Medical and Surgical Nursing

Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

MEDICAL AND SURGICAL NURSING

Musculoskeletal System

Lecturer: Mark Fredderick R. Abejo RN,MAN

______________________________________________________________________________________________

COMMON HEALTH PROBLEMS OF THE ADOLESCENT

I. SCOLIOSIS
 lateral curvature of spine
 è may involve all or only a portion of SC
 è may be functional (2°) or structural (1° deformity)
 I. FUNCTIONAL SCOLIOSIS
 II. STRUCTURAL SCOLIOSIS

I. FUNCTIONAL SCOLIOSIS
 è compensatory mechanism related to unequal leg
length, EOR à constantly tilt head sideways
 è pelvic tilt related to unequal leg length & head
tilt à spinal deviation
 è C shaped curve - little change in shape of
vertebrae
 THERAPEUTIC MANAGEMENT of Functional
Scoliosis  Uneven Shoulders
1. correct the difficulty causing spinal curvature  Curve in Spine
2. unequal leg length (as is to medial malleolus)  Uneven hips
3. shoe lift
4. correct EOR A. ASSESSMENT
5. maintain good posture 1. Bra straps adjusted to unequal length
6. sit-ups, pushups, swimming 2. Difficulty buying jeans
3. Skirts & dresses hang unevenly
II. STRUCTURAL SCOLIOSIS 4. Bend forward
 idiopathic 5. Scoliometer: reading >7° ≈ 20°
 permanent curvature of spine accompanied By 6. PPT
damage to vertebrae 7. Chest Xray
 primary lateral curvature
 ® Thoracic convexity+ Compensatory second curve B. MANAGEMENT
↓ 1. Scoliosis (Long term)
 S-shaped curve appearance (rotation angulation) 2. <20° = no treatment; close observation until 18y/0
 family history = 30% but no specific inheritance 3. >20° = conservative non-surgical treatment, body
pattern brace, traction
 5x more girls > boys 4. >40° = surgery, spinal fusion
 Peak incidence 8-15 y/o 5. Bracing > 20° - 40° skeletally immature
 Most marked during pre-puberty (rapid growth) 6. Milwaukee brace (Thoracolumbar support)
7. worn under clothing
8. worn 23H/day
9. at night è Charleston Bending brace
10. Milwaukee Brace

1
MS Abejo
 Medical and Surgical Nursing
Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

11. Braces 14 ½ y/o ♀

16 ½ y/o ♂ A. ASSESSMENT
1. usually taller children (rapid bone growth)
12. Halo Traction 2. pain & swelling at tumor site
3. History of recent trauma ç not the cause
4. Pathologic fracture
5. Diagnostic biopsy
6. ↑ alkaline phosphatase fm rapidly growing bone cells
7. Metastatic workup
 CBC, UA
 CXR
 Chest CT Scan
 Bone scan

B. Therapeutic Management of Osteogenic Sarcoma

1. small tumor in leg – child has reached adult size
↓
Surgical removal of bone
+
Bone or metal prosthesis
If extensive è total hip amputation
C. NURSING MANAGEMENT
1. Health teaching how to apply braces 2. lung managements è thoracotomy - lobectomy,
2. Right fit pneumonectomy
3. Adjustment q3mos 3. pre-op chemotherapy
 methotrexate
 cisplatin
 doxorubicin
COMMON HEALTH PROBLEMS OF THE YOUNG ADULT  ifosfamide
4. present prognosis
 early detection è 60-65% cure rate
I. OSTEOGENIC SARCOMA
 è malignant tumor of long bone involving rapidly C. NURSING MANAGEMENT
growing bone tissue 1. Post-op: swelling disrupting neurologic & circulatory
 more commonly in boys > girls function
 common sites 2. proper position
 Distal femur (40-50%) 3. monitor
 Proximal tibia (20%)  Capillary refill < 5s
 Proximal humerus (10-15%)  (-) numbness & tingling
 History of radiation  Warm, pink
 Early metastasis 2° to ↑vascularity of bones 4. Post-op: Phantom Pain Syndrome
 Lungs – 25% brain, other bones 5. Nerve trunks continue to report pain
 Chronic cough 6. Need analgesics!
 Dyspnea
 Chest pains
 Leg pains

