, and pillows.Rheumatoid Arthritis: A type of chronicsystemic inflammatory arthritis and connectivetissue disorder affecting more women ages 35-45 than men.Factors: Genetics: autoimmune connectivetissue disorders. Fatigue, emotional stress,cold, infection.Patho: Immune reaction in the synovium--attracts neutrophils -- releases enzymes --breakdown of collagen -- irritates the synoviallining -- causing synovial inflammation edemaand pannus formation and joint erosions andswelling.Assessment: Pain; Joint Swelling and stiffness:symmetrical, bilateral; Warthm, erythema andlack of function; Fever, weight loss, anemia,fatigue; Palpation of joint reveals spongytissues; hesitancy in joint movement.Assessment Findings: Joint involvement issymmetrical and bilateral: characteristicallybeginning in the hands, wrists, and feet. Jointstiffness occurs early morning last more than30 minutes, not relieved by movement,dimishes as the day progresses. Joints areswollen and warm. Painful when moved.Deformities are common in the hands and feetcausing misalignment. Rheumatoid nodulesmay be found in the subcutaneous tissues.Dx test: 1. xray shows bony erosion. Bloodstudies reveal positive rheumatoid factor,elevated ESR and CRP and anti nuclear antibody. Arthrocentesis shows synovial jointthat is cloudy, milky, or dark yellow containingnumerous WBC and inflammatory proteins.Medical ManagementL: Therapeutic dose of NSAIDS and Aspirin to reduce inflammation.Chemotherapy with methotrexate,antimalarials, gold therapy, and steroids. For advanced cases - arthroplasty, synovectomy.Nutritional therapy.Gold therapy: IM or Oral preparation. takesseverals months 3-6 months before effects canbe seen. Can damage the kidney and causesbone marrow depression.Nsg Management:1.Relieve pain and discomfort: usesplints to immobilize the affectedextremity during acute stage of thedisease and inflammation to reducedeformity. Administer prescribedmedications. Suggest application of Cold packs during the acute phase of