MUSCULOSKELETAL SYSTEM

-consists of bones, muscles, tendons, cartilage, ligaments & bursae

BONES
-provide support to skeletal framework; assist in movement as lever,
hematopoiesis & site of storage for calcium & phosphorus
Types-
Long- central shaft called diaphysis is made of compact bone & 2 ends
called epiphysis are made of cancellous bone (femur & humerus)
Short- cancellous bone covered by thin layer of compact bone like the
carpals & tarsals
Flat- 2 layers of compact bones separated by layer of cancellous bone like
skull & ribs
Irregular- sizes & shapes vary like vertebrae & mandible

JOINTS
-where articulations of bones occur; movable joints provide mobility & stability
Classification
Synarthrosis- immovable joints like sutures of the skull
Ampiarthrosis- partially movable joints
Diarthrosis (synovial): freely movable like knees; have joint cavity between
articulating bones; articular cartilage covers the ends of bones & fibrous
capsule encloses the joint; capsule is lined with synovial membrane that
secretes synovial fluid to lubricate the joint & reduce friction

MUSCLES
-provide shape to body, protect bones, maintain posture & cause movement of
body parts
Types
Cardiac- involuntary & found only in the heart
Smooth- involuntary & found in walls of hollow structures
Striated- voluntary & found in skeletal muscles
Skeletal muscles are attached to the skeleton at point of origin & to bones at
point of insertion; they have properties of contraction, extension & elasticity
allowing isotonic (shortening & thickening of muscle) & isometric (increased
muscle tension) movements

CARTILAGE
-form of connective tissue whose functions are to cushion bony prominences &
offer protection were resiliency is needed

TENDONS
-attach bone to bone
-dense, fibrous connective tissue
LIGAMENTS
-attach muscle to bone
-dense, fibrous connective tissue

ASSESSMENTS
-includes Past health, Family health, Personal, Social, Nutritional, Life-style
Histories & present history of muscles & joints like pain, swelling, limitation of
movement
-also PE & lab tests like muscle enzymes (CPK, aldolase, SGOT {AST}), ESR,
Rheumatoid factor, complement fixation, LE prep, ANA, Anti-DNA, CRP, uric
acid, X-rays, urine myoglobin, urinalysis, CBC; Bone scan which measures
radioactivity in bones 2 hours after injection of radioisotope detects bone
tumors & osteomyelitis (have client void pre-procedure); Arthroscopy where
fiberoptic endoscope is inserted into joint to visualize, perform biopsies & remove
loose bodies from joint (routine pre- & post- Op care); Arthrocentesis where
needle is inserted into joint to aspirate synovial fluid for diagnostic purposes or
remove excess fluids; Myelography where LT is used to withdraw small amount
of CSF & dye is injected to detect tumors or herniated discs (if oil based dye is
used keep client flat & if H2O based dye is used elevate head 30-450 to
prevent upward displacement of dye which may cause meningeal irritation &
seizures; Electromyelography which measures & records activity of contracting
muscles in response to electrical stimulation differentiate between muscle
disease & motor neuron dysfunction

Immobility Complications Preventions

CVS:
Complications- orthostatic hypotension, DVT pulmonary embolism & increased
workload of the heart
Nursing Interventions- active or passive ROM exercises, plantar-flexion &
dorsiflexion foot exercises; quadriceps & gluteal setting exercises; frequent
turning, slow mobilization, no pillows behind the knees, antiembolic stockings
Respiratory:
Complications- decreased chest expansion & accumulation of secretions in
respiratory tract
Nursing Interventions- frequent turning & encourage deep breathing & coughing
Integumentary:
Complications- skin integrity breakdown 20 to friction, pressure or shearing
Nursing Interventions- frequent turning & repositioning; monitoring of skin; gentle
skin massage over bony prominences
GIT:
Complications- constipation
Nursing Interventions- frequent movement & turning; increase fluid & dietary fiber
intake; use of laxatives or stool softeners as ordered
Musculoskeletal:
Complications- muscular atrophy weakness; contractures, osteoporosis
Nursing Interventions- active & passive ROM & isometric exercises; encourage
participation in ADL & proper positioning & repositioning of bones
GU:
Complications- increased calcium excretion from bone destruction calculi
formation stasis of urine in kidney & bladder increased urine pH UTI
Nursing Interventions- increase fluid intake; decrease calcium intake, use of acid
ash in diet & commode if possible
Neurologic:
Complications- sensory deprivation
Nursing Interventions- frequently orient patient, provide diversional activites &
inclusion of patient in decision making activities

