PERCEPTION & COORDINATION Musculoskeletal Disorders

Christian S. Tu, RN 1

FUNCTIONS
S upport P rotection M ovement S torage of
Christian S. Tu, RN

Minerals H ematopoiesis

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Christian S. Tu, RN

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See what happens when YOU have NO MUSCLES««.

Christian S. Tu, RN

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Christian S. RN 5 .Muscle Tissue ‡ A specialized tissue that has the ability to shorten or ´contractµ. Tu.

Properties 1. RN 6 . Tu.Excitability/Irritability 3.Extensibility Christian S.Elasticity 4.Contractility 2.

Tu. RN 7 .Functions ‡ Movement ‡ Posture ‡ Joint Stability ‡ Heat Production Christian S.

‡ Strong . Tu. RN 8 . fibrous connective tissues that bind bones ‡ Provide joint stability and allow restricted joint movement Christian S.

non-elastic connective tissue extending from muscle sheath ‡ Bind muscles to bones Christian S. fibrous. Tu. RN 9 .‡ Strong.

‡ Nonvascular. Tu. ‡ Absorption of weight. stress and strain ‡ Protection of bones. RN 10 . and joint tissue Christian S. supporting connective tissue composed of various cells and fibers. joint. shock.

Christian S. Tu. RN 11 .

‡ Elicit a description of the present illness and chief complaint Christian S. RN 12 . Tu.

Tu. RN 13 .Cardinal Signs and Symptoms ‡ ‡ ‡ ‡ Moderate to severe pain Inability to move body parts Localized edema Altered sensation to affected area ‡ Contour deformity and asymmetry ‡ Contusions Christian S.

4. 2.1. Tu. 5. RN 14 . 3. Medical conditions / Medications Unsafe Environment Decreased Dietary intake Infrequent Exercise/Sedentary lifestyle Family history Christian S.

Tu. RN 15 .Inspection ‡ ‡ ‡ ‡ ‡ ‡ Body alignment Bone discrepancies Mobility Gait Joint alignment Muscle discrepancies Christian S.

Tu. RN 16 .Palpation ‡ Muscle mass ‡ Muscle strength Christian S.

Tu.Christian S. RN 17 .

Tu. must remain still duringRN Christian S. scan 18 .‡ X-ray ² detect structure. must void immediately before procedure ² Pt. texture and density problem ² evaluate the disease progression and treatment efficacy ‡ Bone Scan ² detect skeletal trauma and disease ² Pt.

Christian S. Tu. blood or pus aspirated from joint cavity. RN 19 .‡ Arthrography ² identify acute or chronic tears of the joint capsule ( injection of radiopaque) ‡ Arthrocentesis ² allows analysis of synovial fluid.

Decreased C4 Complement (N: 140-510 mg/L) «« (+) C-reactive protein (CRP) & Antinuclear antibody (ANA) «« X-ray: (+) bony erosion and narrowed joint spaces Christian S. Increased ESR (N: less than 15 mm/hr) ««..Synovial fluid is cloudy. dark yellow and contains numerous inflammatory cells ««.. Decreased RBC ««.(+) RA if«. milky. RN 20 . ««. Tu.

tumor congenital/ degenerative condition ² Keep pt. RN of the needle 21 . flat on bed @ least 12hrs post test ‡ Electromyography (EMG) ² measures muscle electrical impulses for diagnosis of muscle or nerve disease ² Prepare pt.‡ Myelography ² detect herniation. Tu. from discomfort Christian S.

‡ Biopsy ² studies bone. cross sectional images. synovium. bone and the spinal cord in three-dimensional. RN 22 . Tu. Christian S. muscle tissue ‡ CT Scan ² show soft tissue.

allergies Christian S. Tu. RN 23 . hemorrhage.‡ MRI ² allows study of soft tissue in multiple planes of the body ‡ CBC Analysis ² identifies anemias. infection.

‡ CPK-MB ² elevation may identify skeletal muscle necrosis. RN . 24 Christian S. ‡ LDH ² identify skeletal muscle damage. atrophy or trauma. Tu. ‡ Serum Calcium ² bone loss density ‡ C-reactive protein test ² severity and course of inflammatory process ‡ Rheumatoid factor ² measure the presence of macroglobulin type of antibody.‡ Alkaline phosphatase ² identify increases in osteoblastic activity of the inflammatory condition.

RN 25 . Tu.‡ Relief of pain ‡ Maintenance of adequate tissue perfusion ‡ Improved physical mobility Christian S.

Tu.Christian S. RN 26 .

RN 27 . Tu.Neurovascular Assessment (6 P¶s) ain ulses allor aresthesia aralysis olar Christian S.

RN 28 . Tu.Pain ± signals the beginning of muscle ischemia Pulses ± pulselessness indicates disruption of arterial blood flow. Paresthesia ± nerve function may be disrupted by nerve compression. Pallor ± indicates disruption of arterial blood flow. Paralysis ± increasing edema causes nerve compression Polar ± indicates disrupted arterial blood flow Christian S.

‡ Sprain ± complete or incomplete tear in the supporting ligaments surrounding joints. RN 29 . Christian S. Tu. ‡ Strain ± overstretching injury to a muscle or tendon.

RN 30 .‡ Sprain ± commonly result from wrenching or twisting motion ‡ Strain ± typically result from excessively vigorous movement in understretched and overstretched muscles and tendons Christian S. Tu.

‡ Sprain ‡ Pain and discomfort ‡ Edema ‡ Decreased joint motion and function ‡ Feeling of joint looseness Christian S. RN ‡ Strain ‡ Pain ‡ Edema ‡ Ecchymoses 31 . Tu.

4. Administer prescribed medication 2. RN 32 . Provide nursing care for the client who sustain sprain. Provide additional teaching Christian S. Provide nursing care for a client who suffer muscle or tendon strain.1. 3. Tu.

RN 33 .Displacement of a bone from its normal articulation with a joint Christian S. Tu.

RN 34 .‡ May be congenital ‡ May result from trauma or disease of surrounding joint tissue Christian S. Tu.

RN 35 .‡ ‡ ‡ ‡ ‡ ‡ Pain Visible disruption of joint contour Edema Ecchymoses Impaired joint mobility Change in extremity length and in axis of dislocated bones Christian S. Tu.

Assist physician in reducing displaced parts as necessary 4. Administer prescribed medication 2. RN 36 . Prevent from further injury 3. Tu. Provide teaching Christian S.1.

