MUSKULOSKELETAL NURSING

BY:
DIANNE MAYDEE MANDAL RN, USRN,
REMT-B, AREMT-B
http://stuffednurse.blogspot.com

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The Musculoskeletal System

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 The Musculoskeletal System
• Functions:
– Locomotion and protection
– blood production in the bone marrow
– heat generation,
– maintenance of posture and
– storage of minerals

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 The Muscles

Three types of muscles exist in our body

• Voluntary skeletal muscle
• Involuntary cardiac muscle
• Involuntary visceral smooth muscle

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 The Muscles

Muscles are composed of

muscle fibers having
numerous nuclei and
striations

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 Properties of Muscles

• Electrical excitability
– Ability to contract to certain stimuli
• Contractility
– Ability to contract forcefully when stimulated
• Extensibility
– Ability to stretch without being damaged
• Elasticity
– Ability to return to its original length and shape

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 Muscle Physiology

• Muscle fibers are enclosed sheaths- perimysium, epimysium

and endomysium
• Each muscle cell has actin and myosin filaments arranged in a
sarcomere
• This sarcomere is the basic structural unit of the muscle

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 Muscle Physiology

• Muscle contraction occurs as actin and myosin slide past one

another causing the sarcomeres to shorten
• Calcium ion is released by the muscle endoplasmic reticulum
to initiate contraction
• ATP is used both for muscle contraction and muscle relaxation

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 Muscle Physiology

Muscle contraction can be of two types

• 1. ISOMETRIC- iso= same, metric=distance: The length of the
muscle does not change, but the tension increases
• 2. ISOTONIC- iso=same, tonus=tone: The amount of muscle
tension is constant but the length of the muscle varies

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 Muscle Physiology

• Muscle tone= refers to the constant tension produced by

muscles of the body for long periods of time

FAST-twitch muscles= contract quickly and fatigue quickly

SLOW-twitch muscles=contract slowly and are more resistant to
fatigue

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 Muscle Physiology

• Smooth Muscle= is not striated, contracts more slowly, is

autorhythmic and under involuntary control

• Cardiac muscle- is striated, is autorhythmic, and under

involuntary control

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 MUSCLE and JOINT MOVEMENTS

• Flexion- decreasing the angle between two joints

• Extension- increasing the angle between two joints
• Abduction- movement of the limb away from the midline
• Adduction- movement of the limb towards the midline

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 MUSCLE and JOINT MOVEMENTS

• Internal rotation- moving the body part inward towards the

midline
• External rotation- moving the body part outward away from
the midline
• Supination- turning a body part upward
• Pronation- turning a body part downward

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 MUSCLE and JOINT MOVEMENTS

• Inversion- turning the foot inward

• Eversion- turning the foot outward
• Retraction- moving a body part backward
• Protraction- moving a body aprt forward

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 Muscles of the face

• 1. Frontalis
• 2. Orbicularis oculi
• 3. orbicularis oris
• 4. Buccinator
• 5. Zygomaticus
• Facial Nerve innervation

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 Muscles of Mastication

• 1. Masseter
• 2. Temporalis
• 3. Pterygoid muscles

• Innervated by TRIGEMINAL NERVE

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 Muscles of the neck

• 1. Platysma
• 2. Sternocleidomastoid

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 Muscle of the upper limb

• 1. Biceps
• 2. triceps
• 3. deltoid

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 Muscles of the lower limb

• 1. Hamstring muscles
• 2. Quadriceps
• 3. Gluteal muscles
• 4. calf muscles

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 TENDONS

• These are bands of fibrous connective tissue that attach

muscles to bones

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 LIGAMENTS

• These are dense, strong, flexible bands of fibrous connective

tissue that bind bones to other bones

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 BONES

• Bone is a living growing tissue made of porous mineralized

structure.
• The human skeleton contains 206 bones
• Axial bones are bones on the midline like the vertebrae, skull,
facial bones, ribs and sternum
• Appendicular bones include the scapulae, bones of the arms
and legs

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 Classification of Bones
• Long bones- - These bones have a shaft and ends. Ex: tibia,
humerus, femur
• Short bones- Small and cubical shaped- Ex: carpals and tarsals
• Irregular bones- vertebrae, mandible
• Sesamoid bones- bones embedded in the tendons. Ex:patella
• Flat bones- with spongy bones inside. Ex: scapulae, ribs,
clavicle

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 Structure of the bone

• Long bones have a diaphysis ( shaft) and epiphysis (ends)

Bones consist of layers of calcified matrix occupied by bone
cells.

The outer layer of bone is composed of dense compact bone
(cortical bone)

The inner layer is composed of spongy cancellous bones

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 Bone Structure

• Blood supply of bones reaches by way of arterioles in the

haversian canal, through the vessels in the Volkmann's canal
• Bone formation can be from the cartilage and from the
membrane

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 Bone Structure

• OSTEOBLAST- bone cell responsible for bone formation and

calcification

• OSTEOCLAST- bone cell responsible for bone resorption and

destruction

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 Bone Ossification

• Ossification is the formation of bone by the osteoblasts. This

involves the mineralization of bones from a cartilage
(endochondral) and from a membrane (membranous).

