MUSCULO-SKELETAL NU

Prepared by: Liddell Karl C. Pasa, RN

Review of Anatomy and
Physiology
 The musculo-skeletal system consists
of the muscles, tendons, bones and
cartilage together with the joints
 The primary function of which is to
produce skeletal movements
Muscles
Three types of muscles exist in the body
 1. Skeletal Muscles
 Voluntary and striated
 2. Cardiac muscles
 Involuntary and striated
 3. Smooth/Visceral muscles
 Involuntary and NON-striated
TENDONS
 Bands of fibrous connective tissue that
tie bones to muscles
LIGAMENTS
 Strong, dense and flexible bands of
fibrous tissue connecting bones to
another bone
BONES
 Variously classified according to shape,
location and size
 Functions
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
JOINTS
 The
part of the Skeleton where two or
more bones are connected
CARTILAGES
A dense connective tissue that consists
of fibers embedded in a strong gel-like
substance
BURSAE
 Saccontaining fluid that are located
around the joints to prevent friction
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
The nurse usually evaluates
this small part of the over-all
assessment and concentrates
on the patient’s posture, body
symmetry, gait and muscle and
joint function
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
 1. HISTORY
 2. Physical Examination
 Perform a head to toe assessment
 Nurses need to inspect and palpate
 The special procedure is the
assessment of joint and muscle
movement
 Usually, a tape measure and a
protractor are the only instruments
ASSESSMENT OF THE
MUSCULO-SKELETAL SYSTEM
 Gait
 Posture
 Muscular palpation
 Joint palpation
 Range of motion
 Muscle strength
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
 1. BONE MARROW ASPIRATION
 Usually involves aspiration of the marrow to
diagnose diseases like leukemia, aplastic
anemia
 Usual site is the sternum and iliac crest
 Pre-test: Consent
 Intratest: Needle puncture may be painful
 Post-test: maintain pressure dressing and
watch out for bleeding
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
 2. Arthroscopy
 A direct visualization of the joint cavity
 Pre-test: consent, explanation of
procedure, NPO
 Intra-test: Sedative, Anesthesia,
incision will be made
 Post-test: maintain dressing,
ambulation as soon as awake, mild
soreness of joint for 2 days, joint rest
for a few days, ice application to relieve
discomfort
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
3. BONE SCAN
 Imaging study with the use of a contrast
radioactive material
 Pre-test: Painless procedure, IV radioisotope is
used, no special preparation, pregnancy is
contraindicated
 Intra-test: IV injection, Waiting period of 2 hours
before X-ray, Fluids allowed, Supine position for
scanning
 Post-test: Increase fluid intake to flush out
radioactive material
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
4. DXA- Dual-energy XRAY absorptiometry
 Assesses bone density to diagnose
osteoporosis
 Uses LOW dose radiation to measure bone
density
 Painless procedure, non-invasive, no special
preparation
 Advise to remove jewelry
Common musculoskeletal
problems

The Nursing Management

Nursing Management of common musculo-
skeletal problems
PAIN
 These can be related to joint inflammation,
traction, surgical intervention
 1. Assess patient’s perception of pain
 2. Instruct patient alternative pain
management like meditation, heat and cold
application, TENS and guided imagery
Nursing Management
PAIN
 3. Administer analgesics as prescribed
 UsuallyNSAIDS
 Meperidine can be given for severe pain

 4.
Assess the effectiveness of pain
measures
Nursing Management
IMPAIRED PHYSICAL MOBILITY
 1. Instruct patient to perform range of motion
exercises, either passive or active
 2. Provide support in ambulation with
assistive devices
 3. Turn and change position every 2 hours
 4. Encourage mobility for a short period and
provide positive reinforcements for small
accomplishments
 Nursing Management
SELF-CARE DEFICITS
 1. Assess functional levels of the patient
 2. Provide support for feeding problems
 Place patient in Fowler’s position
 Provide assistive device and supervise
mealtime
 Offer finger foods that can be handled by
patient
 Keep suction equipment ready
Nursing Management
SELF-CARE DEFICITS
 3. Assist patient with difficulty bathing
and hygiene
 Assist with bath only when patient has
difficulty
 Provide ample time for patient to finish
activity
Musculoskeletal Modalities
Traction
Cast
Nursing Management
Traction
 A method of fracture immobilization by
applying equipments to align bone
fragments
 Used for immobilization, bone alignment
and relief of muscle spasm
Traction
 Skin traction- Buck, Bryant