ROM Exercises
-prevent contractures & increase or maintain muscular tone & strength
Types
Active: carried out by patient to increase muscle tone & joint mobility
Passive: carried out by RN without assistance from client to maintain joint
mobility only don’t move part beyond existing ROM
Active Assistive: moves body part as far as possible & RN completes
movement
Active Resistive: contraction of muscles against opposing force
increases muscle size & strength

Isometric Exercises
-active exercises through contraction & relaxation of muscle with no joint
movement & muscular length don’t change
-client increases tension in the muscle for several seconds relaxes maintains
muscle size & strength

Assistive Devices for Walking

Cane:
Types: single, straight-legged cane; tripod & quad cane
Nursing Interventions- teach to hold cane in hand opposite affected extremity &
advance cane at same time affected leg is moved forward

Walker
-has 4 legs to support
Nursing Interventions- teach to hold upper bars of walker at each side move
forward & step into it

Crutches-ensure proper length by asking client to assume erect position with the
top of crutch 2 inches below the axilla & the tip of each crutch 6 inches in front &
to the side of the feet; client’s elbows should be slightly flexed when hand is on
the grip & weight shouldn’t be placed on the axillae
Types of gaits
 4-point gait- used when weight bearing is allowed on both extremities;
advance right crutch step forward with left foot advance left crutch
step forward with right foot
2-point gait- typical walking pattern & acceleration of the 4-point gait; step
forward moving both right crutch & left leg simultaneously step forward
moving both left crutch & right leg simultaneously
3-point gait- used when weight bearing is allowed in 1 extremity only;
advance both crutches & affected extremity several inches Maintain
good balance advance unaffected leg to crutches while supporting the
weight of the body on the hands
Swing-to-gait- used for clients with paralysis of both extremities who are
unable to lift feet from floor; both crutches are placed forward client
swings forward to crutches
Swing-through-gait- same indications as swing-to-gait; both crutches are
placed forward client swings body through crutches

Care for Casted Client

Types include long arm, short arm, long leg, short leg, walking cast with heel,
body cast, shoulder spica & hip spica

Casting Materials
Plaster of Paris: traditional; takes 24-72 hours to completely dry; prevent
dents to prevent pressure areas; shiny white, hard, resistant cast is dry
is kept dry since H2O may deform it
Synthetic Cast: fiberglass; strong, lightweight & sets in 20 minutes; can be
dried with cast dryer or hair blow dryer but some synthetic casts need
special lamp to dry out; H2O resistant but if becomes wet dry
thoroughly prevent skin problems under cast