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 Fig. 6.5a

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 Fig. 6.6

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 Bone Remodeling

• Bone remodeling involves the removal of old bones by cells

called osteoclasts and deposition of new bones by the
osteoblasts.
• Bone is the major storage of calcium
• If calcium levels in the blood falls, it is removed from the bone

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 Bone repair

• When a bone is broken, blood vessels are also damaged

clot
• 2-3 days after injury, blood vessels and cells invade the blood
clot callus formation
• Osteoblasts enter the callus and begin to form a spongy bone
• Immobilization of the bone is required because the delicate
new matrix of bone is easily damaged by excessive
movement

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 Fig. 6.8

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 The Skull

• Skeleton of the head

• Made of 21 bones
• Cranial bones
– Frontal
– Parietal
– Temporal
– occipital

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 The Skull

• Facial bones
– Maxilla
– Mandible
– Zygoma
– Nasal
– Vomer
– Palatine

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 The paranasal sinuses

• These are air-filled cavities in the facial bones surrounding the

nose and open into the nasal cavity
• They decrease the weight of the skull and act as resonator of
sounds
• Frontal, maxillary, ethmoid and sphenoid

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 The Vertebrae

• Composed of 32-33 bones

• 7 cervical
• 12 thoracic
• 5 lumbar
• 5 sacral
• 3-4 coccygeal

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 Functions of the vertebrae

• 1. Supports the weight of the head and trunk

• 2. Protects the spinal cord
• 3. Allows spinal nerves to exit the spinal cord
• 4. Provides a site for muscle attachment
• 5. Permits the movement of the head and trunk

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 The Cervical Vertebrae

• 7 in number
• C1- atlas
• C2- axis
• C7- cervical prominence
• Atlas and occipital bone=
“yes” motion
• Atlas and Axis=
“no” motion

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 The Thorax

• Made up of the sternum and ribs

• The sternum has 3 parts
– Manubrium
– Body
– Xiphoid process
– The slight elevation in the sternum is called the Sternal
Angle of Louis. It identifies the location of the second rib

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 The Ribs

• The ribs are 12 pairs

– True ribs= 1-7
– False ribs= 8-10
– Floating ribs=11-12

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 The shoulder

• The clavicle and scapulae constitute the shoulder

• The clavicle
– Articulates with the sternum
– Most commonly fracture bone
• The Scapulae
– Attached to the ribs and vertebrae by muscles only
– Has an acromion process, where the clavicle attaches

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 The Upper extremity

• Composed of the following bones

• Humerus
• Ulna
• Radius
• Carpals (wrist bones)
• Metacarpals
• Phalanges

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The pelvic girdle

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 The pelvic girdle

• Female pelvis has the following structure: The pelvic inlet is

large/oval, symphysis is shallow. obturator foramen is oval or
triangular, sacrum is broader

• The male pelvis has the following: The pelvic inlet is

small/round to heart-shape, symphysis is deep. Obturator
foramen is round

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 Fig. 6.32

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 The Lower extremity bones

Composed of the
• Thigh bones- femur
• The leg bones- Tibia and Fibula
• The ankle- tarsal bones
• The foot- metatarsal bones

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 CARTILAGE

• A dense connective tissue that consists of fibers embedded in

a strong, gel-like substance.
• Cartilage supports and shapes various structures such as the
ear pinna, intervertebral disks, ear canal, larynx, etc.
• It serves as cushion and shock absorber

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 Types of Cartilage

• Fibrous cartilage
– Found in the intervertebral disks
• Hyaline cartilage
– Found in the symphisis, the thyroid cartilage
• Elastic cartilage
– Found in the ears, the epiglottis

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 Fig. 6.39a

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 Fig. 6.39b

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 Fig. 6.40a

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 Fig. 6.40b

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 Joints

• These are point of attachment or contact between two bones

• Variously classified according to its movement and flexibility
• Fibrous joints- with fibrous tissue with little or no movement
• Cartilaginous joints- with cartilage
• Synovial joints- with capsule; freely movable joints

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 Synovial joints

• Freely movable joints

• With joint cavity/capsule
• Articular surface
• Synovial membrane
• Synovial fluid

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 Synovial joints

• Plane joint- intercarpal joint of wrist

• Hinge joint- elbow and ankle
• Pivot- atlas and axis
• Condyloid- “egg-shape” metacarpophalengeal joint

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 Synovial joints

• Saddle joint- joint of the thumb

• Ball and socket- hip joint

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 Bursae

• Small synovial fluid sacs located at friction points around joints,

between tendons, ligaments and bones
• Act as cushions, decrease stress on adjacent structure

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• 1. Which of the following terms refers to a grating or
crackling sound or sensation?

• Crepitus
• Crepitus may occur with movement of ends of a broken
bone or irregular joint surface.

• Callus
• Callus is fibrous tissue that forms at the fracture site.

• Clonus
• Clonus refers to rhythmic contraction of muscle.

• Fasciculation
• Fasciculation refers to involuntary twitch of muscle fibers.

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• 2. Which of the following terms refers to muscle tension
being unchanged with muscle shortening and joint motion?

• Isotonic contraction
• Exercises such as swimming and bicycling are isotonic.

• Isometric contraction
• Isometric contraction is characterized by increased muscle
tension, unchanged muscle length, and no joint motion.

• Contracture
• Contracture refers to abnormal shortening of muscle, joint,
or both.

