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Nursing Musculoskeletal

Nursing Musculoskeletal

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Published by: Maria Carmela Tormes on Aug 25, 2010
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Board review

Dynamic specialty with a history of changing in reaction to development in the society, health care provision, disease patterns, technology, medical and nursing development and of course the needs of the patient with musculoskeletal disturbance.

Changes have happened over the past 20 years: People are more active(prone to injuries) Family dynamics have changed Lifestyle has continued to evolve

The impact of these changes must be anticipated by the nurse and the needs that goes with it.

Orthopedic and Trauma Nurses must:
Perform specialist roles Work on nursing development Work collaborately with the health care team Lead nsg practice (this ensures that an appropriate action taken inspires and innovates, supports and empowers the nursing team)

Greek Language Orthos = straight + paedios = child

Orthopedic Nursing evolved from the needs of children affected by crippling musculoskeletal problems.

1841 ± first orthopedic nurse was appointed (children with congenital and developmental disorders, nowadays, adult) Royal Orthopedic Hospital ± the first ortho hosp in 1871 Dame Agnes hunt (1867-1948) ± opened her home to crippled children Sir Robert Jones ± helped Hunt to turn her home into a hospital in 1900 1900s ± the start of the recruitment of more orthopedic nurses 1937 ± two-year training program for ONs, provides good training ground

ATTRIBUTES that enable the nurse to judge when to act and when to empower patients:
Good relationship and communication skills Intuitive nursing actions(develop to knowledge, skills, values and beliefs) The science of nursing involves the application of knowledge and skills to specific patient needs. Nurses need to keep pace with changes in nursing and medical knowledge and adapt to the technology involved in care. In addition, they need expert knowledge of the patient¶s orthopedic condition to understand how their needs are met and how complications are prevented.

From medical to a nursing model of care An illness-focused to a health-focused care Viewing the patient as a disease or condition to a holistic patient-centered view of care

dynamic, changeable state which requires the ability to adapt to circumstances, including changes in quality of life and the interplay of attitudes, emotions, thoughts and feelings.

Dimensions of Health:
Physical Social Mental Spiritual

Increased life expectancy Changes in workplace (musculoskeletal stress, injury) Increased leisure time (sports injury) Changes in the infectious dse with the emrgence of multiresistant pathogens Surgical and technological advances

ILL PREVENTION -- Health oriented approach to nursing practice in promoting health and prevention of illness

Primary Prevention ± actions taken before disease or disability takes place; accident prevention, immunization, and advice on preventing sports injuries Secondary prevention ± early detection and the treatment of health problems Tertiary prevention -- Aims to avoid the progression of ill health and potential complications

Health professionals have a moral and professional responsibility to be involved in maintaining and improving the health of the patients and the community Health promotion is basically achieved thru health education

5 Approaches to Health promotion accdg to Kiger: Political action ± patient¶s rights Media/propaganda ± aims to persuade, motivate and make people change their behavior Community models ± accept that professional and lay people can work together to create change Information-giving/medical models ± provide info through professional expertise Educational model ± accepts that beliefs, values and feelings influence behavior

Have led nurses to develop their skills in identifying their emergency care

Specialist role continues to develop Pre-admission clinics ± enables nurses to develop their skills in patient assessment, diagnostic process and interpretation of medical investigation.

Good rehabilitation reduces length of hospital stay

To maximize the patient¶s independence physically and socially, allowing them to return to their normal place of living.

Rehabilitation must include the cognitive and emotional aspects of recovery.

Traditionally, orthopedic care has been delivered mainly within in-patient setting. Over the years, provision of care has been deinstitutionalized. The following circumstances are effects of the transference of responsibility from secondary to primary care: Early screening and pre operative assessment in primary care for elective surgery More minor surgery in general practice more HaH More community hospital offer rehab Provision of health maintenance and health promotion services in primary care

ORTHOPEDIC LAIASON NURSE ± a specialist orthopedic nurse which lead and coordinate the assessment process and laiase between the primary and secondary care environments
The laiason nurse communicate with the primary care team and hospital staff to ensure the patient receives the required investigation and treatment.

The shift in emphasis toward a primary care-led health service has resulted in a more minor orthopedic surgery being carried out in general practice. Minor procedures such as removal of ganglions or removal of wires (managed in primary care).

HOSPITAL-AT-HOME This aims to facilitate early discharge of patients from hospital, prevent admission or provide palliative care in patient¶s home.
It aims to facilitate discharge for elective or trauma patients as early as 3-4 days following a surgery. Such schemes provide intensive levels of care for rehabilitation of acutely ill patients in their own home.