Remember ‡ Rest ‡ Ice ‡ Compress ‡ Elevate Christian S. Tu. RN 37 .

Christian S. Tu. RN 38 .

women aged 65 years and older Christian S. RN 39 .‡ Disruption in the continuity of bone as a result of trauma or various disease process ‡ Highest incidence in males 15-24 years and in elderly persons. Tu.

Tu. RN 40 .‡ ‡ ‡ ‡ Direct blow Crushing force Sudden twisting motion Extreme muscle contraction Christian S.

Fractures Complete fractureClosed fracture ± does involves a break not produce a break in across the entire cross the skin. the only part of the cortex on the covade cross section of the side remain intact Christian S. section of the bone Open fracture ± and is frequently presence of break in displaced from normal the skin. RN 41 bone. . position Greenstick ± bone Incomplete fracture ± bends w/out fracturing break occurs through across completely. Tu.

short bone resulting Spiral/ oblique ± from strong direct fracture twisting pressure. caused by a compression force. around the shaft of the Compression ± bone.Other fractures Crush ± occurs in Transverse ± fracture cancellous bone as that is straight across result of a the bone. force applied to the Burst ± occurs in a site. Tu. RN diseased bone. Pathologic ± fracture Impacted. caused by fracture which the violence forced bone has been compressed through the limb.fracture through an area of where the fragment Christian S. are driven into one 42 .

RN .Other fractures Avulsion ± pulling away of a fragmet of bone by a ligament or tendon & its attachment. Include more than one break in the bone. Tu. Epiphyseal ± fracture through the epiphysis Compound ± fracture with a surface or open wound. Comminuted ± fracture with more than one fragments 43 Christian S.

RN 44 .‡ ‡ ‡ ‡ ‡ ‡ ‡ Pain Loss of function/sensation Deformity Shortening/lenghtening Crepitus (grating sensation) Swelling Discoloration Christian S. Tu.

‡ ‡ ‡ ‡ Excessive motion on site Soft tissue edema Warmth over injured area Paralysis distal to injury resulting from nerve entrapment ‡ Signs of shock related to severe tissue injury Christian S. RN 45 . Tu.

sensation. or temperature of injured part observe for signs of shock Christian S. Tu. RN 46 .Fracture care ‡ ‡ ‡ ‡ ‡ ‡ splinting of fracture preservation of body alignment elevation of body part to limit edema application of cold packs observe for changes in color.

RN 47 .‡ ‡ ‡ ‡ ‡ ‡ Fat embolism Compartment syndrome Nonunion Arterial damage Infection Hemorrhage/ Shock Christian S. Tu.

Christian S.serious.Fat emboli . RN 48 . potentially life-threatening complication S/Sx: Restlessness mental status changes tachycardia tachypnea hypotension Dyspnea Petechial rash over the upper chest and neck. Tu.

viability. RN 49 .increased pressure within a limited anatomic space compromising circulation.Compartment syndrome . Tu. and function of tissues within that space. ‡ ‡ ‡ ‡ ‡ ‡ S/Sx: increased pain and swelling pain with passive motion inability to move joints loss of sensation pulselessness Christian S.

Tu. RN 50 . ‡ S/Sx: ± fever ± pain ± erythema in the affected area ± tachycardia ± elevated WBC count Christian S.caused by the interruption of the integrity of the skin. the infection invades bone tissue.Infection and osteomyelitis .

RN 51 . which results in the death of the bone.Avascular necrosis. Tu.interruption in the blood supply to the bony tissue.caused by immobility precipitated by a fracture ‡ S/Sx: ‡ restlessness and apprehension ‡ Dyspnea ‡ Diaphoresis ‡ ABG changes Christian S. ‡ S/Sx: ‡ pain ‡ decreased sensation Pulmonary Emboli.

Treatment ‡ Splinting.provides rigid immobilization of affected body part for support and stability Christian S. Tu.immobilization of the affected part to prevent soft tissue from being damaged by bony parts Casting. RN 52 ‡ .

RN 53 ‡ ‡ .use of metal screws. Tu. Christian S.restoration of the fracture fragments into anatomic alignment and rotation.Treatment ‡ Internal fixation. nails and pins to stabilize reduced fractures Traction Reduction. plates.

iron. RN 54 . Tu. moderate carbohydrates (prevent weight gain) ‡ increase fluid intake Christian S. vitamins (tissue repair).Nursing care plan/implementation for clients with Fracture Promote healing and prevent complications ‡ diet: high protein.

pulselessness. RN 55 ‡ . decubitus ulcers. numbness Christian S. osteoporosis) assess casted extremity for presence of foul odor. change in temperature. constipation. drainage. Tu.Nursing care plan/implementation for clients with Fracture ‡ assess for complications of immobility (pneumonia. paleness or blueness. tingling.

Nursing care plan/implementation for clients with Fracture Prevent injury or trauma ‡ avoidance of high-risk activities (sky diving. Tu. RN 56 . high impact sports. rollerblading) ‡ avoidance of safety hazards (throw rugs. untreated vision problems) ‡ regular exercise Christian S.

Nursing care plan/implementation for clients with Fracture ‡ Provide care related to ambulation with crutches ‡ Provide safety measures related to possible complications following fracture Christian S. Tu. RN 57 .

support the affected side. RN 58 . Tu. Christian S.Nursing Management ‡ Administer prescribed medication ‡ Provide care during transfer of the patient .immobilized the fractured extremity .

Tu. RN 59 .Teach the proper use of assistive devices.explain prescribed activity restriction . .‡ Provide client and family teaching .Provide additional teaching Christian S.

Stages of Bone Healing ‡ HEMATOMA AND INFLAMMATION ‡ ANGIOGENESIS AND CARTILAGE FORMATION ‡ CARTILAGE CALCIFICATION ‡ CARTILAGE REMOVAL ‡ BONE FORMATION ‡ REMODELING Christian S. RN 60 . Tu.

RN 61 .‡ Callus formation: 3 to 4 weeks ‡ Ossification begins within 2 to 3 week up to 3 to 4 months ‡ Progress should be monitored by serial x-rays ± reveals complete bone union Christian S. Tu.

Tu. Plaster Casts ( POP) ± mold very smoothly to the body contour. Non Plaster/ Synthetic Casts± fiberglass casts that are commonly used today Christian S. 2. RN 62 .Types of CASTS 1.