2
MS Abejo
 Medical and Surgical Nursing
Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

COMMON HEALTH PROBLEMS OF ADULT

I. RHEUMATIC DISEASES – “Arthritis”

 1° affects skeletal MS, bones, cartilages, ligaments,
tendons, joints of males & females of all ages.
 RHEUMATIC ARTHRITIS – Inflammatory Arthritis
 2-3x women > men
 Autoimmune reaction primarily occurs in synovial tissue

A. PATHOPHYSIOLOGY
1. Phagocytosis produces enzymes within joint
2. Enzymes break down collagen
1. Edema Extra - Articular Manifestations of Rheumatoid Arthritis
2. Proliferation of synovial membrane 1. fever, wt loss, fatigue, anemia, LN enlargement,
3. Pannus formation Raynaud’s phenomenon, Arterities, Scleritis,
 Destroys cartilage, erodes bones Sjogren’s pericarditis, splenomegaly
 Loss of articular surfaces & joint motion 2. Rheumatoid nodules – with Rheumatoid Factors
3. Muscle è degenerative Δs 3. ≈50% of Patients
4. Tendon & ligament elasticity & contractile 4. Usually non-tender & movable in subcutaneous
power lost tissues
5. Over bony prominences
6. May disappear spontaneously

C. Assessment & diagnostic of Rheumatoid Arthritis

1. Hx & PE
 Bilateral & symmetric stiffness
 Tenderness & swelling
 Temperature Δs in joints
 Extraarticular Δs
2. Rheumatoid Factor (+) 80%
3. ESR ↑
4. RBC C4 & C4 complement ↓
5. C Reactive proteins maybe (+)
6. ANA
7. Arthrocentesis: cloudy, milky, or dark yellow
8. X-ray: bone erosions, narrowed joint spaces
B. SIGNS AND SYMPTOMS
1. joint pain, swelling, warmth, erythema, lack of
function II. GOUT
2. joint fluid
3. small joints in hands, wrists, hips, elbows, ankles,
cervical spines, temporo-mandibular joint
4. acute
5. bilateral and symmetric
6. joint stiffness in AM > 30min

 è heterogenous group of conditions related to genetic

defect of purine metabolism è hyperuricemia
 oversecretion of uric acid
3
MS Abejo
Medical and Surgical Nursing
Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

 renal defect è ↓excretion of UA 9. Abrupt onset awakening patient at night

 combination 10. Subdues within 3-10 days even w/o treatment
 è males > females 11. Symptom free period (intercritical stage)
 è ↑ incidence w/ ↑ age & Body Mass Index 12. Tophi also found in aortic walls, heart valves, etc
 PRIMARY HYPERURICEMIA >7 mg/dl (0.4 fmol/L) 13. Definite Diagnosis
 usually faulty uric acid metabolism  Polarized microscopy of synovial fluid
 severe dieting or starvation  Uric acid crystals
 food high in purines  (+)
 heredity  PMN Leukocytes
 SECONDARY HYPERURICEMIA
 ↑ cell turnover C. MANAGEMENT
 Leukemia 1. Colchicine, NSAIDs è treatment of acute attack
 Multiple myeloma 2. Then management of Hyperuricemia after
 Anemia inflammatory process has subsided
 Psoriasis 3. Colchicine
 Uric acid under excretion 4. lowers deposition of uric acid & interferes w/
 SE of drugs (thiazide & furosemides) leukocytes & kinnin formation, thus reducing
 Low dose salicylates inflammation
5. Does not alter serum or urine levels of uric acid,
A. PATHOPHYSIOLOGY used in acute and chronic mgt.
1. Hyperuricemia è monosodium urate crystal 6. administer until pain relief or diarrhea
deposition 7. prolonged use è ↓Vit B12 absorption, GI upset
2. Sudden ↑ or ↓ of serum acid levels 8. Probenecid:Uricosuric agent
3. Inflammatory response  Inhibits renal reabsorption of urates
4. Tophi formation  ↑ urinary excretion of UA
5. great toe, hands, ear  Prevents tophi formation
6. èRenal urate lithiasis  S.E. nausea, rash, constipation
7. Chronic renal disease 9. Allopurinol: Xanthine oxidase inhibitor
8. IgG coating urate crystals – immunologic  Interrupts breakdown of purines before uric
acid is formed
B. SIGNS AND SYMPTOMS  Inhibits xanthine oxidase
1. Acute Gouty Arthritis  S.E. BM depression, vomiting, abdominal pain
 recurrent attacks of sever articular & peri- 10. Corticosteroids: Anti-inflammatory
articular inflammation
2. Tophi
 Crystalline deposits III. CARPAL TUNNEL SYNDROME
3. Gouty Nephropathy  entrapment neuropathy; median nerve at the wrist is
4. Uric Acid Calculi compressed by
5. Tophi in hand and ears  thickened flexor tendon sheath
 skeletal encroachment
 edema
 soft tissue mass