• Fasciculation
• Fasciculation refers to involuntary twitch of muscle fibers.

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• 3. Which nerve is assessed when the nurse asks the
patient to spread all fingers?

• Ulnar
• Asking the patient to spread all fingers allows the nurse
to assess motor function affected by ulnar innervation
while pricking the fat pad at the top of the small finger
allows assessment of the sensory function affected by
the ulnar nerve.

• Peroneal
• The peroneal nerve is assessed by asking the patient to
dorsiflex the ankle and extend the toes.

• Radial
• The radial nerve is assessed by asking the patient to
stretch out the thumb, then the wrist, and then the
fingers at the metacarpal joints.

• Median
• The median nerve isdiannemaydee
assessed by (tm)
asking the patient to
touch the thumb to the little finger.
• 4. Diminished range of motion, loss of flexibility, stiffness, and loss of
height are history and physical findings associated with age-related
changes of the:

• joints.
• History and physical findings associated with age-related changes of the
joints include diminished range of motion, loss of flexibility, stiffness, and
loss of height.

• bones.
• History and physical findings associated with age-related changes of
bones include loss of height, posture changes, kyphosis, flexion of hips
and knees, back pain, osteoporosis, and fracture.

• muscles.
• History and physical findings associated with age-related changes of
muscles include loss of strength, diminished agility, decreased
endurance, prolonged response time (diminished reaction time),
diminished tone, a broad base of support, and a history of falls.

• ligaments.
• History and physical findings associated with age-related changes of
ligaments include joint pain on motion that resolves with rest, crepitus,
joint swelling/enlargement, and degenerative joint disease
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• 5. Which of the following is an indicator of neurovascular
compromise?

• Capillary refill more than 3 seconds

• Capillary refill more than 3 seconds is an indicator of
neurovascular compromise. Other indicators include cool
skin temperature, pale or cyanotic color, weakness, paralysis,
paresthesia, unrelenting pain, pain on passive stretch, and
absence of feeling.

• Warm skin temperature

• Cool skin temperature is an indicator of neurovascular
compromise.

• Diminished pain
• Unrelenting pain is an indicator of neurovascular
compromise.

• Pain on active stretch.

• Pain on passive stretch is an indicator of neurovascular
compromise.
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ARTHRITIS

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 ARTHRITIS

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• Situation: Tonnie Miccio is a 43-year old divorced man
who has been rushed to the emergency room with an
acute gouty arthritis.

• 1. While admitting Mr. Miccio to the hospital, the nurse

should recognize those factors that can
precipitate an acute attack. They include

• A. excessive smoking
• B. large alcohol intake
• C. emotional stress
• D. improper rest

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• 2. A serum uric acid level is performed by the
hospital laboratory. In acute gout, the uric acid
level is approximately:

• A. 1.0 mg/100 ml
• B. 2.1 mg/100 ml
• C. 6.5 mg/100 ml
• D. 10 mg/100 ml

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• 3. Colchicine is the standard drug used to treat acute
gout: The physician orders colchicines, 1.0 mg
every 2 hours. After receiving the third dose, the
patient complains of nausea, vomiting, and
diarrhea. The nurse should recognize that this is:

• A. a transient side effect and give the next dose

• B. a sign of toxicity and withhold the medication
• C. an allergic response to the drug and notify the
physician
• D. a psychogenic response to the severe pain

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• 4. After the acute attack subsides, the physician
orders allopurinol (Zyloprim), 300 mg/day. The
expected outcome for this drug is to:

• A. lower the plasma and urinary uric acid level

• B. reduce inflammation of the affected joints
• C. produce diuresis
• D. relieve pain

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• 5. About 2 months after taking the allopurinol, Mr.
Miccio develops a skin rash. The nurse should :

• A. recognize this as a minor side effect that will

subside
• B. ask the patient if he has been taking any aspirin
while taking the allopurinol
• C. recognize this is an indication to discontinue
the drug
• D. be aware that concomitant use of colchicines
with allopurinol causes this reaction

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• 6. A patient presents to the Rheumatology Clinic
where a diagnosis of Rheumatoid Arthritis is made.
Which of the following would NOT be an assessment
finding by the nurse:

• A. Presence of Heberden's Nodes

• B. Warm, tender, painful joints
• C. Serum RF, and elevated ESR
• D. Pt. c/o increased pain and stiffness in
the morning

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• Situation: Martha S is a 27-year old patient who has
experienced increasing generalized stiffness,
especially in the morning, fatigue, general malaise,
and swelling and pain in the finger joints. She has a
tentative diagnosis of rheumatoid arthritis.

• 7. Upon admission, Mrs. S is noted to have a rectal

temperature of 37.7ºC (100ºF). A white blood count
is ordered, and the report comes back at
8,500/mm³. The nurse should recognize this as being
consistent with rheumatoid arthritis because it is

• A. within normal limits

• B. evidence of leukopenia
• C. only slightly elevated
• D. indicative of a generalized infectious process

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• 8. Which of the following blood-analysis tests would
be consistent with diagnosis of rheumatoid arthritis?