Effectiveness of HaH
Less costly due to the reduction in terms of access to health care facility in case of emergency Gives patients and informal carer the choice about whether to be involved in an early discharge scheme

Considerations for HaH
Appropriateness of home condition in terms of accessibility in case of emergency Patient¶s over all health status Patient¶s psychological aspect Ability of family members to take on the role of informal carer.

Patient Satisfaction ± providers of health services are increasingly expected to supply information relating to patient outcomes and clinical effectiveness following various treatment and intervention
Patient¶s participation in their care and satisfaction with delivery directly influence treatment compliance and patient wellbeing

*Pre operative Assessment ± traditionally,
orthopedic patients booked for elective surgery has been assessed in hospital based pre operative assessment units. This gives the nurse the opportunity to provide detailed information for the patient and carer about the surgery and post op care

Done 2-4 weeks before the surgery date This also helps the nurse identify possible problems or complications

Three importance of Patient Satisfaction
Patient satisfaction is known to be associated with better health outcomes Dissatisfied patients are often unable to take their custom elsewhere The need to develop a consumer based service model of healthcare.

Positive Impact of Satisfaction to Clients:
Patients are more likely to adhere to medical advice Satisfaction has a placebo effect or psychological well-being Patient outcomes ± is necessary to demonstrate clinical effectiveness.

Review of Anatomy and Physiology
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

Movement Posture Support Protection of vital organs Storage of minerals Heat production Propulsion of blood Movement of food in GIT and urine in the ureters

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

Structure of the Muscle
Epimysium ± outermost layer that surrounds the muscle. Perimysium ± separate the muscle tissue
into small sections.

Endomysium ± thin covering of a fascicle

Skeletal Muscles¶ Actions

PRIME MOVERS ± muscles whose contractions actually produces the movement. SYNERGISTS ± muscles that contract at the same time as the prime mover, helping it produce the movement so the prime mover can produce a more effective movement. ANTAGONISTS ± muscles that relax while the prime mover is contracting.



Different Contractions of the Skeletal Muscles

ISOTONIC CONTRACTIONS -- shorten muscle length while maintaining muscle tension generating movement.

2. ISOMETRIC CONTRACTIONS -- tighten the muscle by increasing muscle tension without shortening the muscle. -- does not usually produce direct movement.

Different Contractions of the Skeletal Muscles
3. TWITCH CONTRACTIONS -- quick, jerky reactions to a single stimulus. -- muscle shortens for a fraction of a second. 4. TETANIC CONTRACTIONS -- serial, continuous contractions, in which individual contraction can¶t be distinguished.

Different Contractions of the Skeletal Muscles
5. TROPPE (Staircase Phenomenon) -- series of increasingly stronger twitch contractions occurring in response to repeated stimuli of constant intensity. 6. FASCICULATION -- abnormal contraction visible through the skin as a slight ripple. -- occurs after neuron destruction

Different Contractions of the Skeletal Muscles
7. CONVULSIONS -- abnormal, violent rhythmic contractions and relaxations of muscle groups.

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 Functions 1. Locomotion 2. Protection 3. Support and lever 4. Blood production 5. Mineral deposition

There are two divisions of the skeleton AXIAL± body upright structure with 80 bones -- consists of the: skull, vertebral column,
and ribs

APPENDICULAR ± body appendages with 126

-- consists of the arms, hips and legs

1. 2. 3. 4.

Long bones ± length exceeds breadth and

Short bones ± equal in main dimensions found
mainly on hands and feet

Flat bones ± primarily made up of cancellous
bone tissue

Irregular bones ± irregular in shape

Difference between Male and Female Skeletons
Male skeletons are larger and heavier than female skeleton Male pelvis--deep and funnel shaped with narrow pubic arc; female pelvis± shallow, broad, and flaring with wider pubic arc

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

Gait Posture Muscular palpation Joint palpation Range of motion Muscle strength

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, assist in ambulation as ordered, mild soreness of joint for 2 days, joint rest for a few days, ice application to relieve discomfort

LABORATORY PROCEDURES 3. 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 PROCEDURES 4. 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

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 Pathologic conditions

TYPES OF FRACTURE 1. Complete fracture
Involves a break across the entire crosssection

2. Incomplete fracture
The break occurs through only a part of the cross-section

BROAD CLASSIFICATION OF FRACTURE: 1. Close or simple fracture
The fracture that does not cause a break in the skin

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

Classification of Fracture as to Pattern:

1. Transverse fracture
The break runs across the bone

2. Oblique fracture
The break runs in slanting direction 45 degrees angle

3. Spiral fracture
The break coils around the bone

4. Longitudinal fracture
The break runs parallel to the bone

Classification as to Appearance:

Comminuted fracture
Bone splintered into fragments

Impacted fracture
When fractured ends of the bone are pushed into each other

Compressed fracture
A condition in which a bone, particularly the vertebra collapses

Depressed fracture
Usually occurs in the skull with the broken bone being driven inward

Greenstick 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

ASSESSMENT FINDINGS 1. Pain Continuous and increases in severity Muscle spasm accompanies the fracture as a reaction of the body to immobilize the fractured bone

ASSESSMENT FINDINGS 2. Loss of function Abnormal movement and pain can result to this manifestation

ASSESSMENT FINDINGS 3. Deformity Displacement, angulations or rotation of the fragments causes deformity

ASSESSMENT FINDINGS 4. Crepitus A grating sensation produced when the bone fragments rub each other


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 may be 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 fracture

Emergency First aid splinting

MEDICAL MANAGEMENT 1. Principles of fracture treatment
Reduction of fracture Maintenance of realignment by immobilization Restoration of function

2. Reduction
Closed manipulation using casts or sling Open reduction External fixation Traction

3. Immobilization
the most important phase in obtaining union of fracture fragments.

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

Stages of Bone Healing 1. Formation of hematoma
When a bone is fractured, blood extravasates between and around the fragments and the bone marrow.

2. Cellular proliferation
Periostal elevation, granulation tissue containing blood vessels, fibroblasts and osteoblasts

3. Callus formation
Differentiated tissue bridging the fracture

4. Ossification
Final laying down of bone State in which the fracture ends have knit together

5. Remodeling
When consolidation is completed, the excess cells are absorbed. Compact bone is being formed

Average period for firm union of various bones are as follows:
Clavicle Radius-ulna Metacarpals Femur Fibula Phalanges Humerus Lower 3rd radius Tarsals Metatarsals 3-4 weeks 6-13 weeks 4 weeks 12 weeks 12-14 weeks 3 weeks 6 weeks 4 weeks 6-8 weeks 5-6 weeks

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 5. Heterotrophic ossification


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

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

Displacement of a bone from its normal joint position to the extent that articulating surface partially lose contact. CAUSES
Trauma Disease Congenital condition

Burning pain Deformity Stiffness and loss of joint function Moderate or severe edema around the joint

NURSING MANAGEMENT To lessen swelling, elevate the affected extremity. Assess affected extremity for signs for neurovascular problems. Give pain medications as ordered by the doctor. Provide appropriate care if patient is immobilized. Encourage patient to exercise.

Common musculoskeletal problems
The Nursing Management

Nursing Management of common musculoskeletal problems
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

Nursing Management
PAIN 3. Administer analgesics as prescribed 4. Assess the effectiveness of pain measures

Nursing Management
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

Nursing Management
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 meal time Offer finger foods that can be handled by patient Keep suction equipment ready

Nursing Management
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

Musculoskeletal Modalities

Traction Cast

Nursing Management
A method of fracture immobilization by applying equipments to align bone fragments Used for immobilization, bone alignment and relief of muscle spasm

Nursing Management
TRACTION It is the act of pulling or drawing which is associated with counter traction. Traction means that a pulling force is applied to a body part or extremity while a counter traction pulls in the opposite direction.

Nursing Management
TRACTION Purposes of Traction
1.Traction is often used in the treatment of fractured extremities To lessen muscle spasm To reduce fracture To provide immobilization To maintain alignment

Nursing Management
2. Traction is also used to correct, lessen or prevent deformities as in the case of arthritis patients with flexion contraction. 3. Prior to total hip surgery, surgeons may apply skeletal traction in an attempt to stretch muscles to obtain more working space. 4. Lessens muscle spasm in back pain

Nursing Management
Traction: General principles 1. patient¶s position must be supine 2. avoid friction 3. allow the weights to hang freely 4. apply traction continuously 5. there should be an adequate counter traction 6. line of pull must be in line with deformity

Nursing Management
Traction: What to watch out for? 1. Impaired circulation in the extremities 2. Observe for DVT, skin irritation and breakdown 3. Signs of infection
Provide pin care

4. Deformity like foot drop
Provide foot board

Skin traction
Application of a pulling force to the skin from where it is transmitted to the muscles and then to the bones Uses adhesive and non-adhesive type of materials

Skeletal traction
The pulling force is applied directly to the bone using pins and wires such as Kirshner¶s wire, Steinman¶s pin, Vinki¶s skull retractor and crutch field tongs.