Long arm posterior moldfx of radius & ulna w/ compound affection Christian S.CASTS & MOLDS Short arm circular cast ± wrist and finger Short arm posterior moldwrist and finger with compound affection Long arm circular castradius/ ulna Fuenster¶s or munster¶s cast.radius/ ulna with callus formation. RN 63 . Tu.

CASTS & MOLDS Hanging cast shaft of humerus Functional arm cast ± humerus (allows abduction & adduction) Shoulder spica ± humerus and shoulder joint Airplane ± humerus and shoulder compound affection Christian S. Tu. RN 64 .

RN 65 .CASTS & MOLDS Rizzer¶s jacket ± scoliosis Minerva ± upper dorsal cervical spine 1 & ½ hip spica ± hip & femur Body cast ± lower dorsolumbar spine Double hip spica ± hip & femur Long leg cast.tibia. fibula Long leg posterior mold.fx of the tibia & fibula w/ compound affection Basket ± severe leg trauma w/ open wound or inflammation Christian S. Tu.

CASTS & MOLDS
Cylindrical leg cast- patella Quadrilateral/ ischial weight bearing cast ± shaft of femur w/ CF Cast brace ± fx of the femur distal 3rd Short leg circular cast ± ankle & foot PTB- tibia/ fibula w/ CF Delbit cast- Tibia & fibula Short leg posterior mold ± ankle & foot w/ compound affection Boot leg cast for traction ± hip & femoral fx Internal rotator splint ± post hip operation Christian S. Tu, RN

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CASTS & MOLDS
Collar cast ± cervical affection Pantalon cast ± pelvic bone fracture Frog cast ± congenital hip dislocation Single hip spica ± hip & 1 femur 1 & ½ spica mold ± hip & femur w/ compound affection Double hip spica- pelvic Christian affection w/ CF +2 femur S. Tu, RN

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CASTS & MOLDS

Single hip spica mold- pelvic bone fx w/ CF Night splint ± post polio

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immobilized a body part Exert uniform compression Provide for early mobilization Correct or prevent deformities Stabilize and support unstable joints

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provide cast care Initiate pain relief measures as indicated Observe for signs of cast syndrome especially with client who are immobilized in large cast. Tu.1. RN 70 . Christian S. 4. 2. 3. Prepare the client Assist during application of casts PRN After cast application. 5.

if indicated 7.6. Provide nursing care for compartment syndrome. Notify the physician if ³hot-spots´ occur 9. Ensure proper technique and procedure in cast removal. RN 71 . Christian S. Provide client teaching 10. Tu. Notify the physician immediately if signs of other neurovascular complications occur 8.

close to room temperature and resonant to percussion.1. Support fresh cast with the palm of the hand to prevent indentations from tips of the fingers 2. circulating. RN 72 . Expose the cast to warm. Christian S.5-15 minutes up to 48 hours ‡ Synthetic cast ± 30 minutes Dry cast : white. dry air. Tu. Wet Cast: gray. musty smelling and dull to percussion. cool. odorless. ‡ Plaster cast .

Potential Pressure Areas/ Points Christian S. RN 73 . Tu.

Tu. ‡ AVOID getting plaster cast wet. especially the padding under the cast ‡ DO NOT cover cast with plastic or rubber boots. Christian S.‡ Check neurovascular status ‡ Alternate ambulation with periods of elevation to the cast when seated ‡ Perform active ROM hourly when awake by wiggling fingers/ toes. RN 74 .

Cast Care ‡ NO weight bearing exercises for 24 hours after cast application ‡ Clean plaster cast using slightly damp cloth. by rubbing soiled areas with scouring powder and by wiping off residual moisture ‡ AVOID walking on wet floors or sidewalks to prevent falls ‡ DO NOT place objects under the cast to pressure and skin injury. Tu. Christian S. RN 75 .

1. Immobility/ Disuse Syndrome ± results to multi-system problems Christian S. purulent drainage & presence of ³hot spots´ 3. Tu. RN 76 . foul odor. Neurovascular problems (Compartment Syndrome) 2. Pressure Ulcers/ Sores ± severe initial pain over bony prominences.

Signs & Symptoms of COMPARTMENT SYNDROME 6 P¶s ‡ ‡ ‡ ‡ ‡ ‡ Pain ± aggravated by moving or elevating affected extremity. Paralysis ± late sign Puffiness ± late sign Christian S. usually not relieved by analgesics Pallor Pulselessness Paresthesia ± occur early in the syndrome which progresses to«. Tu. RN 77 .

‡ An orthopedic treatment that involves placing tension on a limb. Tu. RN 78 . bone or muscle group using variety of weight and pulley systems Christian S.

Tu. RN 79 .Christian S.

and immobilize fractures 3. align. Christian S. Tu. RN 80 .1. Correct or prevent deformity 4. Decreased muscle spasm 2. Increase space between joint surfaces. Reduce.

‡ Balanced suspension traction ± involves exertion of a pull while the limb is supported by hammock or splint Christian S.‡ Straight or Running traction ± involve straight pulling force in one plane. Tu. RN 81 .

Tu. RN 82 .‡ Skin traction ± involves weight applied and held to the skin with a Velcro splint. ‡ Skeletal traction ± involves weight applied and attached to metal/pin inserted into bone Christian S.

RN 83 .Buck¶s Extension Traction ± femur & hip fracture Overhead ± fracture of humerus Head halter ± cervical spine affection Pelvic girdle ± lumbosacral affection. Tu. herniated nucleus pulposus Christian S.

Dunlop¶s Traction ± fractured elbow and humerus Christian S. RN 84 . Tu.

Halo pelvic ± scoliosis Halo femoral ± severe scoliosis Christian S. Tu. RN 85 .

RN 86 . Hip injuries among kids below 3 years old ‡ Buttocks are slightly elevated and clear off the bed.Bryant¶s traction ± femoral fracture. Boot leg ± hip and femoral affection Christian S. Tu.

in ±chest ± severe chest injury with multiple rib fracture Christian S. RN 87 . Tu.Ninety degrees ± fracture of the femur Stove.

Hammock suspension ± pelvic affection Christian S. Tu. RN 88 .

RN 89 . Tu.Skin Traction ‡ To control muscle spasm ‡ To immobilize an area before surgery Christian S.

Uses wires. or tongs placed through the bones 2. RN 90 . Christian S. humerus. MOST frequently used in treating fractures of femur.Skeletal Traction 1. Tu. pins. tibia & cervical spine.