• A. an elevated erythrocyte sedimentation rate

and negative C-reactive protein
• B. an elevated erythrocyte sedimentation rate
and positive C-reactive protein
• C. a low erythrocyte sedimentation rate and
negative C-reactive protein
• D. a low erythrocyte sedimentation rate and
positive C-reactive protein

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• 9. The primary goal of nursing care for Mrs. S during
this initial acute phase of rheumatoid arthritis
should be to:

• A. prevent deformity and reduce inflammation

• B. prevent the spread of the inflammation to other
joints
• C. provide for comfort and relief of pain
• D. assist her to accept the fact that rheumatoid
arthritis is a log-term illness

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• 10. Whenever Mrs. S feels pain from her arthritis, she
tells the nurse she feels not only the pain but that
her “whole body feels threatened.” Which
response by the nurse is the most therapeutic?

• A. I will have someone stay with you so you

won’t harm yourself
• B. I will teach you some relaxing exercises so you
won’t be so tense
• C. you must have some medication to help you
gain control
• D. arthritic pain will lessen if you try to grin and
bear it

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• 11. When Mrs. S is discharged, she is instructed to take
aspirin at home. It is important that she be told
to take the drug:

• A. on a regular basis throughout the day

• B. only when other measures are not effective
• C. upon arising and again at bedtime
• D. between meals to promote its absorption

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• 12. When completing the history and physical
examination of a client diagnosed with
osteoarthritis, which of the following would the
nurse assess?

a. Anemia
• c. Weight loss
b. Osteoporosis
• d. Local joint pain

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• 13. At which of the following times would the
nurse instruct the client to take ibuprofen
(Motrin), prescribed for left hip pain secondary to
osteoarthritis, to minimize gastric mucosal
irritation?

a. At bedtime
• c. Immediately after meal
b. On arising
• d. On an empty stomach

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• 14. When preparing a teaching plan for the
client with osteoarthritis who is taking celecoxib
(Celebrex), the nurse expects to explain that
the major advantage of celecoxib over
diclofenac (Voltaren), is that the celecoxib is
likely to produce which of the following?

a. Hepatotoxicity
b. Renal toxicity
c. Gastrointestinal bleeding
d. Nausea and vomiting

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 Arthritis

• Pathology:
OA: wear and tear, excessive workload, collagen replacement from
type II to type I  synovitis leading to osteophytes formation.
RA: viral pathogen initiate inflammatory RF combining with IgG to form
immune complex leading to articular destruction from synovial
hypertrophy, necrosis, pannus formation and fibrous and bony
alkalosis.
GA: errors in purine metabolism leading to uric acid level increase and
precipitation that initiate inflammatory response

• Risk:
OA: obesity; males; heredity
RA: middle age; female; genetic; autoimmune
GA: generally men, postmenopausal, obesity, alcohol intake, disease
states, drugs( thiazides, antitumor ABx, aspirin, ethambutol)
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 Arthritis
• Dx:
OA: X-ray
RA: X-ray, RF, ESR
GA: serum uric acid and 24 hour uric acid excretion

• Cardinal sign:
OA: crepitus, dull joint pain relieved with rest; bouchard and
heberden’s nodes.
RA: morning joint stiffness; rheumatoid nodules; swan neck, ulnar drift,
boutnonniere’s deformity.
GA: big toe swelling, achille’s tophi

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• Gout: factors that can precipitate an attack of
acute gouty arthritis
“DARK”
Diuretics
Alcohol
Renal disease
Kicked (trauma)

*And, the attack occurs most often at night [thus

"dark"].

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• Gout: major features
“GOUT”
Great toe
One joint (75% monoarticular)
Uric acid increased (hence urolithiasis)
Tophi

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• Osteoarthritis: x-ray signs
“LOSS”
Loss of joint space
Osteopyhtes
Subcondral sclerosis
Subchondral cysts

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 Arthritis

• DOC:
OA: aspirin, corticosteroids
RA: NSAIDs( early treatment) corticosteroid ( long term treatment),
Disease modifying drugs
( DMRD)Auranofin ( Ridaura), Azathioprine( Imuran), cyslosporine (
neoral)
GA: chochicine, allopurinol, probenecid

• Nurse concern:
OA: Home safety; IEC on disease process and treatment regimen
RA: Home safety; IEC on disease process and treatment regimen
GA: Avoid aspirin (↓ uric acid excretion), Hydrate, Strict CBR 24 hours of
acute attack; Limit alcohol.

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• Antirheumatic agents (disease modifying): members
“CHAMP”
Cyclophosphamide
Hydroxycloroquine and choloroquinine
Auranofin and other gold compounds
Methotrexate
Penicillamine

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• Aspirin: side effects
“ASPIRIN”
Asthma
Salicyalism
Peptic ulcer disease/ Phosphorylation-oxidation
uncoupling/ PPH/ Platelet disaggregation/ Premature
closure of PDA
Intestinal blood loss
Reye's syndrome
Idiosyncracy
Noise (tinnitus)

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OSTEOMYELITIS

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OSTEOMYELITIS

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• 1. Mr. Lee develops an acute localized
osteomyelitis. He is placed on intravenous antibiotic
therapy. The wound is incised and drained, and
neomycin irrigations are ordered four times a day. It
is important that these irrigations be performed:

• A. with strict aseptic techniques

• B. with a warm solution
• C. for at least 5 minutes
• D. at equal time intervals

