MEDICAL SURGICAL NURSING 111

ESUT-400LEVEL
LEARNING OUTCOME
At the end of this lesson, students will be able to:
1. Define Fracture and some diseases that affect the musculoskeletal
system.
2. Outline their signs and symptoms
3. Describe their pathophysiology
4. Discuss the medical and nursing management of each of them.
5. Apply the knowledge acquired in practice.

MANAGEMENT OF PATIENTS WITH MUSCULOSKELETAL

PROBLEMS.
Here, the review of the anatomy and physiology of the musculoskeletal system is
done, then general assessment (history taking, physical examination and diagnostic
investigations) of patients with musculoskeletal problems is also reviewed. The
problems that affect the musculoskeletal system can be either trauma (e.g. fracture,
sprain) or a disease condition. Therefore, in this lesson, the overview and
management of problems such as Fracture and diseases affecting the
musculoskeletal system and their general nursing care plan are discussed in details
as follows;

FRACTURE (BROKEN BONE)

A bone fracture is a full or partial break in the continuity of bone tissue, it can also
be said to be “a complete or incomplete disruption in the continuity of the bone
structure which is defined according to its type and extent”. Fractures can occur in
any bone in the body when the bone is subjected to stress greater than it can absorb.
When the bone is broken, adjacent structures are affected, resulting in soft
tissue edema, hemorrhage into muscles and joints, joint dislocations, ruptured
tendons, severed nerves, and damaged blood vessels. There are several different
ways in which a bone can fracture. For example, a closed fracture is a break to the
bone that does not damage surrounding tissue or tear through the skin. By contrast,
a compound (open) fracture is one that damages surrounding tissue and penetrates
the skin. Compound fractures are generally more serious than simple fractures due
to the risk of infection.
Types of Fracture: Other types of fracture includes:

• Avulsion fracture: A muscle or ligament pulls on the bone, fracturing it.

• Comminuted fracture: An impact shatters the bone into many pieces.
• Compression, or crush fracture: This generally occurs in the spongy bone
in the spine. For example, the front portion of a vertebra in the spine may
collapse due to osteoporosis.
• Fracture dislocation: This occurs when a joint dislocates, and one of the
bones of the joint fractures.
• Greenstick fracture: The bone partly fractures on one side but does not break
completely, because the rest of the bone can bend.
• Hairline fracture: This is a thin, partial fracture of the bone.
• Impacted fracture: When a bone fractures, a piece of the bone may impact
another bone.
• Intra-articular fracture: This occurs when a fracture extends into the
surface of a joint.
• Longitudinal fracture: This is when the fracture extends along the length of
the bone.
• Oblique fracture: An oblique fracture is one that occurs opposite to a bone’s
long axis.
• Pathological fracture: This occurs when an underlying condition weakens
the bone and causes a fracture.
• Spiral fracture: Here, at least one part of the bone twists during a break.
• Stress fracture: Repeated stress and strain can fracture a bone. This is
common among athletes.
• Transverse fracture: This is a straight break across the bone.
Symptoms

Symptoms of a fracture vary depending on its location, a person’s age and general
health, and the severity of the injury. However, people with a bone fracture
will typically experience some of the following:

• pain
• swelling
• bruising
• discolored skin around the affected area
• protrusion of the affected area at an unusual angle
• inability to put weight on the injured area
• inability to move the affected area
• a grating sensation in the affected bone or joint
• bleeding if it is an open fracture

In more severe cases, a person may experience:

• dizziness
• faintness or lightheadedness
• nausea

Causes

Healthy bones are extremely resilient and can withstand surprisingly powerful
impacts. However, under enough force, they may crack or break. Therefore, the
following can cause a bone to fracture;
1. Physical trauma, overuse, and health conditions that weaken the bones, such as
osteoporosis, are the leading causes of bone fractures. Other factors can also increase
an individual’s risk of sustaining fractures.

2. Age: A person’s bones will weaken with age, which increases the risk of them
breaking. As a person ages, the likelihood of their developing a condition that
weakens the bones is also greater.

Assessment and Diagnostic Findings

To determine the presence of fracture, the following diagnostic tools are used.

• X-ray examinations: Determines location and extent of fractures/trauma,

may reveal preexisting and yet undiagnosed fracture(s).
• Bone scans, tomograms, computed tomography (CT)/magnetic resonance
imaging (MRI) scans: Visualizes fractures, bleeding, and soft-tissue
damage; differentiates between stress/trauma fractures and bone neoplasms.
• Arteriograms: May be done when occult vascular damage is suspected.
• Complete blood count (CBC): Hematocrit (Hct) may be increased
(hemoconcentration) or decreased (signifying hemorrhage at the fracture site
or at distant organs in multiple trauma). Increased white blood cell (WBC)
count is a normal stress response after trauma.
• Urine creatinine (Cr) clearance: Muscle trauma increases the load of Cr for
renal clearance.
• Coagulation profile: Alterations may occur because of blood loss, multiple
transfusions, or liver injury.

Medical Management

Management of a patient with a fracture can belong to either emergent or post-

emergent.

• Immediately after injury, if a fracture is suspected, it is important to

immobilize the body part before the patient is moved.
• Adequate splinting is essential to prevent the movement of fracture
fragments.
 • In an open fracture, the wound should be covered with a sterile dressing to
prevent contamination of the deeper tissues.