Line of pull must be continuous. Patient is on firm mattress and in good body alignment in the center of the bed. Ropes must be unobstructed and aligned with pulleys 6. never interrupted and in line with the long axis of the bone 4.Principles of Effective Traction 1. 3. should NOT be removed when repositioning unless prescribed intermittently 5. Countertraction must be maintained for effective traction 2. Tu. Knots must not touch the pulley or foot of the bed and secured tightly Christian S. RN 91 . Weights must hang freely.

‡ Line of pull is from the first pulley back to the point on the extremity. ‡ Tie all knots securely. ‡ Skin traction is usually intermittent and skeletal traction is usually continuous. RN 92 ordered .NURSING FOCUS ‡ Weights must hang freely. Tu.] ‡ Never release weights unless Christian S.

Provide client teaching 5. irritation or infection 4. Promote skin integrity 3. Promote self-care within traction limitation Christian S. Tu. Prevent complications of immobility 2. RN 93 . Inspect for signs of skin breakdown.1.

Tu.Care of Client with Skeletal Traction Maintain principles of effective traction Watch for signs of infection especially around the pin site Check neurovascular status regularly especially immediately after application of traction. RN 94 . Observe for pressure at traction Christian S. Assess sensorimotor function.

redness. ± Clean pin tract with sterile applicators and prescribed solutions to prevent plugging at the pin site. RN 95 . Tu.Avoiding infection at PIN SITE ± The pin should be immobile in the bone and skin wound should be dry ± Small amount of serous discharge oozing from pin site may occur ± If infection is suspected. Christian S. percuss gently over the tibia ± (+) pain if infection is developing ± Assess for other signs of infection: heat. fever.

Buck¶s extension ‡ simplest form and provides for straight pull on the affected extremity ‡ relieve muscle spasm ‡ immobilize a limb temporarily ‡ Heel is supported off bed to prevent pressure on heel. and parallel to the bed. weight hangs free of the bed. Tu. Christian S. RN 96 . and foot is well away from footboard of bed.

Russel traction . Tu.permits flexion of the knee joint. Christian S.permits the patient to move freely in the bed . Pillows may be used under lower leg to provide support and keep the heel free of the bed. RN 97 . ‡ used in the treatment of intertrochanteric fracture of the femur when surgery is contraindicated ‡ Hip is slightly flexed.

Russell¶s Traction Christian S. RN 98 . Tu.

motion. and sensation of the affected extremity ‡ Monitor the insertion sites for redness. Tu.Nursing Intervention of Patient¶s with Traction  Monitor color. swelling. RN 99 . or drainage ‡ Patient education ‡ Maintaining the traction ‡ Skin care ‡ Assist in toileting Christian S.

RN 100 . Tu.Christian S.

Tu. or pins Christian S. RN 101 . Internal Fixation ± involves stabilization of reduced fracture with screws. Open reduction ± involves reduction and alignment of fractures through surgical opening ‡ B.‡ A.

RN 102 . Bone graft ± involves placement of bone tissue for healing. stabilization. or replacement ‡ D.‡ C. Tu. Arthroplasty ± involves joint repair through small arthroscope Christian S.

RN 103 .‡ E. ‡ F. Arthrodesis ± involves immobilization of joint through fusion. Joint replacement ± involve replacement of joint surface with metal or plastic materials Christian S. Tu.

femoral.Types of Joint Replacement ‡ 1. and patellar joints. Christian S. Tu. Total knee replacement ± involves replacement to tibial. Total hip replacement ± involves replacement of the ball and socket of a severely damaged hip joint ‡ 2. RN 104 .

‡ G. Tenotomy ± involves cutting tendons ‡ I. RN 105 . Tendon transfer ± involves movement of tendon insertion ‡ H. Fasciotomy ± involves removal of muscle fascia. Tu. relieving constriction Christian S.

Osteotomy ± involves alignment of bone by removal of a wedge ‡ Purpose of Orthopedic Surgery: ± Reconstruct diseased or injured musculoskeletal structure Christian S.‡ J. RN 106 . Tu.

Tu. RN 107 .ASSESSMENT ‡ 1. Preoperative assessment ± Elicit the client¶s medical history ± Identify current medication and condition ± Assess nutritional and hydration status ± Assess skin integrity Christian S.

RN 108 . fluid and electrolyte.‡ 2.respiratory . Nutritional status ‡ Assess neurovascular status ‡ Assess for joint dislocation ‡ Assess for infection ‡ Assess for thromboembolism ‡ Assess and maintain safety and effectiveness of orthopedic apparatus Christian S. Tu. Postoperative Assessment ‡ Assess the cardiovascular .

RN 109 . Tu.Total Hip Replacement ‡ a plastic surgery that involves removal of the head of the femur followed by placement of a prosthetic implant Christian S.

Tu. RN 110 .Signs and symptoms necessitating Surgery ‡ ‡ ‡ ‡ ‡ Severe chronic pain Loss of joint mobility Excessive joint destruction Infection in the joint Contractures Christian S.

Christian S. Tu. RN 111 .

‡ Place affected leg in an abducted position and straight alignment following surgery ‡ Prevent hip flexion of more than 90 degrees. Christian S.Nursing Management ‡ Teach client how to use crutches ‡ Teach client mechanics of transferring. ‡ Discuss importance of turning and positioning post-op. RN 112 . Tu.

and iron. protein. jogging. RN 113 .Nursing Management ‡ Apply support stockings ‡ Advise client to avoid external/internal rotation of affected extremity for 6 months to 1 year after surgery ‡ Instruct client to avoid excessive bending. heavy lifting. Tu. Christian S. jumping ‡ Encourage intake of foods rich in Vitamin C. ‡ Administer prescribed medications.

Complications ‡ ‡ ‡ ‡ ‡ ‡ Infection Hemorrhage Thrombophlebitis Pulmonary embolism Prosthesis dislocation Prosthesis loosening Christian S. Tu. RN 114 .

Christian S. Tu. RN 115 .‡ An implant procedure in which tibial. femoral and patellar joint surfaces are replaced.

Tu. = 200 ml ‡ After 48 hrs = less than 25 ml Christian S.‡ Assess the neurovascular status of the leg ‡ Immobilize knee in extension with a firm compression dressing and an adjustable splint or long leg cast ‡ Elevate on pillows ‡ Apply ice to control edema and bleeding ‡ Encourage active flexion of the foot every hour when patient is awake ‡ Drainage: 1st 8 hrs. RN 116 .