Cast Drying Of Plaster Cast involves use of palms & not fingertips & use of
rubber or plastic-protected pillows with pillowcase along length of cast to support
cast when moving or lifting client; turn client q 2 hours reduce pressure &
promote drying don’t cover cast until dry (may use fan) don’t use hair dryer
or heat lamp to dry cast
Assessment: neurovascular checks distal to cast report diminished pulse,
cyanosis, blanching, coldness, and lack of sensation, inability to move fingers or
toes, excessive swelling, odor, bleeding or inflammatory signs to MD
General care: teach client to wiggle toes or fingers to improve circulation,
reinforce teaching on crutch walking, avoiding getting cast wet; if dried cast
becomes wet may use blow dryer on low setting over wet spot; teach to avoid
scratching or inserting FB under cast direct cool air from blow-dryer; report
signs of impaired circulation; clean surface soil on plaster cast with slightly damp
cloth; mild soap maybe used for synthetic & to brighten cast apply white polish
Care of Client in Traction
-traction is a pulling force exerted on bones to reduce & or immobilize fractures,
reduce muscle spasm, correct or prevent deformities
Types
Skin Traction- attached to moleskin or adhesive strip secured by elastic
bandage or other special device used to cover the limb
Buck’s extension- exerts straight pull on affected limb; used to temporarily
immobilize leg in client with fractured hip; shock blocks at foot of bed
produce counter traction & prevent client from sliding down in bed; may
turn to unaffected side but place pillows between legs before turning
Russell’s traction- knee is suspended in sling attached to rope & pulley on
Balkan Frame upward pull on knee weights are attached to foot of
bed creating horizontal force on tibia & fibula; used to stabilize femoral
shaft fractures while awaiting surgery; elevating foot of bed slightly
produces countertraction; head of bed should remain flat foot of bed
usually elevated by shock blocks to provide countertraction; check
popliteal area frequently & pad the sling with felt covered by stockinette;
may turn slightly from side to side without turning body below waist
Cervical traction- cervical head halter attached to weights that hang over
head of bed; used for soft tissue damage or degenerative disc disease of
cervical spine reduce muscle spasm & maintain alignment; usually
intermittent traction; elevate head of bed to provide countertraction; pad
chin area & protect ears
Pelvic Traction- pelvic girdle with extension straps attached to ropes &
weights; used for low-back pain reduce muscle spasm & maintain
alignment; usually intermittent traction; client in semi-Fowler’s with knee
bent secure pelvic girdle around iliac crests
Skeletal traction- applied directly to the bones using pins, wires or tongs
(Crutchfield tongs) that are surgically inserted; used for fractured femur, tibia,
humerus or cervical spine
Balanced Suspension traction: produced by counterforce other than the
client’s weight; extremity floats or balances in traction apparatus; client may
change position without disturbing line of traction
Thomas splint & Pearson Attachment: hip is flexed at 200 use foot plate to
prevent foot drop; usually used with skeletal traction in femoral fractures; pad top
of splint with same material as in Russell’s traction
Nursing Interventions: check traction apparatus to ensure ropes are aligned &
weights are hanging freely, bed is positioned properly & line of traction is within
the long axis of the bone; maintain client in proper alignment (don’t rest affected
limb against foot of bed; monitor neurovascular status, DVT, skin irritation &
breakdown; prevent footdrop by providing footplate, encourage plantar flexion &
dorsiflexion exercises; provide pincare for skeletal traction (cleansing & antibiotic
application) & monitor for S/S infection; assist with ADL; prevent immobility
complications; encourage ROM exercises

DISORDERS OF THE MUSCULOSKELETAL SYSTEM

Rheumatoid Arthritis
-chronic systemic disease with inflammatory joint changes & affects other
structures
-women > men between ages 35-45; cause unknown but may be autoimmune or
genetically caused; fatigue, cold, emotional stress & infection are predisposing
factors; symmetrical joint involvement affecting smaller peripheral hand joints &
also commonly involves the wrists, elbows, shoulders, knees, hips, ankles &
jaw progress through 4 stages of deterioration synovitis pannus
formation fibrous ankylosis bony ankylosis
Clinical findings: with remissions & exacerbations; fatigue, anorexia, malaise,
weight loss, slight fever; warm, painful & swollen joints, with limited motion, stiff in
the morning & after periods of inactivity crippling if prolonged; muscle
weakness; (+) additional articular manifestations like SC nodules, eye, vascular &
lung problems; X-ray shows various stages of joint disease, (+) anemia,
increased ESR & CRP, (+) ANA & rheumatoid factor
Therapeutic Management: ASA, NSAIDs & Gold compounds in injectable (given
IM for 3-6 months to be effective & with side effects that include proteinuria,
mouth ulcers, skin rash, Aplastic anemia) or oral forms where smaller doses are
effective but with diarrhea as side effect; steroids given intraarticular to suppress
inflammation & systemically if others fail; Methotrexate or Cytoxan to suppress
immune system with side effects like bone marrow suppression; PT & surgery
are also done for severely damaged joints (total hip or knee replacement)
Nursing Interventions: monitor joints & promote mobility; change position
frequently, provide comfort & control of pain & bed rest (provide firm mattress,
maintain proper body alignment, lie x ½ hour BID, avoid pillows under knees,
keep joints in extension; provide heat treatments for chronic cases & cold
treatments for acute cases; emotional & psychologic support; teach about meds
& side effects, assistive devices, energy conservation exercises, nutrition
application of splints