Stages of Gout
a. Asymptomatic Hyperuricemia
b. Acute Gouty Arthritis
c. Intercritical Gout
d. Chronic Tophaceous Gout

6. Metatarsophalangeal joint of big toe

7. 75% of patients
8. attack may be triggered by
 Trauma
 Alcohol  repetitive hand activities
 Dieting  also assoc w/ pregnancy, arthritis, hypothyroid
 Medications  characterized by pain & numbness, paresthesias,
 Surgical stress weakness along median nerve (thumb & 1st 2 fingers)
 Illness
4
MS Abejo
 Medical and Surgical Nursing
Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

 (+) Tinel’s sign

 (+) Night pain
 Treatment for Carpal Tunnel Syndrome
 rest splints
 avoidance of repetitive flexion
 NSAIDs
 Cortisone injections
 Laser release

IV. DEGENERATIVE JOINT DISEASE (Osteoarthritis)

 functional impact on quality of life
 primary (idiopathic) no prior event/disease
 secondary: r/t previous joint disease or inflammatory
disease
 increasing age
 often begins 34d decade
 peaks between 5th and 6th decade
 by age 75- 85 % either xray or clinical evidence C. PATHOPHYSIOLOGY
 But is 15-25% with significant symptoms
 ability of articular cartilage to resist microtrauma Genetic and Mechanical Previous joint
hormonal injury damage
A. RISK FACTORS factors
1. increased age – wear and tear Others
2. obesity
3. previous joint damage
Chondrocyte response
4. repetitive use (occupational or recreational)
5. anatomic deformity
6. genetic susceptibility Release of cytokines
7. congenital sublaxation-dislocation of hip
8. acetabular dysplasia
9. Legg-Calves Perthes Stimulation, production and release of proteolytic
10. slipped capital femoral epiphysis enzymes, metalloproteases, collagensase

B. SIGNS AND SYMPTOMS Resulting damage predisposes to more,,,

1. pain
2. stiffness
3. functional impairment
4. PAIN inflammation of synovium
5. inflammation of nerve endings in periosteum over D. ASSESSMENT
osteophytes 1. Physical Exam
6. stretching of joint capsules or ligaments 2. tender and enlarged joints
7. trabecular microfracture 3. X-Ray
8. intraosseous hpn 4. 30-50%
9. bursitis progressive loss of joint cartilage “narrowing of
10. tendinitis joints spaces”
11. muscle spasm 5. spur=ostephyte formation -> cartilage attempts to
12. STIFFNESS “morning” or after awakening<30 regenerate
min/ decreases with movement
E. MEDICAL MANAGEMENT of Osteoarthritis
1. Preventive measures to slow progress
b. weight reduction
c. prevention of injuries
d. joint rest
e. perinatal screening (congenital hip dysplasia)
f. ergonomic modification
2. Conservative Measures to Slow Progress of
Osteoarthritis
a. use of heat
b. weight reduction
c. joint rest
d. avoidance of joint overuse
e. orthostatic devices (splints, braces)