Tu. RN 117 .Types: ‡Below the knee (BKA) Christian S.

disappears with time . . .Phantom limb pain described as a cramp or uncomfortable sensation .the pain is a real sensation and should not be dismissed as illusionary. Christian S.Amputation of a Lower Extremity ‡ surgical removal of a lower limb or part of the limb. RN 118 .10% of patients experience uncomfortable sensations. Tu.phantom limb pain.

Monitor for bleeding. 5. 4. Elevate the foot of the bed if hemorrhage is suspected. Have clamps available at bedside. RN 119 . 3. Tu. 2. Christian S. Notify surgeon ASAP.1. Apply pressure directly over the area of bleeding.

Complications of Amputation ± Infection ± Wound necrosis ± Phantom limb pain ± Contractures Christian ± Skin breakdown S. Tu. RN 120 .

Christian S. ‡ Keep the stump elevated for 1st 24 hours to prevent edema ‡ After 48 hours DO NOT elevate with pillows BUT rather elevate the foot of the bed. Tu. then q 4 hours. then q 2 hours for 1st 24 hours. RN 121 .‡ Monitor vital signs q 15 min until stable.

‡ Encourage to do active ROM of extremity to strengthen muscles and inhibit contractures. RN 122 . Tu. four times per day. (especially AKA) after 24-48 hrs to stretch the muscles and prevent flexion contracture of hip ‡ Have patient lie in a supine position with the knee in extension (especially BKA).To prevent contractures: ‡ Place patient in a prone position for 15 minutes. ‡ Maintain on low-Fowler¶s or flat position after AKA Christian S.

‡ Encourage exercises to prevent thromboembolism ‡ Encourage patient to ambulate using correct crutchwalking techniques Christian S.‡ In prone position. place a pillow under the abdomen and stump and keep the legs close together to prevent abduction ‡ Support stump with pillow for first 24 hours. RN 123 . place rolled bath blanket along outer aspect to prevent outward rotation. Tu.

RN 124 .‡ Crutch ‡ Cane ‡ Walker Christian S. Tu.

Tu. RN 125 .37 Crutch Walking Crutches ± artificial supports ± assist patients ± aid in walking Preparation: ± strengthen muscles of the shoulder girdle and upper extremities Christian S.

Measurement: ± Lying down: from anterior fold of axilla to the sole of the foot. RN 126 . Christian S. then add 2 inches OR subtract 16 inches from patient¶s height ± Standing: two-finger-width insertion between axillary fold and underarm piece grip with tip of the crutch placed 6 to 8 inches lateral to the floor. Tu.

Tu. should be on HANDS Christian S. 8 to 10 inches in front of and to the side of patient¶s toes ‡ TALLER = WIDER ‡ NO Weight bearing on axilla. RN 127 .Basic stance: TRIPOD POSITION ‡ Crutches rest approx.

Tu. RN 128 .NURSING ALERT Three-point gait is used for non-weight bearing person with a fracture of the leg or hip. Christian S.

Christian S.NURSING ALERT Four-point gait is used for patients affected by polio and cerebral palsy. Tu. RN 129 .

Tu.NURSING ALERT Swing-through gait is used by the paraplegic with leg braces. Christian S. RN 130 .

then advance unaffected (good) leg. Tu. ‡ Going down stair: proceed with both crutches and affected (bad) leg first. RN 131 . then advance crutches and affected (bad) leg.Stair Climbing Using Crutches ‡ Going up stairs: proceed with unaffected (good) leg first. Christian S.

Christian S. THE BAD GO TO HELL (move crutches and bad leg first when going down). RN 132 . Tu.NURSING ALERT Remember: the GOOD GO TO HEAVEN (move good leg first when going up).

Using a Cane ‡ Hold the cane on unaffected (good) side. then affected leg. or advance the cane first. Tu. it should be at the level of the femur. with the elbow flexed at 30 degrees. then advance the good leg. The cane handle should be held. RN 133 . Move the cane and the affected (bad) leg at the same time first (simultaneously). then unaffected leg. ‡ Christian S.

Tu. Christian S. ‡ When using a walker. RN 134 .Using a Walker ‡ The top of the walker should be at the same level as the cane (head at femur level) with elbow flexed at 30 degrees. advance it 6 inches and then move into it.

RN 135 . Tu.Christian S.

Caring for Patient with Christian S. RN 136 . Tu.

‡A disease characterized by exaggerated loss of bone mass and changes in microarchitecture of the bone tissue that compromise bone quality. ‡Bones become fragile and prone to fracture. Tu. Christian S. RN 137 .

It is more common in females than males: in women.Characteristics of Osteoporosis ³Silent": most patients are unaware of osteoporosis until the first bone fracture occurs. hormone secretion drops drastically during menopause and this accelerates bone loss. Tu. RN 138 . Christian S.

6. 5. such as rheumatoid arthritis.These factors increase your risk of developing osteoporosis: 1. 4. 8. 3. RN 139 . 2. 7. Heredity factors Early menopause in women Drinking too much coffee and strong tea Cigarette smoking and alcoholism Low calcium intake Lack of exercise Some diseases. Prolonged use of certain medications. Tu. hyperthyroidism or some reproductive disorders. such as steroids and thyroid hormone Christian S.

Tu. RN 140 .Aging CALCITONIN ESTROGEN PTH BONE RESORPTION BONE FORMATION Loss of BONE MASS Christian S.

Health history includes questions concerning: ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Occurrence of osteoporosis Family history Previous Fractures Dietary consumption of calcium Exercise patterns Onset of menopause Use of corticosteroids Alcohol, smoking & caffeine intake
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BACK PAIN CONSTIPATION SHORTENED STATURE & SPINAL DEFORMITY

FRACTURE

IMPAIRED MOBILITY
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BREATHING PROBLEMS 142

1. Reviewing and evaluating a patient's: ‡ ‡ ‡ physical condition, lifestyle & daily living habits

2. Measuring Bone Density
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1. Balance diet rich in CALCIUM & VITAMIN D 2. Regular weight-bearing EXERCISES 3. Hormone replacement therapy (HRT) with ESTROGEN & PROGESTERONE 4. Other medications: ‡ Alendronate ‡ Calcitonin

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Prevention of osteoporosis begins from childhood as it is important that you maximize your peak bone mass before the age of 35 years.
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Sufficient intake of calcium

Adequate weight-bearing exercises.