Osteoarthritis
-chronic non-systemic disorder of joints characterized by degeneration of
articular cartilage; men & women affected equally & increases with age
-cause unknown but aging, obesity & joint trauma are factors
-weight bearing joints (spine, knee, hips) & interphalangeal joints of fingers are
commonly affected
Clinical findings: pain & stiffness of joints, (+) Heberden’s nodes which are bony
overgrowths at terminal interphalangeal joints, (+) decreased ROM & crepitation,
X-rays show deformity & ESR is slightly elevated
Nursing Interventions: assess joints for pain & ROM, relieve strain & further
trauma by rest, assistive devices, proper posture, weight reduction & excessive
weight bearing; maintain joint mobility, promote comfort & pain; prepare for joint
replacement, teach about meds & side effects, diet & use of heat & cold

Gout
-disorder of purine metabolism high levels of uric acid in blood precipitation
of uric acid crystals in joints joint inflammation
- (+) familial tendency & most often in males
Clinical findings: joint pain, redness, heat, swelling; joints of foot especially great
toe & ankles usually; headache, malaise, anorexia, tachycardia, fever; tophi in
outer ear, hands & feet (chronic tophaceous stage), (+) increased uric acid levels
Therapeutic Management: for acute attack Colchicine IV or PO (D/C if with
diarrhea) & NSAIDs; for prevention, uricosuric meds which increase renal
excretion of uric acid like Probenecid (Benemid) & Allopurinol (Zyloprim) which
inhibits uric acid formation; low purine diet, joint rest & protection & heat or cold
therapy
Nursing Interventions: assess joints for pain, ROM & appearance; bed rest & joint
immobility, give anti-gout meds & analgesics; increase fluid intake to 2L-3L/day;
bed cradle & local heat or cold application; client teaching on meds & side
effects, low-purine diet (avoid shellfish, organ meats, sardines, sweat breads &
anchovies), limitation of alcohol use, weight reduction & exercise

SLE
-chronic connective tissue disease involving multiple organs; more frequently in
young women; cause is unknown but it may be immune, genetic or viral
-defect in immunologic system antibody production against components of
client’s own cell nucleiaffects cells in body involves kidneys, heart, joints,
CNS, skin & pulmonary system
Clinical findings: fatigue, fever, anorexia, weight loss, malaise, joint pains,
morning stiffness, erythematosus rash on face, neck or extremities may occur,
butterfly rash, photosensitivity with rash in areas exposed to sun, oral or
nasopharyngeal ulcerations, alopecia; proteinuria & hematuria renal failure;
peripheral neuritis, organic brain syndrome seizure & psychosis; (+) pericarditis
& pleurisy; increased infection susceptibility; increased ESR, (+) ANA, LE prep,
Anti-DNA antibody, decreased WBC, Hgb/Hct & platelets; chronic false (+) test
for syphilis
Therapeutic Management: ASA & NSAIDs, steroids & immunosuppressive
agents like Azathioprine (Immuran) & Cyclophosphamide (Cytoxan);
plasmapharesis & supportive therapy
Nursing Interventions: monitor S/S to determine systems involved, VS, I & O,
daily weights; give meds as ordered,, seizure precautions, psychologic &
emotional support; teach client disease process, therapeutic regimen, rest, daily
heat & exercise, avoidance of stress & direct sun exposure; regular follow up

