MUSCULO-SKELETAL NURSING METABOLIC BONE DISORDERS Osteoporosis A disease of the bone characterized by a decrease in the bone mass and

d density with a change in bone structure METABOLIC BONE DISORDERS 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 METABOLIC BONE DISORDERS Osteoporosis: TYPES 1. Primary Osteoporosis- advanced age, post-menopausal 2. Secondary osteoporosis- Steroid overuse, Renal failure METABOLIC BONE DISORDERS 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 METABOLIC DISORDER ASSESSMENT FINDINGS 1. Low stature 2. Fracture 3. Bone pain METABOLIC DISORDER 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 METABOLIC DISORDER 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

METABOLIC DISORDER Osteoporosis Nursing Interventions: 1. Promote understanding of osteoporosis and the treatment regimen Provide adequate dietary supplement of calcium and vitamin D Instruct to employ a regular program of moderate exercises and physical activity Manage the constipating side-effect of calcium supplements METABOLIC DISORDER Osteoporosis Nursing Interventions: Take calcium supplements with meals Take alendronate with an EMPTY stomach with water Instruct on intake of Hormonal replacement METABOLIC DISORDER Osteoporosis Nursing Interventions 2. Relieve the pain Instruct the patient to rest on a firm mattress Suggest that knee flexion will cause relaxation of back muscles Heat application may provide comfort Encourage good posture and body mechanics Instruct to avoid twisting and heavy lifting METABOLIC DISORDER 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 METABOLIC DISORDER 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 DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS The most common form of degenerative joint disorder DEGENERATIVE JOINT DISEASE

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 DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Risk factors 1. Increased age 2. Obesity 3. Repetitive use of joints with previous joint damage 4. Anatomical deformity 5. genetic susceptibility DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Assessment findings 1. Joint pain 2. joint stiffness 3. functional joint impairment The joint involvement is ASYMMETRICAL This is not systemic, there is no FEVER Usual joint are the WEIGHT bearing joints DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Diagnostic findings 1. X-ray Narrowing of joint space Loss of cartilage Osteophytes 2. Blood test will show no evidence of systemic inflammation and are not useful DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Nursing Interventions 1. Provide relief of PAIN Administer prescribed analgesics Application of heat modalities Plan daily activities when pain is less severe Pain meds before exercising DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Nursing Interventions 2. Advise patient to reduce weight Aerobic exercise Walking 3. Administer prescribed medications

Rheumatoid arthritis A type of chronic systemic inflammatory arthritis affecting more women than men Rheumatoid arthritis Pathophysiology Immune reaction in the synovium attracts neutrophils releases enzymes breakdown of collagen irritates the synovial lining-- Causing synovial inflammation edema and pannus formation and joint erosions Rheumatoid arthritis ASSESSMENT FINDINGS 1. PAIN 2. Joint swelling and stiffness 3. Warmth, erythema and lack of function 4. Fever, weight loss, anemia, fatigue 5. Palpation of joint reveals spongy tissue 6. hesitancy in joint movement Rheumatoid arthritis ASSESSMENT FINDINGS 7. Deformities are common in the hands and feet causing misalignment 8. Rheumatoid nodules may be found in the subcutaneous tissues Rheumatoid arthritis 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

Rheumatoid arthritis Diagnostic test 1. X-ray: Shows bony erosion 2. Blood studies: (+) rheumatoid factor, elevated ESR and CRP 3. Arthrocentesis: synovial fluid that is cloudy, milky or dark yellow containing WBC and inflammatory proteins Rheumatoid arthritis Nursing MANAGEMENT 1. Relieve pain and discomfort USE splints to immobilize the affected extremity during acute stage of the disease and inflammation

Administer prescribed medications Suggest application of COLD packs during the acute phase of pain, then HEAT application as the inflammation subsides

Rheumatoid arthritis Nursing MANAGEMENT 2. Decrease patient fatigue Schedule activity when pain is less severe Provide adequate periods of rests 3. Promote restorative sleep 4. Increase patient mobility Advise proper posture and body mechanics Support joint in functional position Advise ACTIVE ROME Gouty arthritis 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 caused by other diseases Gouty arthritis 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 Gouty arthritis ASSESSMENT FINDINGS 5. Fever, malaise 6. body weakness and headache 7. renal stones DIAGNOSTIC TEST Elevated levels of uric acid Gouty arthritis Medical management 1. Allopurinol 2. Colchicine

Gouty arthritis Nursing Intervention: 1. Provide a diet with LOW purine Avoid Organ meats, aged and processed foods 2. Encourage an increased fluid intake 3. Instruct the patient to avoid alcohol 4. Provide alkaline ash diet to increase urinary pH 5. Provide bed rest during early attack of gout Gouty arthritis Nursing Intervention 6. Position the affected extremity in mild flexion 7. Administer anti-gout medication and analgesics Fracture A break in the continuity of the bone and is defined according to its type and extent

Fracture Severe mechanical Stress to bone bone fracture Direct Blows Crushing forces Sudden twisting motion Extreme muscle contraction Fracture 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 Fracture 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 Fracture 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

Fracture ASSESSMENT FINDINGS 1. Pain or tenderness over the involved area 2. Loss of function 3. Deformity 4. Shortening 5. Crepitus 6. Swelling and discoloration Fracture DIAGNOSTIC TEST X-ray Fracture 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 Fracture 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 Fracture 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 Fracture 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 FRACTURE COMPLICATIONS Early: 1. Shock 2. Fat embolism 3. Compartment syndrome 4. Infection 5. DVT Fracture FRACTURE COMPLICATIONS Late: 1. Delayed union 2. Avascular necrosis 3. Delayed reaction to fixation devices Fracture 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 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 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 FRACTURE COMPLICATIONS: Fat Embolism Nursing Management: 2. Administer drugs Corticosteroids Dopamine Morphine Fracture 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

Fracture Early complication: Compartment syndrome A complication that develops when tissue perfusion in the muscles is less than required for tissue viability Fracture 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 Fracture 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

Fracture 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 Strains 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 Sprains 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 Sample question Susan lei was assigned to a 60 year-old client with a diagnosis of gout Sample question 1. In advanced gout, urate crystal develop in the hands, feet, forearm, ear and achilles tendon. Which of the following terms refers to the deposits? A. Athralgia B. gout nodules C. podagra D. tophi Sample question 2.The client has been prescribed low purine diet. Which of the following foods will the nurse teach to avoid eating? A. fruits and vegetables B. Milk, ice cream and cake C. anchovies, sardines sweetbreads and lentils D. cream cheese and preserved fruits