5
MS Abejo
 Medical and Surgical Nursing
Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

f. isometric and postural exercises 4. Epiphyseal- fracture thru epiphysis

g. aerobic exercises 5. Impacted- bone fragment is driven thru another
h. OcTherap and PhysTher bone fragment
6. Pathologic- occurs thru an area of diseased bone
F. SURGICAL MANAGEMENT 7. Stress- results from repeated loading without bone
1. use of heat and muscle recovery
2. weight reduction 8. Incomplete (greenstick) break thru only part of
3. joint rest cross section of bone
4. avoidance of joint overuse 9. Transverse-fracture straight across the bone
5. orthostatic devices (splints, braces) 10. Closed (simple)- no break in skin
6. isometric and postural exercises
7. aerobic exercises
8. OcTherap and PhysTher
9. Osteotomy- to alter the force distribution of the
joint
10. Arthroplasty- to replace diseased joint
compnonents
11. Viscosupplemetation-reconstitution of joint fluid
viscosity using hyaluronic acid
12. (Hyalgan, Synvise Rx)
13. Tidal Lavage of Knee – stimulate production of
synoviocytes
14. Approximately 6 months pain relief

G. NURSING MANAGEMENT
1. Pain management
2. Optimizing functional ability 11. Oblique occur at an angle across the bone (less
3. Pt referral stable than transverse)
4. Lifestyle changes 12. Comminuted one that produces several bone
5. Planning daily activities fragments
13. Spiral fracture that twists around shaft of bone
14. Open, Compound, Complex skin or muscle
extends thru fractured bone

COMMON HEALTH PROBLEMS ACROSS LIFESPAN

I. FRACTURE
 FRACTURE- break in the continuity of bone and
adjacent structures
 soft tissue edema
 hemorrhage into muscles and joints
 joint dislocation
 ruptured tendons
 severed nerves
 damaged blood vessels
 body organ damage secondary to force or fracture A. CLINICAL MANIFESTATIONS
fragments 1. pain
2. loss of function, abnormal movement
Types of fractures 3. deformity: displacement, angulation, rotation,
1. Complete break across entire cross section of bone swelling – VISIBLE or PALPABLE
(displacement) 4. shortening- 2.5-5cm r/t contraction of muscles
2. Open, Compound, Complex skin or muscle 5. crepitus – grating sensation
extends thru fractured bone 6. swelling and discoloration
a. Grade I clean wound <1cm
b. Grade II larger wound without extensive soft B. MANAGEMENT
tissue damage OPEN FRACTURE
c. Grade III highly contaminated 1. cover wound with a clean / sterile dressing
d. Compressed – bone has been compressed 2. do not attempt to reduce fracture
(ie. Vertebral fractures) 3. ASSESS NEUROVASCULAR STATUS DISTAL
3. Depressed- fragments driven inwards TO INJURY
e. (ie. Skull and facial bones)
6
MS Abejo
Medical and Surgical Nursing
Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

C. MEDICAL MANAGEMENT FRACTURE HEALING AND COMPLICATIONS

1. Reduction “setting the bone”
2. restore the fracture fragments to anatomical  Factors that Enhance Fracture Healing
alignment and rotation 1. immobilization of fracture fragments
 OPEN 2. maximum bone fragment contact
 CLOSED 3. sufficient blood supply
3. early Fracture reduction, gentle manipulation 4. nutrition
4. Nursing consideration written consent / analgesia 5. exercise: weight bearing for long bones
6. Hormones: GH, Thyroid, Calcitonin, Vit. D.
CLOSED REDUCTION anabolic Steroids
-bring bone fragments into apposition (ends in 7. electric potential across fracture
contact) via
a. manipulation 1. Factors that Inhibit Fracture Healing
b. traction and counter traction (thru patients 1. extensive local trauma
weight and bed position) 2. bone loss
c. splint or cast 3. inadequate mobilization
d. x-rays 4. space between fragments
e. traction (skin or skeletal) for fracture 5. infection
reduction/ for fracture immobilization 6. local malignancy
7. Metabolic bone disease (ie. Paget’s disease)
PRINCIPLES OF TRACTION 8. irradiated bone (radiation necrosis)
1. traction must be continuous to be effective 9. avascular necrosis
2. skeletal muscle traction is never interrupted 10. intra-articular fracture (synovial fluid contains
3. do not remove weights unless intermittent is fibrolysis, which lyse initial clot and retard clot
prescribed formation)
4. eliminate any factor that reduces effective pull or 11. age
alter resultant line of pull 12. steroids
 good body alignment in center of bed 13. flat bones heal rapidly (pelvis, scapula)
 ropes unobstructed 14. fx at ends of ling bones heal rapidly than
 weights should hang free midshaft fracture – more vascular and
 knot in rope or footplate must not touch pulley cancellous
or foot of bed 15. weight bearing stimulates healing of stabilized
5. VECTOR OF FORCE fractures
6. RESULTANT LINE OF PULL
EARLY COMPLICATIONS
7. Types of Traction  SHOCK
1. Straight or running traction  FAT METABOLISM
2. balanced suspension traction  SYSTEMIC EMBOLIZATION
3. skeletal
4. skin: traction tape/foam boot
5. manual SHOCK
6. SKELETAL TRACTION  hypovolemia, traumatic shock leads to blood
7. BUCK’S EXTENSION TRACTION loss and ECF – extracellular fluid
 -restore blood volume and circulation
OPEN REDUCTION (ORIF) Open  -pain relief
reduction internal  -splint
fixation  -protect from other injuries