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• 2. The client who had an open femoral fracture
was discharged to her home, where she
developed, fever, night sweats, chills, restlessness
and restrictive movement of the fractured leg. The
nurse interprets these finding as indicating which of
the following?

a. Pulmonary emboli
b. Osteomyelitis
c. Fat emboli
d. Urinary tract infection

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 osteomyelitis

• Pathology: chronic infection of bone leading to sequestra ( bone

breakage surrounded by pus) and involucrum ( new bone
formations around necrotic bone). Most commonly by
Staphylococcus aureus.
• Risk: recent trauma, surgery, puncture wound, IV drug use, the very
young.
• Dx:X-ray, bone scan, ESR, WBC, culture
• Cardinal sign: limited joint movement; with/ without fever
• DOC: ABx and narcotic analgesic
• Nurse concern: Strict CBR, Heat application is contraindicated
during acute phase; Wound care; Safety precaution.

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• Osteomyelitis: complications
“FIBERS”
Fractures
Intraosseous (broidie) abscesses
Bacteremi/ Brodie abscess
Endocarditis
Reactive amyloidosis
Sinus tracts/ Squamous cell CA

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PAGET’S DISEASE

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PAGET’S DISEASE

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• 1. Localized rapid bone turnover, most commonly affecting the
skull, femur, tibia, pelvic bones, and vertebrae, characterizes
which of the following bone disorders?

• A. Osteitis deformans
• Osteitis deformans (Paget's disease) results in bone that is highly
vascularized and structurally weak, predisposing to pathologic
fractures.

• B. Osteomalacia
• Osteomalacia is a metabolic bone disease characterized by
inadequate mineralization of bone.

• C. Osteoporosis
• Osteoporosis is characterized by reduction of total bone mass and
a change in bone structure which increases susceptibility to
fracture.

• D. Osteomyelitis
• Osteomyelitis is an infection of bone that comes from extension of
soft tissue infection, direct bone contamination, or hematogenous
spread.
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 Paget’s disease ( Osteitis Deformans)

• Pathology: chronic bone disease with inflammation hypertrophy and

deformity.
• Risk: male adults over 40 y.o.
• Dx: X-ray; ↑ alkaline phosphatase
• Cardinal sign: asymptomatic for years. Bone pain kyphosis, gait
waddling, and bowing of legs.
• DOC: calcitonin ( to regulate bone metabolism) and plicamycin (
antineoplastic)
• Nurse concern: Assess for hypercalcemia from ↑ osteoclast activity;
safety from fracture; Hydrate.

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• Pagets disease of bone: signs and symptoms
“PANICS”
Pain
Arthralgia
Nerve compression / Neural deafness
Increased bone density
Cardiac failure
Skull / Sclerotic vertebrae

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MUSCULAR DYSTHROPY

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MUSCULAR DYSTHROPY

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 Muscular dystrophy
• Pathology: genetically transmitted recessive gene on X chromosome:
the protein dystrophin kill muscle cells leading to progressive muscle
wasting.
rapid: Duchenne’s  onset by age 5, common.
slow: Becker’s onset by age 5-15
Fasciculoscapulohumeral 10-30 years
• Risk: male children with family history
• Dx: EMG; muscle biopsy; ↑CPK/LDH
• Cardinal sign:
Duchenne’s  waddling gait; toe walking
Becker’s generalized muscle weakness
Fasciculoscapulohumeral face, neck, shoulder weakness with
inflammation
• DOC: N/A
• Nurse concern: Maintain mobility and incorporate G/D activities
appropriate for age. Patient can have immobility ( wheel chair
confinement by teen years)diannemaydee
and death (tm)by early adulthood from
cardiopulmonary failure
SYSTEMIC LUPUS ERYTHEMATOSUS

diannemaydee (tm)
SYSTEMIC LUPUS ERYTHEMATOSUS

diannemaydee (tm)
• Situation: Maria Alfredo is a 30-year old married
woman who has systemic lupus erythematosus (SLE).

• 73. While doing as nursing history on Mrs. Alfredo, the

nurse should recognize that the most common
initial symptoms of SLE are

• A. petechiae in the skin, nosebleeds, and pallor

• B. hematuria, increased blood pressure, and
edema
• C. tachycardia, tremors, and loss of weight
• D. painful muscles and joints, stiffness, and
inflammation of joints

diannemaydee (tm)
 SLE

• Pathology: Hyperactivity of B-cells produces

autoantibodies leading to chronic inflammation. Maybe
drug induced, discoid (skin), systemic.
• Risk: childbearing years, race( asian, black, hispanic)
• Dx: ↑anti-DNA antibody
• Cardinal sign: alopecia, butterfly rash, sclerosis.
• DOC: NSAIDs for pain, antimalarials for joint and skin
disorders; corticosteroids for exacerbations.
• Nurse concern: IEC on exacerbation triggers( pregnancy,
UV rays, contraceptive pills, Penicillins and sulfonamides),
good nutrition, infection precaution, routine eye exam,
Exercise program.
diannemaydee (tm)
Systemic Lupus Erythematosis
"SOAP BRAIN"
• S erositis (pleuritis, pericarditis)
O ral ulcers
A rthritis
P hotosensitivity
• B lood (all are low - anemia, leukopenia,
thrombocytopenia)
R enal (proteinuria)
A NA
I mmunologic (dsDNA, etc.)
N eurologic (e.g. seizures)

diannemaydee (tm)
SLE: factors that make SLE active
“UV PRISM”
UV (sunshine)
Pregnancy
Reduced drug (eg steroid)
Infection
Stress
More drug

diannemaydee (tm)
SCLERODERMA

diannemaydee (tm)
SCLERODERMA

diannemaydee (tm)
• 1. Which of the following connective tissue
disorders is characterized by insoluble collagen
being formed and accumulating excessively in
the tissues?