Reduction and Immobilization

Bone healing is a natural process that, in most cases, will occur naturally.
Therefore, treatment typically focuses on providing the injured bone with the best
circumstances for healing, and ensuring optimal future function. For the natural
healing process to begin, a doctor will reduce the fracture. This involves lining up
the ends of the broken bones. In smaller fractures, a doctor can do this by
manipulating the affected area externally. Once a medical professional has aligned
the fracture, they will ensure it stays in place. Methods of doing so includes:

Cast Immobilization: A plaster or fiberglass cast is the most common type of

fracture treatment, because most broken bones can heal successfully once they have
been repositioned and a cast has been applied to keep the broken ends in proper
position while they heal.

Functional Cast or Brace: The cast or brace allows limited or controlled movement
of nearby joints. This treatment is desirable for some, but not all, fractures.

Traction: Traction is usually used to align a bone or bones by a gentle, steady pulling
action. It is not typically used as a definitive treatment.

However, in some instances, this may require surgery which includes:

External Fixation: In this type of operation, the doctor places metal pins or screws
into the broken bone above and below the fracture site. The pins or screws are
connected to a metal bar outside the skin. This device is a stabilizing frame that holds
the bones in the proper position while they heal. In cases where the skin and other
soft tissues around the fracture are badly damaged, an external fixator may be
applied until surgery can be tolerated.
Open Reduction and Internal Fixation: During this operation, the doctor first
repositions (reduces) the bone fragments into their normal alignment and holds the
bones together with special screws or by attaching metal plates to the outer surface
of the bone. The fragments may also be held together by inserting rods down through
the center of the bone. A specially designed metal rod, called an intramedullary nail,
provides strong fixation for this thighbone fracture.

Fractures can take several weeks to several months to heal, depending on their
severity. The duration is contingent on which bone has become affected and whether
there are any complications, such as a blood supply problem or an infection or Other
factors that can affect bone healing such as; smoking,
excessive alcohol consumption, a high body mass index, nonsteroidal anti-
inflammatory drug use and a person’s age. After the bone has healed, it may be
necessary to restore muscle strength and mobility to the affected area
through physical therapy.
Nursing Management (using the Nursing Process)

Nursing management for close and open fractures should be differentiated.

Nursing Assessment

Assessment of the fractured area includes the following:

• Close fracture. The patient with close fracture is assessed for absence of
opening in the skin at the fracture site.
• Open fracture. The patient with open fracture is assessed for risk for
osteomyelitis, tetanus, and gas gangrene.
• The fractured site is assessed for signs and symptoms of infection.

Diagnosis

Based on the assessment data gathered, the nursing diagnoses developed include:

• Acute pain related to fracture, soft tissue injury, and muscle spasm.
• Impaired physical mobility related to fracture.
• Risk for infection related to opening in the skin in an open fracture.
Planning & Goals

Planning and goals developed for a patient with fracture are:

• Relief of pain.
• Achieve a pain-free, functional, and stable body part.
• Maintain asepsis.
• Maintain vital signs within normal range.
• Exhibit no evidence of complications.

Nursing Interventions

Nursing care of a patient with fracture include:

• The nurse should instruct the patient regarding proper methods to control
edema and pain.
• It is important to teach exercises to maintain the health of the unaffected
muscles and to increase the strength of muscles needed for transferring and
for using assistive devices.
• Plans are made to help the patients modify the home environment to promote
safety such as removing any obstruction in the walking paths around the
house.
• Wound management. Wound irrigation and debridement are initiated as
soon as possible.
• Elevate extremity. The affected extremity is elevated to minimize edema.
• Signs of infection. The patient must be assessed for presence of signs and
symptoms of infection.

Evaluation

The following should be evaluated for a successful implementation of the care plan.

• Pain was relieved.

• Achieved a pain-free, functional, and stable body part.
• Maintained asepsis.
• Maintained vital signs within normal range.
 • Exhibited no evidence of complications.

Discharge and Home Care Guidelines

After completion of the home care instructions, the patient or caregiver will be able
to:

• Control swelling and pain. Describe approaches to reduce swelling and pain
such as elevating the extremity and taking analgesics as prescribed.
• Care of the affected area. Describe management of immobilization devices
or care of the incision.
• Consume diet to promote bone healing.
• Mobility aids. Demonstrate use of mobility aids and assistive devices safely.
• Avoid excessive use of injured extremity and observe weight-bearing limits.

Complications

While bone fractures typically heal well with appropriate treatment, there can be
complications, such as:

• Bone heals in the wrong position: A fracture may heal in the wrong position,
or the bones may shift during the healing process.
• Disruption of bone growth: If a childhood bone fracture becomes disrupted
during healing, this may affect the typical development of that bone. This can
raise the risk of future deformity in the bone.
• Bone or bone marrow infection: In a compound fracture, bacteria can enter
through a break in the skin and infect the bone or bone marrow. This can
become a persistent infection.
• Bone death (avascular necrosis): If the bone loses its essential supply of
blood, it may die.
Delayed unions and non-unions

Non-unions are fractures that fail to heal, while delayed unions are those that take
longer to heal. Treatments for non-unions and delayed unions include:

• Ultrasound therapy: A medical professional will apply low

intensity ultrasound to the affected area. This may help fractures heal.
• Bone graft: If the fracture does not heal, a surgeon will transplant a natural
or synthetic bone to stimulate the broken bone.
• Stem cell therapy: Stem cell-derived therapies may assist in the healing of
bone fractures.

Prevention

A person can reduce their risk of bone fractures through a number of remedies and
lifestyle changes.

1. Diet: A person’s diet can affect their risk of fractures. The human body needs
adequate supplies of calcium for healthy bones. Milk, cheese, yogurt, and
dark green leafy vegetables are good sources of calcium. The body also
requires vitamin D to absorb calcium. Exposure to sunlight and eating eggs and oily
fish are good ways of getting vitamin D.