Osteomyelitis
-open wound or direct extension from infected adjacent tissue  infection of
bone & surrounding tissues bone destruction; S.Aureus is common organism
-acute or chronic
Clinical findings: fatigue, fever, anorexia, malaise, pain & tenderness of bone,
difficulty with weight bearing (+) drainage from site; WBC & ESR increased, (+)
blood culture
Nursing Interventions: give analgesics & antibiotics; aseptic technique in dressing
changes, maintain proper body alignment & change position frequently prevent
deformities; psychologic support; teach on meds & side effects & complications
of recurrence; prepare for surgery like Incision & drainage of bone abscess;
Sequestrectomy which is removal of dead, infected bone & cartilage; Bone
grafting after repeated infections & Leg Amputation

Fractures
-break in bone continuity
-pathologic fractures are spontaneous bone breaks found in certain diseases like
osteoporosis, osteomyelitis, and multiple myeloma & bone CA
Types: complete may be transverse, oblique or spiral or incomplete; may be
comminuted, open or closed –DISCUSSED FURTHER IN TOPIC OF TRAUMA
Clinical findings: pain, loss of motion, crepitus, swelling, ecchymosis, (+) X-ray
revealing area of break
Therapeutic Management: traction, closed reduction, open reduction & casting
Nursing Interventions: emergency care for fractures, monitor neurovascular
status & compartment syndrome where swelling increase edema & pressure
within muscle compartment irreversible neuromuscular damage within 4-6
hours (weak pulse pallor cyanosis paresthesias & severe pain; observe for
fat emboli in multiple long-bone fractures (respiratory distress, fever, mental
disturbance, petechiae); diet high in protein & vitamins; encourage high fluid
intake prevent constipation, renal calculi & UTIs; provide care for client in
traction, cast or open reduction; client teaching on cast care, crutch walking &
signs of complication

Open Reduction & Internal Fixation

-requires surgery to realign bones using internal fixation with pins, screws, wires,
plates, rods or nails
-indicated in compound fractures, fractures with neurovascular compromise,
fractures with widely separated fragments; comminuted fractures, fractures of the
femur & fractures within joints
Nursing Interventions: routine pre & post-Op care; meticulous skin care; infection
precautions; maintain proper limb alignment, neurovascular checks

Fractured Hip
-fracture of the head, neck (intracapsular fracture) or intratrochanteric area of the
femur
-more often in elderly women; predisposed by osteoporosis & degenerative bone
changes
Clinical findings: pain on affected limb & affected limb appears shorter &
externally rotated; X-ray reveals hip fracture
Therapeutic Management: Buck’s or Russell’s traction as temporary measures to
align affected limb & reduce pain of muscle spasm
Surgical Management: Open reduction & internal fixation with pins, nails or plate;
Hemiarthroplasty with prosthesis insertion (Austin Moore) to replace femoral
head
Nursing Interventions: care for fractured & client on Buck’s or Russell’s traction;
monitor confusion, orientation, neurovascular status, LOC, I & O, VS, bowel &
renal function & immobility complications; encourage use of trapeze for
movement; give analgesics & antibiotics & avoid over sedating; routine post-op &
pre-Op care; check dressings for bleeding, drainage, infection; turn to
unoperative side only use pillows in between legs while turning & when lying
on the side; DVT precautions; encourage quadriceps setting & gluteal setting
exercises; assist in getting out of bed 1st-2nd day post-Op; pivot or lift into chair
& avoid weight bearing until with MD consent; care for client with hip prosthesis