• A. Scleroderma
• B. Rheumatoid arthritis
• C. Systemic lupus erythematosus
• D. Polymyalgia rheumatic

diannemaydee (tm)
 scleroderma

• Pathology: autoimmune disorder involving overproduction of

collagen leading to fibrosis and inflammation. Maybe systemic,
CRET, and limited.
• Risk: trauma, sports, elderly falls
• Dx: skin biopsy; ↑ANA, ESR
• Cardinal sign: General: Shiny skin; claw hands& joint pains
systemic( skin of fingers, hand, face, and visceral organs); CREST
syndrome ( Calcinosis, Raynaud’s syndrome, Esophageal
dysfunction, Sclerodactyl, Telangiectasia); Limited ( skin, hands and
face)
• DOC: NSAIDs and corticosteroids

• Nurse concern: Skin care; collaborate with PT; Avoid cold and
smoking for raynaud’s; high fowlers and in SFF while eating

diannemaydee (tm)
FIBROMYALGIA

diannemaydee (tm)
FIBROMYALGIA

diannemaydee (tm)
• 1. Fibromyalgia is a common condition that:

• A. involves chronic fatigue, generalized muscle

aching and stiffness.
• B. is caused by a virus.
• C. is treated by diet, exercise, and physical
therapy.
• D. usually lasts for less than two weeks,

diannemaydee (tm)
 Fibromyalgia

• Pathology: unclear; no inflammation or structural musculoskeletal

changes.
• Risk: stressed women
• Dx: PE, pain scale
• Cardinal sign: Muscle pain
• DOC: NSAIDs and TCA ( for patient to sleep)
• Nurse concern: Psychosocial assessment

diannemaydee (tm)
FRACTURE

diannemaydee (tm)
FRACTURE

diannemaydee (tm)
• 1. When x-ray demonstrates a fracture in which the fragments
of bone are driven inward, the fracture is described as:

• A. depressed.
• Depressed skull fractures occur as a result of blunt trauma.

• B. compound.
• A compound fracture is one in which damage also involves
the skin or mucous membranes.

• C. comminuted.
• A comminuted fracture is one in which the bone has
splintered into several pieces.

• D. impacted.
• An impacted fracture is one in which a bone fragment is
driven into another bone fragment.

diannemaydee (tm)
• 2. A fracture is termed pathologic when the fracture

• A. occurs through an area of diseased bone.

• Pathologic fractures can occur without the trauma of a fall.

• B. results in a pulling away of a fragment of bone by a

ligament or tendon and its attachment.
• An avulsion fracture results in a pulling away of a fragment of
bone by a ligament or tendon and its attachment.

• C. presents as one side of the bone being broken and the

other side being bent.
• A greenstick fracture presents as one side of the bone being
broken and the other side being bent.

• D. involves damage to the skin or mucous membranes.

• A compound fracture involves damage to the skin or mucous
membranes.
diannemaydee (tm)
• 3. A 70 year old patient sustained a hip
fracture and is placed in Buck's Traction while
awaiting a surgical fixation. Of the following,
which would be the PRIORITY intervention in
providing care for this patient?

• A. Turn and change the patient's

position q2h
• B. Check traction ropes, weights and
pulleys q shift
• C. Assess neurological/sensory and
circulatory status q 2 h
• D. Release traction intermittently

diannemaydee (tm)
• 4. A client presents in the emergency
department after falling from a roof. A fracture
of the femoral neck is suspected. Which of
these assessments best supports this diagnosis?

– A. The client reports pain in the affected leg.

– B. A large hematoma is visible in the affected
extremity.
– C. The affected extremity is shortened,
adducted, and externally rotated.
– D. The affected extremity is edematous.

diannemaydee (tm)
• 5. The nurse is caring for a client with a
compound fracture of the tibia and fibula.
Skeletal traction is applied. Which of these
priorities should the nurse include in the care
plan?

– A. Order a trapeze to increase the client’s

ambulation.
– B. Maintain the client in a flat, supine position
at all times.
– C. Provide pin care at least every 8 hours.
• D. Remove traction weights for 20 minutes
every 2 hours

diannemaydee (tm)
• 6. The nurse assesses subtle personality changes,
restlessness, irritability, and confusion in a patient who
has sustained a fracture. The nurse suspects:

• A. fat embolism syndrome.

• B. compartment syndrome.
• C. hypovolemic shock.
• D. reflex sympathetic dystrophy syndrome.

diannemaydee (tm)
• 7. With fractures of the femoral neck, the leg is :

• A. shortened, adducted, and externally rotated.