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Maintain a healthy lifestyle.

Home safety to prevent falls and fractures.

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To maintain bone mass, postmenopausal women may need adequate hormone replacement therapy according to a doctor's advice.
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RN 149 .Christian S. Tu.

‡ Blood-borne (hematogenic) osteomyelitis is common children ‡ Chronic illness ‡ Long term corticosteroid therapy Christian S.ETIOLOGY ‡ Result from trauma or secondary infection. RN 150 . Tu.

RN 151 .Christian S. Tu.

RN 152 . and edema Guarding of the affected area Restricted movement Systemic symptom Purulent drainage malaise Christian S.Clinical Manifestations ‡ ‡ ‡ ‡ ‡ ‡ ‡ Localized bone pain Tenderness. heat. Tu.

Lab/ Dx Findings ‡ WBC count reveals leukocytosis ‡ ESR is elevated ‡ Blood cultures identifies the causative agent (Staph. RN 153 . Aureus) ‡ Radiograph and bone scan Christian S. Tu.

Protect the affected extremity from further injury and pain 3. Promote healing and tissue growth 4. Administer prescribed medication 2. RN 154 . Tu. May apply warm.Nursing Management 1. wet soaks 20 min several times a day Christian S. Prepare client for surgical treatment 5. Provide additional teaching 6.

-a slowly progressive. RN 155 . degenerative joint disease characterized by variable changes in weight-bearing joint. Tu. -Also known as Degenerative Joint Disease/ Hyperthropic Arthritis Christian S.

‡ Associated with ‡ Obesity ‡ Aging (>50yr) ‡ Trauma ‡ Genetic predisposition ‡ Congenital abnormalities Christian S. Tu. RN 156 .

RN 157 . Tu.Christian S.

‡ Pain and muscle spasm. aggravated by use relieved by rest ‡ Limited motion ‡ Joint grating with movement ‡ Flexion contractures ‡ Joint tenderness ‡ Presence of Heberden¶s nodes or Bouchard¶s nodes ‡ Weight loss ‡ Cold intolerance Christian S. Tu. RN 158 .

Tu. RN 159 .‡ Radiographs may reveal a narrowing of joint space Christian S.

Tu.Christian S. RN 160 .

Provide nonpharmacologic comfort measures 3.Plan activities that promote optimal function and independence Christian S. Tu. Administer prescribed medication 2.1. Position the client to prevent flexion deformity 4. RN 161 .

Refer to physical and occupational therapy 6.5. Prepare the client fro surgical treatment as indicated 7. Provide referrals Christian S. Tu. RN 162 .

analgesic. antipyretic action ‡ inhibit platelet aggregation in cardiac disorders Christian S. it diminishes the formation of prostaglandins ‡ anti-inflammatory. RN 163 .Medication Aspirin ‡ inhibits cyclooxygenase enzyme. Tu.

can cause respiratory depression Christian S.Adverse effects: ‡ GI: Epigastric distress. Tu. and vomiting ‡ Blood: inhibition of platelet aggregation and a prolonged bleeding time ‡ Respiratory: In toxic doses. RN 164 . nausea.

‡ Hypersensitivity ‡ Reye¶s syndrome: Acute encephalopathy following a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver Christian S. RN 165 . Tu.

hallucinations. dizziness. vomiting. mental confusion. respiratory and metabolic acidosis and death from respiratory failure. coma. convulsions.Toxicity: (mild or severe) ‡ Mild salicylism: nausea. headache. delirium. Christian S. and tinnitus ‡ Severe salicylism: restlessness. RN 166 . Tu. marked hyperventilation.

Tu.Ibuprofen ‡ anti-inflammatory.and antipyretic acitivity ‡ use for chronic treatment of rheumatoid and osteoarthritis ‡ less GI effects than aspirin ‡ reversible inhibitors of the cyclooxygenases and inhibit the synthesis of prostaglandins Christian S. analgesic. RN 167 .

Adverse effects: ‡ GI: dyspepsia to bleeding ‡ CNS: headache. Tu. RN 168 . tinnitus and dizziness Christian S.

Indomethacin ‡ anti-inflammatory. Tu. analgesic and antipyretic acitivity ‡ inhibits cyclooxygenase enzyme ‡ more potent than aspirin as an antiinflammatory agent Christian S. RN 169 .

diarrhea and abdominal pain ‡ CNS: frontal headache. anorexia. vertigo. and mental confusion ‡ Hypersensitivity reaction Christian S. Tu.Adverse effects: ‡ *dose-related ‡ GI: nausea. dizziness. RN 170 . light-headedness. vomiting.

spasms. Tu. swelling ‡ medications as prescribed. RN 171 . inflammation.Nursing Management Promote comfort: reduce pain. ‡ Heat to reduce muscle spasm ‡ Cold to reduce swelling and pain Christian S.

splints to maintain proper alignment Position: elevate extremity to reduce swelling Promote independence Christian S. RN 172 ‡ ‡ . bed rest on firm mattress. Tu.‡ Prevent contractures: exercise.

Rheumatoid
Pain Early morning stiffness which gets better as the day progresses. May be exacerbated by exercise. Joints Typical deformity is symmetrical (bilateral) with swelling. Ulnar deviation General Weight loss, fatigue, and fever.

Osteoarthritis
Stiffness worsens during the day. Feels better after exercise.

May be localized to a single joint or more, may not be swollen, but may be painful. Finger joints may become affected.

Christian S. Tu, RN

173

Rheumatoid arthritis ‡ chronic systemic inflammatory disease ‡ destruction of connective tissue and synovial membrane within the joints ‡ weakens and leads to dislocation of the joint and permanent deformity

Christian S. Tu, RN

174

Risk Factors: ‡ exposure to infectious agents ‡ fatigue ‡ stress

Christian S. Tu, RN

175

Diagnostic tests
‡ Elevated ESR ‡ Mild leukocytosis ‡ Anemia ‡ Positive RF
Christian S. Tu, RN 176

RN 177 . and decreased range of motion ‡ spongy. soft feeling in the joints ‡ low grade fever. tenderness. and stiffness of the joints ‡ moderate to severe pain and morning stiffness lasting longer than 30 minutes ‡ joint deformities.Signs and Symptoms ‡ inflammation. Tu. muscle atrophy. fatigue and weakness Christian S.