2. Exercise: Engaging in weight-bearing exercise can help improve muscle

mass and bone density. Both of these can reduce the risk of bone fractures.

3. Moreover, levels of estrogen, which plays a role in bone health, drop substantially
during menopause. This makes calcium regulation more difficult and increases the
risk of osteoporosis and fractures. Consequently, people need to be particularly
careful about the density and strength of their bones during and after menopause.
INFLAMMATORY JOINT DISEASE (e.g. RHEUMATOID ARTHRITIS)

Rheumatoid arthritis (RA) is defined as a systemic autoimmune pathology

associated with a chronic inflammatory process, which can damage both joints and
extra-articular organs, including the heart, kidney, lung, digestive system, eye, skin
and nervous system.

Pathophysiology

Rheumatoid arthritis is a chronic, inflammatory, autoimmune disorder that occurs

when the immune system mistakenly attacks one’s own body tissues. It affects the
lining of the joints, causing a painful swelling that can eventually result in bone
erosion and joint deformity. The disorder can affect more than just the joints. Early
rheumatoid arthritis tends to affect the smaller joints first — particularly the joints
that attach the fingers to the hands and the toes of the feet. As the disease progresses,
symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. In
most cases, symptoms occur in the same joints on both sides of the body. In some
people, the condition can damage a wide variety of body systems, including the skin,
eyes, lungs, heart and blood vessels. The inflammation associated with rheumatoid
arthritis is what damages other parts of the body as well. While new types of
medications have improved treatment options dramatically, severe rheumatoid
arthritis can still cause physical disabilities.

Symptoms

Signs and symptoms of rheumatoid arthritis may include:

 • Tender, warm, swollen joints
• Joint stiffness that is usually worse in the mornings and after inactivity
• Fatigue, fever and loss of appetite
About 40% of people who have rheumatoid arthritis also experience signs and
symptoms that don't involve the joints. Areas that may be affected include: Skin,
Eyes, Lungs, Heart, Kidneys, Salivary glands, Nerve tissue, Bone marrow and Blood
vessels

Risk Factors
Factors that may increase the risk of rheumatoid arthritis include:

• Gender (sex). Women are more likely than men to develop rheumatoid
arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins
in middle age.
• Family history. If a member of your family has rheumatoid arthritis, you may
have an increased risk of the disease.
• Smoking. Cigarette smoking increases the risk of developing rheumatoid
arthritis, particularly if you have a genetic predisposition for developing the
disease. Smoking also appears to be associated with greater disease severity.
• Excess weight. People who are overweight appear to be at a somewhat higher
risk of developing rheumatoid arthritis.
Diagnosis

Rheumatoid arthritis can be difficult to diagnose in its early stages because the early
signs and symptoms mimic those of many other diseases. There is no one blood test
or physical finding to confirm the diagnosis. During the physical exam, the doctor
will check the joints for swelling, redness and warmth. He or she may also check
reflexes and muscle strength.

Blood tests

People with rheumatoid arthritis often have an elevated erythrocyte sedimentation

rate (ESR, also known as sed rate) or C-reactive protein (CRP) level, which may
indicate the presence of an inflammatory process in the body. Other common blood
tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP)
antibodies.

Imaging tests

The doctor may recommend X-rays to help track the progression of rheumatoid
arthritis in your joints over time. MRI and ultrasound tests can help your doctor
judge the severity of the disease in your body.

Medical Management

There is no cure for rheumatoid arthritis. But clinical studies indicate that remission
of symptoms is more likely when treatment begins early with medications known as
disease-modifying antirheumatic drugs (DMARDs).

Medications

The types of medications recommended by the doctor will depend on the severity of
symptoms and how long rheumatoid arthritis has been.

• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and

reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil,
Motrin IB, others) and naproxen sodium (Aleve). Stronger NSAIDs are
available by prescription. Side effects may include stomach irritation, heart
problems and kidney damage.
• Steroids. Corticosteroid medications, such as prednisone, reduce inflammation
and pain and slow joint damage. Side effects may include thinning of bones,
weight gain and diabetes. Doctors often prescribe a corticosteroid to relieve
symptoms quickly, with the goal of gradually tapering off the medication.
• Conventional DMARDs. These drugs can slow the progression of rheumatoid
arthritis and save the joints and other tissues from permanent damage.
Common DMARDs include methotrexate (Trexall, Otrexup, others),
 leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine
(Azulfidine). Side effects vary but may include liver damage and severe lung
infections.
• Biologic agents. Also known as biologic response modifiers, this newer class
of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra
(Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi),
infliximab (Remicade), rituximab (Rituxan), sarilumab (Kevzara) and
tocilizumab (Actemra).
Biologic DMARDs are usually most effective when paired with a
conventional DMARD, such as methotrexate. This type of drug also increases
the risk of infections.

• Targeted synthetic DMARDs. Baricitinib (Olumiant), tofacitinib (Xeljanz)

and upadacitinib (Rinvoq) may be used if conventional DMARDs and biologics
haven't been effective. Higher doses of tofacitinib can increase the risk of blood
clots in the lungs, serious heart-related events and cancer.
Therapy

Physical or occupational therapist can teach exercises to help keep the joints flexible.
The therapist may also suggest new ways to do daily tasks that will be easier on the
joints. For example, picking up an object using the forearms.

Assistive devices can make it easier to avoid stressing the painful joints. For
instance, a kitchen knife equipped with a hand grip helps protect the finger and wrist
joints. Certain tools, such as buttonhooks, can make it easier to get dressed. Catalogs
and medical supply stores are good places to look for ideas.

