MUSCULO-SKELETAL NURSING

METABOLIC BONE DISORDERS

Osteoporosis
 A disease of the bone characterized by a decrease in the bone mass and
density with a change in bone structure

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
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
LABORATORY FINDINGS
 1. DEXA-scan
 Provides information about bone mineral density
 T-score is at least 2.5 SD below the young adult mean value
 2. X-ray studies
Medical management of Osteoporosis
 1. Diet therapy with calcium and Vitamin D
 2. Hormone replacement therapy
 3. Biphosphonates- Alendronate, risedronate produce increased bone
mass by inhibiting the OSTEOCLAST
 4. Moderate weight bearing exercises
 5. Management of fractures
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
Nursing Interventions:
 Take calcium supplements with meals
 Take alendronate with an EMPTY stomach with water
 Instruct on intake of Hormonal replacement

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
3. Improve bowel elimination
 Constipation is a problem of calcium supplements and immobility
 Advise intake of HIGH fiber diet and increased fluids

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
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

Risk factors
 1. Increased age
 2. Obesity
 3. Repetitive use of joints with previous joint damage
 4. Anatomical deformity
 5. genetic susceptibility
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
: 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
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

 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
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
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
7. Deformities are common in the hands and feet causing misalignment
8. Rheumatoid nodules may be found in the subcutaneous tissues

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

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

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

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
 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
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

 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

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

 5. Open fracture is managed by covering a clean/sterile gauze to prevent

contamination
 6. DO NOT attempt to reduce the facture

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,
For OPEN FRACTURE
 poor alignment and continuous pain
 1. Prevent wound and bone infection
 Administer prescribed antibiotics
 Administer tetanus prophylaxis
 Assist in serial wound debridement
 2. Elevate the extremity to prevent edema formation
 3. Administer care of traction and cast

FRACTURE COMPLICATIONS
Early:
 1. Shock
 2. Fat embolism
 4. Infection

Late:
 1. Delayed union
 2. Avascular necrosis
 3. Delayed reaction to fixation devices
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

 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

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

:
 2. Administer drugs
 Corticosteroids
 Dopamine
 Morphine

:
 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

 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