Total Hip Replacement

-replacement of acetabulum & head of femur with prosthesis in rheumatoid
arthritis or osteoarthritis & fractured hip with non-union
Nursing Interventions: routine pre- & post Op care; maintain hip abduction with
abductor splint or 2 pillows between legs & prevent external rotation by placing
trochanter rolls along leg; prevent hip flexion by keeping head of bed flat but may
raise bed to 450 when feeding; turn only on unoperative side assist client in
getting out of bed while avoiding weight bearing; teach to prevent adduction of
affected hip & limb avoiding crossing of legs & bending down or sitting in low
chairs; use raised toilet seat; monitor S/S infection; encourage exercise & partial
weight bearing  full weight bearing with MD consent

Herniated Nucleus Pulposus

-protrusion of nucleus pulposus (central intervertebral disc part) into spinal
canal compression of spinal nerve roots; more often in men; herniation usually
at 4th-5th intervertebral spaces in the lumbar area; heavy lifting or pulling & trauma
are predisposing factors
Clinical findings: Myelogram shows site of herniation plus
Lumbosacral: backpain radiating across buttock & down the leg (along
sciatic nerve); weakness of leg & foot on affected side; numbness &
tingling of foot & toes; (+) straight leg raise test that shows pain on raising
leg; depressed or absent Achilles tendon reflex; muscle spasm in lumbar
region; placed on pelvic traction & corset is used
Cervical disc: shoulder pain radiating down the arm to the hand;
weakness of affected upper extremity; paresthesias & sensory
disturbances; placed on cervical traction & cervical collar is used
Therapeutic Management: bed rest, meds like NSAIDs, muscle relaxants,
steroids epidurally & analgesics; local heat application & diathermy
Surgical Management: Discectomy with or without spinal fusion;
chemonucleolysis with injection of chymopapain into disc is used as alternative to
laminectomy in some cases reduce size & pressure on affected nerve root
Nursing Interventions: bed rest on firm mattress with bed board, assist in
applying pelvic or cervical traction; maintain proper body alignment; give meds;
prevent complications, pre-Op for chemonucleolysis by giving H 2-blocking agent
(Ranitidine) & diphenhydramine & steroids q 6 hours reduce allergic reaction,
post-Op for chemonucleolysis; monitor for anaphylaxis & less serious allergies &
neurologic deficits like numbness or tingling in extremities & inability to void;
teach back-strengthening exercises, good posture; use of body mechanics; meds
& side effects; weight reduction

Discectomy
-excision of intervertebral disc; used for herniated nucleus pulposus not
responsive to conservative treatment or with decreased sensory or motor status;
also for spinal decompression in spinal cord injury to remove broken bone
fragments or remove spinal neoplasm or abscess; spinal fusion may be done at
same time if with unstable spine
Nursing Interventions:
Pre-Op: routine care; teach log-rolling & use of bedpan
Post-Op routine care; position as ordered with lower spine surgery it’s
generally flat & with cervical spine surgery, slight head of bed elevation;
maintain proper body alignment avoiding neck flexion & applying cervical
collar in cervical surgery; turn client by log rolling & placing pillows
between legs; monitor bladder & bowel function, neurovascular, motor &
sensory status, respirations & dressings for hemorrhage & CSF leak; keep
suction & tracheostomy set available; promote comfort; give analgesics;
prevent immobility complications; assist with ambulation & if allowed to
sit use straight back chair & keep feet flat on floor; teach wound care &
S/S of infection, good posture maintenance & allow activity as ordered

Spinal Fusion
-fusion of spinal processes with bone graft from iliac crest stabilize spine; done
with laminectomy
Nursing Interventions: routine pre-Op & post-Op care for laminectomy; position
properly for lumbar keep flat on bed x 12 hours may elevate head of bed 20-
300 keep off back 1st 48 hours; for cervical elevate head slightly; assist with
ambulation usually out of bed 3rd-4th day post-Op, apply brace before getting
client out of bed & apply special collar for cervical spine fusion; promote comfort;
teach to wear brace x 4 months & lighter corset x 1 year post-Op; avoid bending,
stooping, lifting or sitting for prolonged periods x 4 months & encourage walking
& diet modifications weight reduction