Surgery

If medications fail to prevent or slow joint damage, surgery may be considered to

repair damaged joints. Surgery may help restore the ability to use the joint. It can
also reduce pain and improve function.

Rheumatoid arthritis surgery may involve one or more of the following procedures:

• Synovectomy. Surgery to remove the inflamed lining of the joint (synovium)

can help reduce pain and improve the joint's flexibility.
 • Tendon repair. Inflammation and joint damage may cause tendons around
your joint to loosen or rupture. Your surgeon may be able to repair the tendons
around your joint.
• Joint fusion. Surgically fusing a joint may be recommended to stabilize or
realign a joint and for pain relief when a joint replacement isn't an option.
• Total joint replacement. During joint replacement surgery, your surgeon
removes the damaged parts of your joint and inserts a prosthesis made of metal
and plastic.
Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks.

Complications

• Osteoporosis. Rheumatoid arthritis itself, along with some medications used

for treating rheumatoid arthritis, can increase your risk of osteoporosis — a
condition that weakens your bones and makes them more prone to fracture.
• Rheumatoid nodules. These firm bumps of tissue most commonly form
around pressure points, such as the elbows. However, these nodules can form
anywhere in the body, including the heart and lungs.
• Dry eyes and mouth. People who have rheumatoid arthritis are much more
likely to develop Sjogren's syndrome, a disorder that decreases the amount of
moisture in the eyes and mouth.
• Infections. Rheumatoid arthritis itself and many of the medications used to
combat it can impair the immune system, leading to increased infections.
Protect yourself with vaccinations to prevent diseases such as influenza,
pneumonia, shingles and COVID-19.
• Abnormal body composition. The proportion of fat to lean mass is often
higher in people who have rheumatoid arthritis, even in those who have a
normal body mass index (BMI).
• Carpal tunnel syndrome. If rheumatoid arthritis affects the wrists, the
inflammation can compress the nerve that serves most of the hand and fingers.
 • Heart problems. Rheumatoid arthritis can increase the risk of hardened and
blocked arteries, as well as inflammation of the sac that encloses your heart.
• Lung disease. People with rheumatoid arthritis have an increased risk of
inflammation and scarring of the lung tissues, which can lead to progressive
shortness of breath.
• Lymphoma. Rheumatoid arthritis increases the risk of lymphoma, a group of
blood cancers that develop in the lymph system.

DEGENERATIVE JOINT DISEASE (e.g. OSTEOARTHRITIS)

Osteoarthritis is a degenerative joint disease, in which the tissues in the joint break
down over time. It is the most common type of arthritis and is more common in older
people. People with osteoarthritis usually have joint pain and, after rest or inactivity,
stiffness for a short period of time. The most commonly affected joints include the:
Hands (ends of the fingers and at the base and ends of the thumbs), Knees, Hips,
Neck, and Lower back. Osteoarthritis affects each person differently. For some
people, osteoarthritis is relatively mild and does not affect day-to-day activities. For
others, it causes significant pain and disability. Joint damage usually develops
gradually over years, although it could worsen quickly in some people.
Causes/Risk Factors
Factors that may contribute to the development of OA include

• Age. The risk of developing OA increases with age and symptoms generally,
but not always, appear in people over 50.
• Joint injury. A bone fracture or cartilage or ligament tear can lead to OA,
sometimes more quickly than in cases where there is no an obvious injury.
• Overuse. Using the same joints over and over in a job or sport can result in
OA.
• Obesity. Excess weight adds stress and pressure on a joint, plus fats cells
promote inflammation.
 • Musculoskeletal abnormalities. Mal-alignment of bone or joint structures
can contribute to faster development of OA.

• Weak muscles. If muscles don’t provide adequate joint support, poor

alignment can result, which can lead to OA.
• Genetics. People with family members who have OA are more likely to
develop it.
• Gender. Women are more likely to develop OA than men.
• Environmental Factors. Modifiable environmental risk factors include
things like someone’s occupation, level of physical activity, quadriceps
strength, presence or absence of prior joint injury, obesity, diet, sex hormones,
and bone density.

Pathophysiology of Osteoarthritis (OA)

Osteoarthritis occurs due to a combination of factors, including physical stress on

the body, such as general wear and tear, physical changes that affect joint function,
which may be present from birth or may develop due to excess weight placing
pressure on the joint or an injury, other risk factors, such as aging or genetics. People
with the condition have higher levels of pro-inflammatory markers, which
indicate inflammation, and proteases, which are enzymes that break down protein.
These eventually cause joint deterioration.

In most cases, the first changes that occur in the body due to OA affect the articular
cartilage. This is the cartilage covering the ends of the bones where they meet at the
joint. The articular cartilage may erode or become irregular, split, or frayed. If there
are erosions in the cartilage, these may gradually expand down to bone level and
affect more of the joint surface. Articular cartilage contains a group of cells called
chondrocytes, which produce and maintain the matrix. Injury or damage to the
cartilage can cause damage to the matrix, resulting in chondrocytes multiplying and
forming clusters. This causes bony lumps called bone spurs to form. Damage to
the matrix can also cause thickening of the bone underneath the cartilage and may
sometimes cause fluid-filled areas in the bone called bone cysts. Alongside these
changes to the cartilage, there may be inflammation of the joint’s synovium. These
changes can occur gradually, and people may slowly start to experience symptoms
of OA, such as pain, stiffness, and limited range of motion.