• B. shortened, abducted, and internally rotated.
• C. adducted and internally rotated.
• D. abducted and externally rotated.

diannemaydee (tm)
 Fracture
• Pathology: break in bone: open, close, complete,
incomplete, comminuted, compression, impacted, spiral,
greenstick, transverse.
• Risk: trauma, sports, elderly falls
• Dx: Hx with subjective data
• Cardinal sign: pain, asymmetric limb, loss of function and
crepitus
• DOC: analgesics and ABx
• Nurse concern: Assess the 6Ps, IEC on closed and open
reduction and hazards of immobility; safety precautions
with assistive devices; elevate extremity and apply ice
packs for edema; Cast care; traction care; Monitor
complications ( Hypovolemic shock, fat emboli, DVT, and
compartment syndrome)
diannemaydee (tm)
• Fractures: principles of management “FRIAR”
First aid
Reduction
Immobilization
Active Rehabilitation

diannemaydee (tm)
OSTEOPOROSIS

diannemaydee (tm)
OSTEOPOROSIS

diannemaydee (tm)
• 1. Lifestyle risk factors for osteoporosis include:

• A. lack of exposure to sunshine.

• B. lack of aerobic exercise.
• C. a low protein, high fat diet.
• D. an estrogen deficiency or menopause.

diannemaydee (tm)
• 2. The nurse teaches the patient with a high risk for
osteoporosis about risk-lowering strategies including
which of the following statements?

• A. Walk or perform weight-bearing exercises out of

doors.
• B. Increase fiber in the diet.
• C. Reduce stress.
• D. Decrease the intake of vitamin A and D.

diannemaydee (tm)
 Osteoporosis

• Pathology: loss of bone mass from increase activity of

osteoclast and decrease activity of osteoblast that leads
to bone resorption: type 1 ( post menopausal estrogen
deficiency); type 2 ( calcium deficiency)
• Risk: post menopausal women, race( caucasian, asian),
endocrine disorders, caffeine, smoking, tetracycline,
drugs with aluminum, sedentary lifestyle
• Dx: X-ray; bone density studies
• Cardinal sign: loss of height, kyphosis, low back pain,
fracture.
• DOC: calcium or estrogen supplements
• Nurse concern: Calcium supplement ( 1000mg/d
premenopausal; 1500mg/d post menopausal )

diannemaydee (tm)
• Osteoporosis risk factors
“ACCESS”
Alcohol
Corticosteroid
Calcium low
Estrogen low
Smoking
Sedentary lifestyle

diannemaydee (tm)
BONE TUMORS

diannemaydee (tm)
BONE TUMORS

diannemaydee (tm)
 Bone Tumors

• Pathology: neoplasm of skeletal tissues. Most common sites are

femur, humerus, and pelvis.
Osteosarcoma: rapid growth, common in males 10-25 y.o. during teen
age years; discovered following an injury, originated from
metaphysis of long bone.
Chondrosarcoma: slow growth, common in adult males, originated
from cartilage.
Ewing’s sarcoma: rapid growth with fast lung metastasis, common in
males 10-25 y.o. during teen age years; originating from nerve tissue
within bone marrow
• Risk: genetics; primary or secondary
• Dx: Bone biopsy and bone scan
• Cardinal sign: bone pain
• DOC: Codeine and other chemotherapeutic drugs
• Nurse concern: Safety; alternative pain management; Pre-op
teaching on possible amputation
diannemaydee (tm)
SJOGREN’S SYNDROME

diannemaydee (tm)
SJOGREN’S SYNDROME

diannemaydee (tm)
 Sjogren’s Syndrome

• Pathology: autoinflammatory disorder

• Risk: genetic ( HLA-DR3)
• Dx: ANA
• Cardinal sign: Keratoconjunctivitis sicca( dry eyes); Xerostomia(
absent salivary secretions); Inflammatory arthritis
• DOC: steroids
• Nurse concern: Oral care, eye care, safety

diannemaydee (tm)
MARFAN’S SYNDROME

diannemaydee (tm)
MARFAN’S SYNDROME

diannemaydee (tm)
 Marfan’s disease

• Pathology: defect in fibrillin-1 gene causing connective

tissue abnormality  complication involves cardiac
valvular dilatation, optic lens disorder.
• Risk: genetic
• Dx: ANA; X-ray
• Cardinal sign: longer bones with joint laxity; scoliosis.
• DOC: beta blockers and steroids.
• Nurse concern: safety; prevent CHF; IEC on annual eye
exam; scoliosis screening; monitor cardiac status; genetic
counselling. Priority dx are decrease cardiac output;
sensory-perceptual deficits; and body image
disturbances.

diannemaydee (tm)
Traction and casts care

diannemaydee (tm)
diannemaydee (tm)
• 1. Which nursing intervention is appropriate for a
client with skeletal traction?

– A. Pin care
– B. Prone positioning
– C. Intermittent weights
– D. 5-lb weight limit

diannemaydee (tm)
• 2. In order for Buck’s traction applied to the right
leg to be effective, the client should be placed
in which position?

– A. Supine
– B. Prone
– C. Sim’s
– D. Lithotomy

diannemaydee (tm)
• 3. Which of these nursing actions will best promote
independence for the client in skeletal traction?

– A. Instruct the client to call for an analgesic before

pain becomes sever.
– B. Provide an overhead trapeze for client use.
– C. Encourage leg exercises within the limits of
traction
– D. Provide skin care to prevent skin breakdown.

diannemaydee (tm)
• 4. To prevent foot drop in a client with Buck’s
traction, the nurse should

– A. place pillows under the client’s heels.