Signs and Symptoms ‡ anorexia. Tu. RN 178 . weight loss. and positive RF ± Nonreactive: 0-39 IU/ml (CRP) ± Weakly reactive: 40-79 IU/ml (CRP) ± Reactive: greater than 80 IU/ml (CRP) ‡ X-ray showing joint deterioration Christian S. and anemia ‡ elevated ESR.

Rheumatoid Arthritis Christian S. Tu. RN 179 .

RN 180 . Tu.Rheumatoid Arthritis Christian S.

anti-inflammatory ‡ Gold salts Christian S. Tu. RN 181 .Medication ‡ Salicylates (acetylsalicylic acid ) ‡ NSAIDs ‡ Corticosteroids.

Aurothioglucose. rather they can only prevent further injury . Tu.these drugs cannot repair existing damage.use in the treatment of RA that does not respond to salicylates or other NSAID therapy Christian S. RN 182 . Auranofin . anti-inflammatory agents Gold sodium thiomalate.Gold salts ‡ ‡ ‡ ‡ slow-acting.

pregnancy.‡ Adverse effects: ‡ dermatitis of the skin or of the mucous membranes ‡ proteinuria and nephrosis ‡ Gold salts should be avoided in patients suffering from hepatic or renal disease. ‡ Serious Toxicity: Dimercaprol Christian S. Tu. RN 183 .

Treatment ‡ Hot and Cold packs to affected joints ‡ Surgical Procedures: synovectomy. arthroplasty Christian S. Tu. arthrotomy. arthrodesis. RN 184 .

Nursing Management Prevent or correct deformities ‡ ‡ ‡ ‡ bed rest daily ROM exercises heat and/or pain medication increase oral fluid intake at least 1500 mL to prevent renal calculi Christian S. RN 185 . Tu.

RN 186 . Tu.A metabolic disease marked by urate crystal deposits in joints throughout the body. Christian S.

Higher incidence in men Christian S..Linked to a genetic deficit in purine metabolism . Tu.Age (>50yr) . RN 187 .

RN 188 .Signs and Symptoms ‡ ‡ ‡ ‡ ‡ extreme pain swelling erythema of the involved joints fever tophi Christian S. Tu.

Christian S. RN 189 . Tu.

usually at night ‡ Pain.‡ sudden attacks. joint swelling and inflammation ‡ Intolerance to the weight of bed linen over the affected joint ‡ Pruritus or skin ulceration ‡ Signs of renal involvement Christian S. RN 190 . Tu.

Arthrocentesis reveals urate crystal in synovial fluid ‡ 2. Serum uric acid level is increased ‡ 3. RN 191 .‡ 1. Christian S. Radiographs may show joint damage in advanced disease. Tu.

a purine analog .Treatment ‡ Allopurinol . Tu. RN 192 . Christian S.reduces the production of uric acid by competitively inhibiting uric acid biosynthesis which are catalyzed by xanthine oxidase.

‡ Adverse effects: hypersensitivity reactions. RN 193 . Tu. nausea and diarrhea Christian S.Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies).Allopurinol .

RN 194 .Colchicine ‡ Effective for acute attacks of gouty arthritis pain ‡ Reduces inflammation in the joint. prophylactic effect reducing the frequency of acute attacks and relieves pain. ‡ Does not prevent the progression of gout but have a suppressive. Tu. ‡ Anti-inflammatory activity alleviating pain within 12 hours Christian S.

abdominal pain. aplastic anemia. diarrhea. agranulocytosis. RN 195 . alopecia Christian S. vomiting.Colchicine ‡ Adverse effects: nausea. Tu.

Provide measures to promote comfort and reduce pain 4. Tu.1. Promote measures to prevent exacerbations. 3. Provide client teaching Christian S. Administer prescribed medication 2. RN 196 .

Tu.Caring for Patient with Christian S. RN 197 .

Tu. Christian S.What is ‡ Osteomalacia involves softening of the bones caused by a deficiency of vitamin D or problems with the metabolism of this vitamin. RN 198 ? .

RN 199 .‡ In children. Christian S. Tu. the condition is called rickets and is usually caused by a deficiency of vitamin D .

Inadequate dietary intake of vitamin D 2.‡ In adult. Malabsorption of vitamin D Christian S. Inadequate exposure to sunlight (ultraviolet radiation) 3. the condition is usually caused by: 1. Tu. RN 200 .

Side effects of medications used to treat seizures . Tu. Christian S. Kidney failure and acidosis . Hereditary or acquired disorders of vitamin D metabolism 2. 3. RN 201 .‡ Other conditions: 1. PO4 depletion associated with low dietary intake or kidney disease 4.

Tu. Christian S. ± In the elderly. there is an increased risk for those who tend to remain indoors and who avoid milk because of lactose intolerance ‡ The incidence is 1 in 1000 people.‡ Risk factors are related to the causes. RN 202 .

Decrease in height/ Spinal Deformities (i. Waddling or limping GAIT 5.‡ diffuse bone pain . Tu. KYPHOSIS) Christian S. numbness around the mouth & of extremities 2. Carpopedal spasms 3. Bowing of legs 4. RN 203 .e. especially in the hips ‡ muscle weakness ‡ symptoms associated with low calcium 1.

Christian S. crawling. and the development of bowlegs or knock-knees.‡ In children. and walking. pain when walking. symptoms of rickets include: ² delayed sitting. RN 204 . Tu.

RN 205 . Elevated ALP (Alkaline Phosphatase) Christian S. Low serum vitamin D level 5. Tu. 3. Low serum calcium & phosphate levels 6. Bone biopsy: (+) increase in osteoid 2.1. Studies of the vertebrae: (+) compression fx 4. Bone X-ray or CT scan of lumbosacral spine shows demineralization.

Tu.1. RN 206 . Adequate exposure of the body to sunlight Christian S. Adequate dietary intake of dairy products that are fortified with vitamin D 2.

Tu. RN 207 . and phosphorus Christian S. calcium.‡ Oral supplements of vitamin D .

Christian S.‡ Large doses of Vitamin D with exposure to sunlight may be indicated in people with intestinal malabsorption . RN 208 . Tu.

‡ Braces or surgery to correct deformities Christian S. Tu. RN 209 .‡ Monitoring of blood levels of phosphorus and calcium may be indicated with some underlying conditions.