Symptoms of Osteoarthritis

The symptoms of osteoarthritis often begin slowly and usually begin with one or a
few joints. The common symptoms of osteoarthritis include:

• Pain when using the joint, which may improve with rest. For some people, in
the later stages of the disease, the pain may be worse at night. Pain can be
localized or widespread.
• Joint stiffness, usually lasting less than 30 minutes, in the morning or after
resting for a period of time.
• Joint changes that can limit joint movement.
• Swelling in and around the joint, especially after a lot of activity or use of that
area.
• Changes in the ability to move the joint.
• Feeling that the joint is loose or unstable.

Osteoarthritis symptoms can affect joints differently. For example:

• Hands. Bony enlargements and shape changes in the finger joints can happen
over time.
• Knees. When walking or moving, you may hear a grinding or scaping noise.
Over time, muscle and ligament weakness can cause the knee to buckle.
• Hips. You might feel pain and stiffness in the hip joint or in the groin, inner
thigh, or buttocks. Sometimes, the pain from arthritis in the hip can radiate
(spread) to the knees. Over time, you may not be able to move your hip as far
as you did in the past.
• Spine. You may feel stiffness and pain in the neck or lower back. As changes
in the spine happen, some people develop spinal stenosis, which can lead to
other symptoms.

Diagnosis
Medical history, a physical examination and lab tests help to make up the OA
diagnosis.
A primary care doctor may be the first person to talk to about joint pain. The doctor
will review medical history, symptoms, how the pain affects activities, as well as the
medical problems and medication use. He or she will also look at and move the
patient’s joints, and may order imaging. These tests help to make the diagnosis:

• Joint aspiration. After numbing the area, a needle is inserted into the joint to
pull out fluid. This test will look for infection or crystals in the fluid to help
rule out other medical conditions or other forms of arthritis.
• X-ray. X-rays can show joint or bone damage or changes related
to osteoarthritis.
• MRI. Magnetic resonance imaging (MRI) gives a better view of cartilage and
other parts of the joint.

Medical Management
There is no cure for OA, but medication, assistive devices and other therapies that
don’t involve drugs can help to ease pain. As a last resort, a damaged joint may be
surgically fused or replaced with one made of a combination of metal, plastic and/or
ceramic. Pain and anti-inflammatory medicines for osteoarthritis are available as
pills, syrups, patches, gels, creams or injectable. They include:

• Analgesics. These are pain relievers and include acetaminophen and opioids.
Acetaminophen is available over the counter (OTC); opioids must be
prescribed by a doctor.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). These are the most
commonly used drugs to ease inflammation and pain. They
include aspirin, ibuprofen, naproxen and celecoxib, available either OTC or
by prescription. The OTC versions help with pain but not inflammation.
• Counterirritants. These OTC products contain ingredients like capsaicin,
menthol and lidocaine that irritate nerve endings, so the painful area feels
cold, warm or itchy to take focus away from the actual pain.
• Corticosteroids. These prescription anti-inflammatory medicines work in a
similar way to a hormone called cortisol. The medicine is taken by mouth or
injected into the joint at a doctor’s office.
• Platelet-rich plasma (PRP). Available from a doctor by injection, this
product is intended to help ease pain and inflammation. This is not approved
by the Food & Drug Administration and evidence is still emerging, so discuss
it with your doctor before trying it.
• Other drugs. The antidepressant duloxetine (Cymbalta) and the anti-seizure
drug pregabalin (Lyrica) are oral medicines that are FDA-approved to treat
OA pain.
Nondrug Therapies
Exercise
Movement is an essential part of an OA treatment plan. Getting 150 minutes of
moderate-to-vigorous exercise per week should be the goal, according to the U.S.
Department of Health and Human Services. A good exercise program to fight OA
pain and stiffness has four parts:

• Strengthening exercises build muscles around painful joints and helps to

ease the stress on them.
• Range-of-motion exercise or stretching helps to reduce stiffness and keep
joints moving.
• Aerobic or cardio exercises help improve stamina and energy levels and
reduce excess weight.
• Balance exercises help strengthen small muscles around the knees and ankles
and help prevent falls.

Talk to a doctor or physical therapist before starting a new exercise program.

Weight Loss
Excess weight puts additional force and stress on weight-bearing joints, including
the hips, knees, ankles, feet and back, and fat cells promote inflammation. Losing
extra weight helps reduce pain and slow joint damage. Every pound of weight lost
removes four pounds of pressure on lower-body joints.
Physical Therapies and Assistive Devices
Physical therapists, occupational therapists and chiropractors can provide:

• Specific exercises to help stabilize your joints and ease pain.

• Information about natural treatments and products that can ease pain.
• Instruction to make movement easier and to protect joints.
• Braces, shoe inserts or other assistive devices.

Surgery
Joint surgery can improve pain and function. Joint replacement surgery replaces
damaged joints to restore mobility and relieve pain. Hips and knees are the joints
most commonly replaced. An orthopedic surgeon can determine the best procedure
based on how badly damaged the joint is.
Self-Care practices to slow disease progression
Practicing these habits can slow down OA, keep you healthier overall and delay
surgery as long as possible. It is important to pursue a number of different self-care
approaches simultaneously. They are listed below.
Maintain a Healthy Weight
Excess weight worsens OA. Combine healthy eating with regular exercise to
maintain a healthy weight.
Control Blood Sugar
Many people have diabetes and OA. Having high glucose levels can make cartilage
stiffer and more likely to break down. Having diabetes causes inflammation, which
also weakens cartilage.
Maintain Range of Motion
Movement is medicine for joints. Make a habit of putting your joints through their
full range of motion, but only up to the point where it doesn’t cause more pain.
Gentle stretching, raising and lowering legs from a standing or seated position, daily
walks and hobbies such as gardening can help. But listen to your body and never
push too hard.