– B. Tuck the sheets into the foot of the bed.
– C. Teach the client isometric exercises.
– D. Ensure proper body positioning.

diannemaydee (tm)
• 5. A nursing measure for john while he is in cervical
traction should be to:

• A. massage the back of his head

• B. position him from side to side
• C. remove the weights at least once a shift
• D. encourage involvement in his own care

diannemaydee (tm)
• 6. The nurse is assessing the casted extremity of a client.
The nurse assesses for which of the following signs and
symptoms indicative of infection?

a. Coolness and pallor of the extremity

b. Presence of a "hot spot" on the cast
c. Diminished distal pulse
d. Dependent edema

diannemaydee (tm)
SCOLIOSIS

diannemaydee (tm)
 SCOLIOSIS

diannemaydee (tm)
• 1. One day, Jennifer asks her roommate, Erin, how her
scoliosis was first recognized. Erin replies, “The school
health nurse told me that there may be a problem
after all the girls in my class were asked to stand erect
while she examined our backs.” The nurse suspected
scoliosis when she observed that Erin’s shoulder on
one side was elevated and her

• A. head appeared aligned to the opposite side

• B. leg on the same side appeared shorter
• C. hip on the opposite side appeared prominent
• D. arm on the same side appeared longer

diannemaydee (tm)
• 2. When Erin’s scoliosis was diagnosed after x-ray
examination of her spine, she was fitted with
a Milwaukee brace. Erin asks the nurse when it could
be removed each day. Which of the following would
be the best response?

• A. only when you are lying flat, either resting or

sleeping
• B. for 1 hour a day when you bathe, shower, or go
swimming
• C. only for special occasions, such as a party
• D. for 3 hours a day: one in the morning, one in the
afternoon, and one in the evening

diannemaydee (tm)
AMPUTATION

diannemaydee (tm)
AMPUTATION

diannemaydee (tm)
• 1. You are assigned to care for a patient with a
Below the Knee Amputation (BKA). Among the
patient's orders is one which states that the patient
should be placed in the prone position twice daily.
The nurse knows that the reason for this is:

• A. Changing the patient's position will help

to prevent skin breakdown
• B. To observe the stump for signs of
infection
• C. To assist the patient in doing ROM
(Range of Motion) exercises
• D. To stretch the flexor muscles and
prevent flexion contractures

diannemaydee (tm)
• 2. A client in the PACU with a left below the knee
amputation complains of pain in her left big toe.
Which of the following would the nurse do first?

a. Tell the client it is impossible to feel the pain

b. Show the client that the toes are not there
c. Explain to the client that the pain is real
d. Give the client the prescribed narcotic analgesic

diannemaydee (tm)
• 3. The nurse has taught the client with a below the
knee amputation about prosthesis and stump care.
The nurse evaluates that the client states to:

a. Wear a clean nylon stump sock daily

b. Toughen the skin of the stump by rubbing it with
alcohol
c. Prevent cracking of the skin of the stump by
applying lotion daily
d. Using a mirror to inspect all areas of the stump
each day

diannemaydee (tm)
• 4. The client with an above the knee amputation is to
use crutches until the prosthesis is being adjusted. In
which of the following exercises would the nurse
instruct the client to best prepare him for using
crutches?

a. Abdominal exercises
b. Isometric shoulder exercises
c. Quadriceps setting exercises
d. Triceps stretching exercises

diannemaydee (tm)
• 5. The client with an above the knee amputation is to
use crutches until the prosthesis is properly lifted.
When teaching the client about using the crutches,
the nurse instructs the client to support her weight
primarily on which of the following body areas?

a. Axillae
b. Elbows
c. Upper arms
d. Hands

diannemaydee (tm)
• 6. The nurse is giving the client with a left cast
crutch walking instructions using the three point
gait. The client is allowed touchdown of the
affected leg. The nurse tells the client to advance
the:

a. Left leg and right crutch then right leg and left
crutch
b. Crutches and then both legs simultaneously
c. Crutches and the right leg then advance the
left leg
d. Crutches and the left leg then advance the
right leg

diannemaydee (tm)
• 7. The doctor ordered bed rest on a client with
edema of the leg and ankle. Which of the following
accessory device should the nurse integrate
planning care for this patient?

• A. Footboard
• B. Rolled pillows
• C. Sand Bag
• D. Cradle Bed

diannemaydee (tm)
• 8. Pain unrelieved by analgesic in patients with
casted leg is a sign of:

• A. Infection
• B. Hemorrhage
• C. Skin irritation
• D. Compartment syndrome

diannemaydee (tm)
• 9. The client with right sided weakness needs to learn
how to use a cane. The nurse plans to teach the client
to position the cane by holding it with the:

a. Left hand and placing the cane in front of the left

foot
b. Right hand and placing the cane in front of the right
foot
c. Left hand and 6 inches lateral to the left foot
d. Right hand and 6 inches lateral to the left foot

diannemaydee (tm)
 • Thank you!!!

• DIANNE MAYDEE MANDAL RN, USRN, REMT-B, AREMT-B

• http://stuffednurse.blogspot.com

• eye_contact_poor@yahoo.com

diannemaydee (tm)