Manual traction
Pulling force is applied by hands of the operator

Application of skeletal traction«

Equipments for Balanced Skeletal Traction
Thomas splint Pearson¶s attachment Rest splint 5 slings (different sizes) 5 safety pins Cord pulleys

Equipments cont¶n
Weight traction and suspension weight bag Steiman¶s pin holder Kirshner¶s wire holder Overhead trapeze Foot board Balkan frame

Different Kinds of Traction

Halo ± femoral traction 

Skin Severe scoliosis


Head-halter traction 

Skin Several cervical sprains, cervical strains, mild cervical trauma, Pott¶s disease

Different Types of Traction 3. Dunlop traction 

Skin Supracondylar fracture of the humerus

4. Buck¶s traction 

Skin (adhesive tape) Injuries to the hip and femur bone

Different Types of Traction 5. Halo-pelvic traction 

Skin Scoliosis

6. Pelvic traction 

Skin (non-adhesive) Low back pain

Different Types of Traction 7. Cotrel  

Skin (combination of head halter and pelvic traction) Scoliosis

8. Pelvic traction 

Skin (non-adhesive) Low back pain, lumbar affection

Different Types of Traction 9. Bryant¶s traction 

Skin (adhesive tape) Femur fracture, congenital hip dislocation in infants less than 6 years old

10. Boot cast traction 

Skin Hip and femur fracture, post poliomyelitis with residual paralysis

Different Types of Traction 11. 90-90 lower extremity traction
Skin or skeletal  Displaced femoral fracture 

12. Stove-in Chest
Skin  Severe chest injury with multiple fracture 

Different Types of Traction 12. Balance skeletal traction 

Skeletal Femoral affectation

13. Side arm traction (90-90 upper extremity traction) 

Skeletal or skin Supracondylar fracture of the humerus

14. Crutchfield Tong and halo traction
Skeletal  Cervical fracture or subluxation 

14. Russel traction
Skin (adhesive)  fracture of femur 

Head-halter traction

Skull traction

Dunlop traction

Pelvic traction

Acetabular traction

Buck¶s Traction And Russel¶sTraction

Banjo Splint
Peripheral nerve injury

Bilateral Long Leg Brace

Chair Back Brace
Lumbo-sacral affectation

Cock-up Splint
Wrist drop

Dennis Brown Splint
Congenital clubfoot or talipes

Finger Splint
Fractured digits

Forester Brace
Cervico-thoraco-lumbar spine affectation

Jewette Brace
Lower thoracic and upper lumbar affectation

Milwaukee Brace
Scoliosis T9 and above

L-S Corset
Thoraco-lumbar affectation

Philadelphia brace

L-S Corset

8 Figure Brace

Velpeau Brace

Nursing Management
CAST Immobilizing tool made of plaster of Paris or fiberglass Provides immobilization of the fracture

Nursing Management
CAST: types 1. Long arm 2. Short arm 3. Spica

Casting Materials
Plaster of Paris
Drying takes 1-3 days If dry, it is SHINY, WHITE, hard and resistant

Lightweight and dries in 20-30 minutes Water resistant

Nursing Management
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

Nursing Management
CAST: General Nursing Care 5. 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

Nursing Management
CAST: General Nursing Care 7. 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

Different Kinds of Cast

Common Musculoskeletal conditions
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

3. Bone pain

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 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

Osteoporosis Nursing Interventions Take calcium supplements with meals Take alendronate with an EMPTY stomach with water Instruct on intake of Hormonal replacement

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

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

OSTEOARTHRITIS The most common form of degenerative joint disorder

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 The joint involvement is ASYMMETRICAL This is not systemic, there is no FEVER Usual joint are the WEIGHT bearing joints

OSTEOARTHRITIS: Assessment findings 1. Joint pain Caused by
Inflamed synovium Stretching of the joint capsule Irritation of nerve endings

OSTEOARTHRITIS: Assessment findings 2. Stiffness commonly occurs in the morning after awakening Lasts only for less than 30 minutes DECREASES with movement

OSTEOARTHRITIS: Diagnostic findings 1. X-ray Narrowing of joint space Loss of cartilage Osteophytes 2. Blood tests will show no 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 NSAIDS Use of Glucosamine and chondroitin Topical analgesics

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

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 stiffnessSYMMETRICAL 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

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
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

Rheumatoid arthritis
Diagnostic test 1. X-ray
Shows bony erosion

2. Blood studies reveal (+) rheumatoid factor, elevated ESR and CRP 3. Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing WBC and inflammatory proteins

Rheumatoid arthritis
MEDICAL MANAGEMENT 1. Therapeutic dose of NSAIDS and Aspirin 2. Chemotherapy with methotrexate, antimalarials, gold therapy and steroid 3. For advanced cases- arthroplasty, synovectomy 4. Nutritional therapy

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

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

Gouty arthritis
Medical management 1. Allupurinol 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

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