Protect Joints
Make sure to warm up and cool down when doing exercise. If you play sports,
protects joints with the right gear. Use your largest, strongest joints for lifting,
pushing, pulling and carrying. Watch your step to prevent falls. Balance rest and
activity throughout the day.
Relax
Find ways to reduce or avoid stress through meditation, listening to music,
connecting with friends and family, doing fun activities, and finding ways to relax
and recharge.
Choose a Healthy Lifestyle
Eating healthy food, balanced nutrition, not smoking, drinking in moderation and
getting good sleep will help you to feel your best.

Complications

Pain, reduced mobility, side effects from medications and other factors associated
with osteoarthritis can lead to health complications that are not caused by the disease
itself.
Obesity, Diabetes and Heart Disease
Painful joints, especially in the feet, ankles, knees, hip or ,
back, make it harder to exercise. But physical activity is not only key to managing
OA symptoms, it also can help prevent weight gain, which can lead to obesity. Being
overweight or obese can lead to the development of high cholesterol, type 2 diabetes,
heart disease and high blood pressure.
Falls
Research indicates people with OA experience more falls and risk of fracture than
those without OA. Although study results vary, some research shows they may have
up to 30% more falls and have a 20% greater risk of fracture. Having OA can
decrease function, weaken muscles, affect overall balance, and make falls more
likely, especially among those with OA in knees or hips. Side effects from pain
medications, such as dizziness, can also contribute to falls.

METABOLIC JOINT DISEASE (e.g. GOUT)

Gout is a common form of inflammatory arthritis that is very painful. It usually

affects one joint at a time (often the big toe joint). There are times when symptoms
get worse, known as flares, and times when there are no symptoms, known as
remission. Having gout multiple times can lead to gouty arthritis, a form of arthritis
which gets progressively worse. There is no cure for gout, but you can effectively
treat and manage the condition with medication and self-management strategies.

Causes
Gout is caused by a condition known as hyperuricemia. This is when there is too
much uric acid in the body. Hyperuricemia does not always cause gout. People who
have hyperuricemia but do not have gout symptoms do not need medical treatment.
Pathophysiology of Gout

Uric acid is a normal part of body waste produced by the body during the breakdown
of purines. These are chemicals found in high amounts in certain foods and drinks,
such as alcohol, turkey and goose, liver, and seafood. Typically, uric acid is
dissolved in the blood and excreted in urine via the kidneys. If the body produces
too much uric acid or does not excrete enough, it can build up and form needle-like
crystals. These trigger inflammation and pain in the joints and surrounding tissues.
Gout flares (symptoms getting worse) start suddenly and can last days or weeks.
These flares are followed by long periods of remission—weeks, months, or years—
without symptoms before another flare begins. Gout usually occurs in only one joint
at a time. It is often found in the big toe. Along with the big toe, joints that are
commonly affected are the other toe joints, the ankle, and the knee.

Symptoms in the affected joint(s) may include:

• Pain, usually intense

• Swelling
• Redness
• Heat

Risk factors

Several factors can increase the risk of hyperuricemia and gout, including:

• Advanced age: Gout is more common in older adults and rarely develops in
children.
• Sex: In people younger than 65, gout is four times as prevalent among males
as females. It is three times as prevalent in males after the age of 65.
• Genetics: A family history of gout can increase a person’s risk.
 • Dietary choices: Alcohol interferes with the removal of uric acid from the
body, and a high-purine diet increases the amount of uric acid in the body.
Consuming alcohol and having this type of diet can increase the risk of gout.
• Lead exposure: Studies have suggested a link between chronic lead exposure
and an increased risk of gout.
• Medications: Certain medications can increase the levels of uric acid in the
body. These include some diuretics and drugs containing salicylate.
• Weight: Being overweight or obese and having high levels of visceral body
fat are linked with an increased risk of gout. None of these factors directly
causes the condition, however.
• Other health conditions: Renal insufficiency and other kidney conditions
can reduce the body’s ability to remove waste, leading to elevated uric acid
levels. Other conditions associated with gout include high blood
pressure and diabetes.

Types: The types refer to the various stages of gout.

Asymptomatic hyperuricemia

A person can have elevated uric acid levels without any symptoms. While people do
not need treatment at this stage, high uric acid levels in the blood can cause “silent”
tissue damage. As a result, a doctor may recommend ways to reduce the buildup of
this acid.

Acute gout

This involves uric acid crystals in a joint suddenly causing acute inflammation and
intense pain. This attack may last between 3 days and 2 weeks. Stress and excessive
alcohol consumption can contribute to these attacks, or flares.
Interval or inter-critical gout

This is the period in between attacks of acute gout. As gout progresses, these
intervals become shorter. Between these periods, uric acid crystals may continue to
build up in tissues.

Chronic tophaceous gout

This is the most debilitating type and may result in permanent damage to the joints
and kidneys. At this stage, people may have chronic arthritis and develop tophi in
cooler areas of the body, such as the joints of the fingers. Chronic tophaceous gout
typically occurs after many years of acute gout attacks. However, if a person
receives effective treatment, gout is unlikely to reach this stage.

Pseudogout

One condition that can be easy to confuse with gout is calcium pyrophosphate
deposition, known as pseudogout. The symptoms are very similar to those of gout,
although the flare-ups are usually less severe. The major difference between gout
and pseudogout is that the joints are irritated by calcium pyrophosphate crystals
rather than uric acid crystals. Pseudogout requires different treatments than gout.