2. 4. 3. RN 210 . Pain Sensory changes Loss of reflex Muscle weakness Christian S. Tu.‡ ‡ ‡ Protrusion of the nucleus of the disk into the fibrous ring of the disk with subsequent nerve compression May occur in any portion of the vertebral column Signs & Symptoms 1.

Christian S. RN 211 . Tu.

Tu. Lumbar Nursing Alert: Perform repeated assessments of sensorimotor functions/ reflexes to determine progression of condition Christian S. RN 212 . numbness Weakness Low back pain radiating to the buttocks and leg Postural deformity of the spine (+) Straight-Leg Raise test Weakness & Asymmetric reflexes Sensory loss 2. Cervical         Pain/ Stiffness ± head. neck & upper extremities Paresthesia.1.

and narcotic analgesics 2. RN 213 . muscle relaxants. Moist heat application 5. Bed rest ± supine or low fowler¶s or side lying position with slight knee flexion and pillows between knees.Alleviating pain 1. Use of bed boards under the mattress 3. Anti-inflammatory drugs. Relaxation techniques Christian S. 4. Tu.

Tu. RN 214 .Signs & Symptoms: ‡ ‡ ‡ ‡ Abnormal lateral deviation of spine Unleveled shoulder Asymmetric waistline Prominent scapula Complications: ‡ Related to respiratory problems due to decreased lung expansion as a result of severe curvature of the spine Christian S.

RN 215 . avoiding lotions and powders ± advise the child to wear soft nonirritating clothing under the brace Christian S. Monitor progression of the curvature 2. Tu.Nursing Implementation 1. Prepare the child and parents for the use of a brace if prescribed ± usually worn from 16 to 23 hours a day ± inspect the skin for signs of redness or breakdown ± keep the skin clean and dry.

Tu. RN 216 .Christian S.

avoid twisting movements ‡ logroll the child when turning. Postoperative: ‡ maintain proper alignment. and assist with ambulation Christian S. to maintain alignment ‡ instruct in activity restrictions ‡ instruct the child to roll from a side-lying position to a sitting position.Nursing Implementation Prepare the child and parents for surgery if prescribed. RN 217 . Tu.

Paget's Disease of Bone ‡ Localized rapid bone turnover. femur. RN 218 . tibia. pelvic bones and vertebrae ‡ Primary bone resorption followed by bone formation ‡ Diseased bone is highly vascularized but structurally weak ‡ More common in the adult (>50 y/o) ‡ Male > female Christian S. most commonly affecting the skull. Tu.

Clinical Manifestations ‡ ‡ ‡ ‡ ‡ ‡ bowing of femur and tibia enlargement of the skull cranial nerve compression respiration distress pain high cardiac output failure Christian S. RN 219 . Tu.

RN 220 .elevated Bone scan Christian S. Tu.elevated Serum calcium.Diagnostics ‡ ‡ ‡ ‡ X-rays Serum alkaline phosphatase.

Nursing Management ‡ Prevent pathological fractures ‡ Control pain ‡ Administer drugs as prescribed Christian S. RN 221 . Tu.

‡ Most common sites: metaphysis of long bones especially the distal femur.Bone Tumors Osteosarcoma ‡ Most common primary bone tumor ‡ Occurs between 10-25 years of age. Tu. RN 222 . proximal tibia and proximal humerus Christian S. with Paget's disease and exposure to radiation ‡ Exhibits a moth-eaten pattern of bone destruction.

RN 223 . Tu.Osteosarcoma Christian S.

Clinical Manifestations ‡ local signs ± pain ( dull. anorexia. aching and intermittent in nature). RN 224 . swelling. limitation of motion ‡ systemic symptoms: malaise. and weight loss Christian S. Tu.

RN 225 . Tu.Christian S.

Tu. RN 226 .Diagnostics ‡ ‡ ‡ ‡ Biopsy.confirms the diagnosis X-ray MRI Bone Scan Christian S.

RN 227 . Tu.Medical Management ‡ Radiation ‡ Chemotherapy ‡ Surgical management ± amputation ± limb salvage procedures Christian S.

complications of immobility). Christian S. ‡ Promote coping skills and self esteem ‡ Assess for potential complications (infection. RN 228 .Nursing Management ‡ Promote understanding of the disease process and treatment regimen ‡ Promote pain relief ‡ Prevent pathologic fracture. Tu.

Nursing Management ‡ ‡ ‡ ‡ Provide care for client with amputation Observe for signs of bleeding Elevate stump on pillow for 24-40 hrs Turn patient to prone position for short time first post-op day then 2-3x daily Christian S. RN 229 . Tu.

Tu.Nursing Management ‡ Encourage exercise as soon as possible (1st or 2nd post-op day) ‡ Dangle and transfer patient to wheelchair and back within 1st or 2nd day post-op. crutch walking started as soon as patient feels sufficiently strong ‡ Apply lanolin to dry skin Christian S. RN 230 .

Tu. RN 231 . of the pelvis.Other Musculoskeletal Disorders Dysplasia of the Hip ‡ condition in which the head of the femur is improperly seated in the acetabulum. or hip socket. ‡ Congenital or develop after birth Christian S.

RN 232 . Tu.Christian S.

which allows the femoral head to be displaced from the acetabulum upon manipulation. Tu. RN 233 .Assessment Neonates: laxity of the ligaments around the hip. Implementation: ‡ Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation (neonatal period) Christian S.

RN 234 . Tu.Christian S.

Assessment Infants beyond the newborn period: a. apparent short femur on the affected side (Galleazzi sign. Asymmetry of the gluteal and thigh skinfolds when the child is placed prone and the legs are extended against the examining table. Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed. d. Tu. RN 235 . b. Allis sign) Christian S. c. Limited range of motion in the affected hip.

Spica Cast Christian S. RN 236 . Tu.

Tu. RN 237 .CARPAL TUNNEL SYNDROME: ‡ It occurs when the median nerve at the wrist is compressed ‡ ASSESSMENT: ‡ Pain ‡ Numbness ‡ Paresthesia ‡ Thumb. 1st & 2nd fingers affected=Tinel Sign( tingling sensation when inner wrist is percussed) Christian S.

RN 238 . Tu.Management: ‡ ‡ ‡ ‡ Wrist splinting Avoid repetitive wrist movement Carpal canal cortisone injection Surgical release of tendon sheat Christian S.

RN 239 . Tu.Christian S.