D. NURSING MANAGEMENT FAT METABOLISM

1. encourage patient to return to usual activity as  -usually young adults (20-30%) and elderly
rapidly as possible adults with fracture proximal femur
2. teach patient to control selling and pan  fat globules à blood
3. teach exercises, use assistive devices  As marrow pressure > capillary pressure
4. environmental modification secondary to increase catecholamines
5. self-care, medications, potential complications mobilization of fatty acids
6. open fracture  Occlude small blood vessel lungs, brain,
a. prevent infection (monitor) kidney, etc.
b. delayed closure (5-7 days)  usuall approx. 24-48 degrees ~ week after
c. bone grafting (4-8 weeks to bridge injury
defects)  Hypoxia, tachypnea, pyrexia
 Dyspnea, crackles, wheezes
 Chest pain, thick white sputum, tachycardia
r/t increase pulmonary pressure
7
MS Abejo
Medical and Surgical Nursing
Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

 ABG PaO2 < 60 mmHg Assessment and Diagnostic findings

 Respiratory alkalosis ~ respiratory acidosis 1.paresthesis – early sign
 Chest XRay: Snowstorm infiltrates ~> 2.motor weakness: late sign of nerve ischemia
pulmonary edema. AARDS, CHF 3.paralysis – nerve damage
 CNS: r/t fat emboli in brain and hypoxis Assessment of peripheral circulation
1. color- cyanotic- venous congestion,
SYSTEMIC EMBOLIZATION 2. pale, cold
 pale 3. prolonged capillary refill
 thrombocytopenia- petechiae 4. decrease arterial perfusion
 hyperpyrexia (39.5C) 5. pulselessness if with arterial occlusion, not
 fat emboli àkidneyà failure compartment syndrome
6. Doppler ultrasound
PREVENTION 7. Pain
1. immediate immobilization 8. Hypoesthesia
2. minimal fracture manipulation 9. Anesthesia
3. adequate support 10. Nerve tissue pressure = 8 mmg Hg or less
4. fluid and electrolyte  Compromised = 30 mmHg
5. prompt invitation of respiratory support- high oxygen MEDICAL MANAGEMENT of Compartment Syndrome
1. elevate above level of heart
MANAGEMENT 2. release restrictive dressings
1. respiratory support àcontrolled volume ventilation 3. if unsuccessful à fasciotomy 1 hour
PEEP (positive expiratory e pressure) 4. splint and elevate
2. prevents respiratory and metabolic acidosis 5. Passive range of motion Q 4-6Hours
3. steroids- inflammatory lung reaction and cerebral 6. Deep vein thrombosis
edema 7. Thromboembolism
4. vasoactive meds 8. Pulmonary Embolism
5. accurate fluid Input and Output 9. DIC
6. morphine
7. nursing reassurance