Diagnosis

Doctors usually diagnose gout based on your symptoms and the appearance of the
affected joint. Tests to help diagnose gout may include:

• Joint fluid test. Your doctor may use a needle to draw fluid from your
affected joint. Urate crystals may be visible when the fluid is examined under
a microscope.
• Blood test. Your doctor may recommend a blood test to measure the levels of
uric acid in your blood. Blood test results can be misleading, though. Some
people have high uric acid levels, but never experience gout. And some people
 have signs and symptoms of gout, but don't have unusual levels of uric acid in
their blood.
• X-ray imaging. Joint X-rays can be helpful to rule out other causes of joint
inflammation.
• Ultrasound. This test uses sound waves to detect urate crystals in joints or in
tophi.
• Dual-energy computerized tomography (DECT). This test combines X-ray
images taken from many different angles to visualize urate crystals in joints.

Medical Management
Gout medications are available in two types and focus on two different problems.
The first type helps reduce the inflammation and pain associated with gout attacks.
The second type works to prevent gout complications by lowering the amount of
uric acid in the blood.

The type of medication taken depends on the frequency and severity of the
symptoms, along with any other health problems the patient may have.

Medications to treat gout attacks

Drugs used to treat gout flares and prevent future attacks include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include over-

the-counter options such as ibuprofen (Advil, Motrin IB, others) and naproxen
sodium (Aleve), as well as more-powerful prescription NSAIDs such as
indomethacin (Indocin, Tivorbex) or celecoxib (Celebrex). NSAIDs carry risks
of stomach pain, bleeding and ulcers.
• Colchicine. Colchicine (e.g. Colcrys, Gloperba, Mitigare), is an anti-
inflammatory drug that effectively reduces gout pain. The drug's effectiveness
may be offset, however, it has side effects such as nausea, vomiting and
diarrhea.
• Corticosteroids. Corticosteroid medications, such as prednisone, may control
gout inflammation and pain. Corticosteroids may be in pill form, or they can be
injected into the joint. Side effects of corticosteroids may include mood
changes, increased blood sugar levels and elevated blood pressure.
Medications to prevent gout complications

If one experiences several gout attacks each year, or if your gout attacks are less
frequent but particularly painful, your doctor may recommend medication to reduce
the risk of gout-related complications. If there is already evidence of damage from
gout on joint X-rays, or tophi, chronic kidney disease or kidney stones, medications
to lower the body's level of uric acid may be recommended.

• Medications that block uric acid production. Drugs such as allopurinol

(Aloprim, Lopurin, Zyloprim) and febuxostat (Uloric) help limit the amount of
uric acid the body makes. Side effects of allopurinol include fever, rash,
hepatitis and kidney problems. Febuxostat side effects include rash, nausea and
reduced liver function. Febuxostat also may increase the risk of heart-related
death.
• Medications that improve uric acid removal. Drugs such as probenecid
(Probalan) help improve the kidneys' ability to remove uric acid from the body.
Side effects include a rash, stomach pain and kidney stones.

Complications

Gout can progress, causing permanent damage to the joints and kidneys, and it is
also linked with kidney stones.

INFECTIVE BONE DISEASE (OSTEOMYELITIS)

Definition
Osteomyelitis is an inflammatory condition of bone caused by an infecting organism,
most commonly Staphylococcus aureus. It usually involves a single bone but may
rarely affect multiple sites. It may occur in the peripheral or axial skeleton. Severity
can be staged depending on the etiology of the infection, its pathogenesis, extent of
bone involvement, duration, and host factors particular to the individual patient.
Broadly, bone infection is either haematogenous or contiguous-focus. Despite these
different causes, all forms of acute osteomyelitis may evolve and become chronic,
sharing a final common pathophysiology, with compromised soft-tissue surrounding
dead, infected, and reactive new bone.

Pathophysiology

Osteomyelitis is an infection and inflammation of the bone. It can happen when a

bacterial or fungal infection enters a bone from the bloodstream or surrounding
tissue. A person may have pain, swelling, and flu-like symptoms. Osteomyelitis may
develop quickly or over time. The infection can occur at any age. Long bone
infections, involving the arms or legs, are more common in children. But generally,
older adults are more prone to osteomyelitis because they experience more health
issues that can increase the risk of infections, such
as diabetes or orthopedic problems that require surgery.

Causes
Most cases of osteomyelitis are caused by staphylococcus bacteria, types of germs
commonly found on the skin or in the nose of even healthy individuals.

Germs can enter a bone in a variety of ways, including:

• The bloodstream. Germs in other parts of the body for example, in the lungs
from pneumonia or in the bladder from a urinary tract infection can travel
through your bloodstream to a weakened spot in a bone.
• Injuries. Severe puncture wounds can carry germs deep inside the body. If such
an injury becomes infected, the germs can spread into a nearby bone. Germs
can also enter the body if the bone is broken so severely that part of it is sticking
out through the skin.
• Surgery. Direct contamination with germs can occur during surgeries to
replace joints or repair fractures.

Symptoms

Signs and symptoms of osteomyelitis include:

 • Fever
• Swelling, warmth and redness over the area of the infection
• Pain in the area of the infection
• Fatigue

Risk Factors
The bones are normally resistant to infection, but this protection lessens as one gets
older. Other factors that can make the bones more vulnerable to osteomyelitis may
include:

Recent injury or orthopedic surgery

A severe bone fracture or a deep puncture wound gives bacteria a route to enter your
bone or nearby tissue. A deep puncture wound, such as an animal bite or a nail
piercing through a shoe, can also provide a pathway for infection. Surgery to repair
broken bones or replace worn joints also can accidentally open a path for germs to
enter a bone. Implanted orthopedic hardware is a risk factor for infection.