Harrington Rod Insertion

-spinal fusion & installation of a permanent steel rod along spine; in moderate-
severe curvatures; results in increase in height & (+) body image
Nursing Interventions: routine pre-Op; log roll & don’t raise head of bed; teach
alternate methods of education since will have long recovery period

Limb Amputation-discussed in CVS lecture

Arthritis Drugs
Auranofin (Ridaura)
-mechanism of action is unclear but may partially reverse or stop joint
destruction
-most effective early in rheumatoid arthritis
Adverse Effects: nitroid crisis which is an anaphylactic reaction that
resembles effects of a large dose of nitroglycerin like tachycardia, flushing,
severe hypotension & light headedness; nitroid crisis isn’t common with
oral gold salt therapy; diarrhea; pruritic skin rashes, dermatitis, stomatitis,
blood dyscracias; glomerulonephritis
Nursing Implications: gold salts shouldn’t be given to hepatic & renal
disorders, hypertension, uncontrolled DM, CHF or those receiving
radiation therapy; baseline CBC prior to & during therapy; nitroid crisis is
more apt to occur with IM injection of gold salts test dose is given; VS
monitored & resuscitation equipment should be readily available; diarrhea
more severe with oral gold salts; PO is better tolerated than IM; overdose
is treated with Dimercaprol & BAL; IM is best given via the gluteal muscle;
teach patient that effects may be seen after several months

Aurothioglucose (Solganol) & Gold Sodium Thiomalate

(Myochrysine)
-both given weekly by IM only for several months non-compliance
problems occur
NSAIDS
-interfere with prostaglandin synthesis; alleviate inflammation & discomfort
of rheumatoid condition
-PO & IM preps
General Adverse Effects: GI irritation, skin rash & hypersensitivity, blood
dyscracias, CNS & GU disturbances

Ibuprofen (Motrin)
-for relief of mild-moderate pain, primary dysmenorrhea,
rheumatoid & osteoarthritis
Adverse Effects: may cause sodium or H2O retention,
thrombocytopenia, hemolytic anemia, acute renal failure,
hematuria, elevated liver enzymes
Nursing Implications: don’t take with aspirin, take with meals or
milk, and monitor liver & renal functions
 Naproxen (Flanax)
-for rheumatoid & osteoarthritis, ankylosing spondylytis, primary
dysmenorrhea, acute gout attacks, juvenile DM
Adverse Effects: same as in aspirin & ibuprofen
-Nursing Implications: same as in aspirin & ibuprofen

Indomethacin
-closure of PDA in premature infant, acute gout attacks,
moderate-severe refractory rheumatoid & osteoarthritis,
ankylosing spondylytis
Adverse Effects: GI distress, anorexia, severe headache, corneal
cloudiness, visual field changes
-Nursing Implications: need periodic ophthalmologic consult, don’t
take with ASA

Piroxicam (Feldene)
-acute or long term management of rheumatoid & osteoarthritis
Adverse Effects: high incidence of GI bleeding
-Nursing Implications: same as in aspirin, indomethacin & ibuprofen

Ketorolac (Toradol)
-short term pain management
Adverse Effects: renal impairment & GI bleeding in prolonged use
-Nursing Implications: don’t give longer than 5 days; may cause
anaphylaxis on 1st dose

Diclofenac (Voltaren), Etodolac (Lodine), Celecoxib (Celebrex),

Refecoxib (Bextra)
Acetaminophen
-analgesic & anti-pyretic action
-used in fever & pain control
Adverse Effects: rash, liver toxicity causing thrombocytopenia
Nursing Implications: monitor liver & kidney functions, CBC; may cause
psychologic dependence; notify MD if no relief of symptoms in 5 days
Antidote: N-Acetylcysteine