EARLY COMPLICATIONS:
BONE GRAFT
Compartment Syndrome  osteogenesis-bone formation occurs after
 Tissue Perfusion < tissue viability transplantation of bone containing osteoblasts
 Signs and Symptoms  osteoconduction-provision by graft of structural
 unrelenting pain resistant to opioids r/t matrix for ingrowth of blood vessels and osteoblasts
 reduction in size of muscle compartment  osteoinduction-stimulation of host stem cells to
because enclosing muscle fascia is too tight or differentiate into osteoblasts b several growth factor
constricting cast or dressing including bone morphogenic proteins
 increase in muscle compartment because of edema  autograft- tissue harvested from the donor to the
or hemorrhage donor
 Esp. forearm, leg muscle  Allograft: tissue harvested from donor other than the
 à decrease microcirculationà nerve, muscle person who will receive the tissue
anoxia à necrosis  Healing= 6-12 months
 Loss of function > 6 hours  Problems:
1. Wound or graft infection
2. Graft fracture
3. Non-union
4. Partial acceptance
5. Graft rejection
6. Transmission of disease (rare)

 Electrical Bone Stimulation

 Modifies tissue environment making it
electronegative à enhances mineral
deposition and bone formation
 Non-invasive inductive coupling
 Pulsing electromagnetic field delivered to
fracture approximately 10 hours each day
with electromagnetic coiled over non-union
site 3-6 months

8
MS Abejo
Medical and Surgical Nursing
Musculoskeletal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

NURSING MANAGEMENT LEVEL OF AMPUTATION

1. Provide emotional support and encouragement 1. circulation
2. encourage compliance 2. functional usefulness (prosthesis)
3. pain management
4. monitor for signs and symptoms of infection
5. health teaching-reinforcement COMPLICATIONS OF AMPUTATION
6. Immobilization 1. hemorrhage
2. infection
3. skin break down
4. phantom limb: r/t severing of peripheral nerves
REACTION TO INTERNAL FIXATION DEVICES 5. joint contracture: r/t positioning and protective
1. usually not removed unless with symptoms flexion withdrawal pattern associated with pain and
2. pain and decreased function muscle imbalance
3. mechanical failure: inadequate insertion and stabilize
4. material failure MEDICAL MANAGEMENT of Amputation
5. corrosion 1. Objective
6. allergic reaction  healing of amputation wound
7. osteoporotic remodeling adjacent to fixation device  Non-tender stump
r/t disuse osteoporosis  health skin for prosthesis
2. 1. gentle handling of stamp
COMPLEX REGIONAL PAIN SYNDROME (CRPS) 3. 2. control of edema by rigid or soft compression
 reflex sympathetic dystrophy (RSD) dressings
 upper extremity 4. 3. use of aseptic technique in wound care
 > women 5. CLOSED RIGID CAST DRESSINGS: uniform
 painful sympathetic nervous system problem compression for support soft tissues, control pain
 CLINICAL MANIFESTATIONS of Complex and prevent joint contractures
Regional Pain Syndrome 6. SOFT DRESSINGS- if there is significant wound
1. severe burning pain drainage require frequent inspection
2. local edema
3. hyperesthesia NURSING DIAGNOSIS of AMPUTATION
4. stiffness  acute pain r/t amputation
5. discoloration  Risk for disturbed sensory perception: phantom limb
 vasomotor changes pain r/t amputation
 trophic changes  impaired skin integrity r/t surgical amputation
 disturbed body image r/t amputation of body part
Management of Complex Regional Pain Syndrome  self-care deficit r/t loss of extremity
1. -elevation  impaired physical mobility r/t loss of extremity
2. -immobility device with greatest ROM
3. -pain control NURSING INTERVENTION after Amputation
4. -NSAIDS 1. PAIN RELIEF
5. -Steroids  opioid analgesics
6. -anti-depressants  non pharmaceutical
7. -avoid BP and venipuncture  evac of hematoma / fluid
 counteract muscle spasm
 may be expression of grief
AMPUTATION 2. Minimizing altered sensory perceptions
 removal of body parts (extremity)  phantom limb approx. 2-3 months post-op
peripheral vascular disease *  acknowledge feelings
 folminating gas gangrene  keep patient active
 trauma-crushing, frostbite, electrical  early intensive rehab and stump
 malignant tumor  desensitization with kneading massage
 chronic osteomyelitis  distraction activities
3. TENS (transcutaneous electrical stimulation)
4. Ultrasound
5. local anesthetics
6. identify patient’s strength and resource to facilitate
rehab
7. help patient resolve grieving
8. promote independent self-care
9. help patient achieve physical mobility

9
MS Abejo