Circulation disorders

When blood vessels are damaged or blocked, the body has trouble distributing the
infection-fighting cells needed to keep a small infection from growing larger. What
begins as a small cut can progress to a deep ulcer that may expose deep tissue and
bone to infection.

Diseases that impair blood circulation include:

• Poorly controlled diabetes

• Peripheral artery disease, often related to smoking
• Sickle cell disease
Problems requiring intravenous lines or catheters

There are a number of conditions that require the use of medical tubing to connect
the outside world with your internal organs. However, this tubing can also serve as
a way for germs to get into your body, increasing your risk of an infection in general,
which can lead to osteomyelitis.

Examples of when this type of tubing might be used include:

• Dialysis machine tubing

• Urinary catheters
• Long-term intravenous tubing, sometimes called central lines
Conditions that impair the immune system

If the immune system is affected by a medical condition or medication, there is a

greater risk of osteomyelitis. Factors that may suppress your immune system
include:

• Cancer treatment
• Poorly controlled diabetes
• Needing to take corticosteroids or drugs called tumor necrosis factor inhibitors
Illicit drugs

People who inject illegal drugs are more likely to develop osteomyelitis because they
may use nonsterile needles and are less likely to sterilize their skin before injections.

Diagnostic investigations

Blood tests

Blood tests may reveal elevated levels of white blood cells and other factors that
may indicate that the body is fighting an infection. If osteomyelitis is caused by an
infection in the blood, tests may reveal which germs are responsible. No blood test
can tell the doctor whether you do or don't have osteomyelitis. However, blood tests
can give clues to help the doctor decide what additional tests and procedures may be
needed.
Imaging tests

• X-rays. X-rays can reveal damage to the bone. However, damage may not be
visible until osteomyelitis has been present for several weeks. More-detailed
imaging tests may be necessary if osteomyelitis has developed more recently.
• Magnetic Resonance Imaging (MRI). Using radio waves and a strong
magnetic field, MRI scans can produce exceptionally detailed images of bones
and the soft tissues that surround them.
• Computerized Tomography (CT). A CT scan combines X-ray images taken
from many different angles, creating detailed cross-sectional views of a person's
internal structures. CT scans are usually done only if someone can't have an
MRI.
Bone biopsy

A bone biopsy can reveal what type of germ has infected the bone. Knowing the type
of germ allows the doctor to choose an antibiotic that works particularly well for that
type of infection. An open biopsy requires anesthesia and surgery to access the bone.
In some situations, a surgeon inserts a long needle through the skin and into the bone
to take a biopsy. This procedure requires local anesthetics to numb the area where
the needle is inserted. X-ray or other imaging scans may be used for guidance.

Management of Osteomyelitis

The most common treatments for osteomyelitis are surgery to remove portions of
bone that are infected or dead, followed by intravenous antibiotics given in the
hospital.

Surgery

Depending on the severity of the infection, osteomyelitis surgery may include one
or more of the following procedures:

• Drain the infected area. Opening up the area around the infected bone allows
the surgeon to drain any pus or fluid that has accumulated in response to the
infection.
• Remove diseased bone and tissue. In a procedure called debridement, the
surgeon removes as much of the diseased bone as possible and takes a small
 margin of healthy bone to ensure that all the infected areas have been removed.
Surrounding tissue that shows signs of infection also may be removed.
• Restore blood flow to the bone. The surgeon may fill any empty space left by
the debridement procedure with a piece of bone or other tissue, such as skin or
muscle, from another part of the body. Sometimes temporary fillers are placed
in the pocket until the patient is healthy enough to undergo a bone graft or tissue
graft. The graft helps the body repair damaged blood vessels and form new
bone.
• Remove any foreign objects. In some cases, foreign objects, such as surgical
plates or screws placed during a previous surgery, may have to be removed.
• Amputate the limb. As a last resort, surgeons may amputate the affected limb
to stop the infection from spreading further.
Medications

A bone biopsy will reveal what type of germ is causing the infection so the doctor
can choose an antibiotic that works well against that type of infection. The antibiotics
are usually administered through a vein in the arm for about six weeks. An additional
course of oral antibiotics may be needed for more-serious infections.

If the patient smokes, quitting smoking can help speed healing. It's also important to
take steps to manage any chronic conditions the patient may have, such as keeping
the blood sugar controlled if the patient has diabetes.

Complications

Osteomyelitis complications may include:

• Bone death (osteonecrosis). An infection in the bone can impede blood

circulation within the bone, leading to bone death. Areas where bone has died
need to be surgically removed for antibiotics to be effective.
• Septic arthritis. Sometimes, infection within bones can spread into a nearby
joint.
• Impaired growth. Normal growth in bones or joints in children may be
affected if osteomyelitis occurs in the softer areas, called growth plates, at either
end of the long bones of the arms and legs.
 • Skin cancer. If osteomyelitis has resulted in an open sore that is draining pus,
the surrounding skin is at higher risk of developing squamous cell cancer.

Prevention
Reducing the risk of infection will also help to reduce the risk of developing
osteomyelitis. In general, take precautions to avoid cuts, scrapes and animal
scratches or bites, which give germs easy access to the body. If anyone has a minor
injury, the area should be cleaned immediately and a clean bandage applied. Wounds
should be checked frequently for signs of infection.

GENERAL NURSING CARE PLAN OF PATIENTS WITH

MUSCULOSKELETAL PROBLEMS