 Skeletal traction
Traction
 Balanced Suspension traction

 Running/Straight traction
Traction
 Pulling
force exerted on bones to
reduce or immobilize fractures,
reduce muscle spasm, correct or
prevent deformities
Traction
 TO decrease muscle spasms
 TO reduce, align and immobilize
fractures
 To correct deformities
Nursing Management
Traction: General principles
 1. ALWAYS ensure that the weights hang
freely and do not touch the floor
 2. NEVER remove the weights
 3. Maintain proper body alignment
 4. Ensure that the pulleys and ropes are
properly functioning and fastened by tying
square knot
Nursing Management
Traction: General principles
 5. Observe and prevent foot drop
 Provide foot plate
 6. Observe for DVT, skin irritation and
breakdown
 7. Provide pin care for clients in skeletal
traction- use of hydrogen peroxide
Nursing Management
Traction: General principles
8. Promote skin integrity
 Use special mattress if possible
 Provide frequent skin care

 Assess pin entrance and cleanse the pin

with hydrogen peroxide solution
 Turn and reposition within the limits of
traction
 Use the trapeze
Musculo-Skeletal Therapeutic
Modalities
Bryant’s traction- indicated for children
aged 0-3 year’s not more than 40 lbs.
1. Traction is always applied on both ends

 Nursing Responsibility
 Nurse should be able to pass hand
between the patient’s buttocks and
mattress
Bryant traction

Knee slightly
flexed

Buttocks
slightly
elevated and
clear of bed
Musculo-Skeletal Therapeutic
Modalities
Buck’s Extension Traction
Indicated for older patients to those weighing
over 40 lbs.

Nursing Responsibility
Only the affected extremity is placed on
traction
Buck’s Extension Traction
Musculo-Skeletal Therapeutic
Modalities
Dunlop Traction
Used in affectations of the upper extremities
Dunlop Traction
Skin- non adhesive traction
 Cotrel Traction
• Combination of the head halter and pelvic
traction used in scoliosis
 Russell Traction
• Permits patient to move freely in bed and
permits flexion of the knee and hip joint
• Buck’s extension and the knee is
suspended in a sling to which a rope is
attached
Russell Traction
Skeletal Traction
 Applied into a bone
 Crutchfield Skeletal Traction
• Applied into the parietal; bones
 Indicated for cervical spine affectations
Crutchfield Tong
Balanced Skeletal Traction
CERVICAL HALO TRACTION
BALKAN FRAME
THOMAS SPLINT WITH
PEARSON ATTACHMENT
PELVIC TRACTION
PELVIC TRACTION
Nursing Management
CAST
 Immobilizing tool made of plaster of
Paris or fiberglass
 Provides immobilization of the fracture
Nursing Management
CAST: types
1. Long arm
2. Short arm
3. Short leg
4. Long leg
5. Spica
6. Body cast
Casting Materials
 Plaster of Paris
 Drying takes 1-3 days
 If dry, it is SHINY, WHITE, hard and
resistant
 Fiberglass
 Lightweight and dries in 20-30 minutes
 Water resistant
FIBER GLASS CAST
Cast application
1. TO immobilize a body part in a
specific position
2. TO exert uniform compression to
the tissue
3. TO provide early mobilization of
UNAFFECTED body part
4. TO correct deformities
5. TO stabilize and support unstable
joints
Nursing Management
CAST: General Nursing Care
 1. Allow the cast to air dry (usually
24-72 hours)
 2. Handle a wet cast with the
PALMS not the fingertips
Nursing Management
CAST: General Nursing Care
 3. Keep the casted extremity
ELEVATED using a pillow
 4. Turn the extremity for equal
drying. DO NOT USE DRYER for
plaster cast
 Encourage mobility and range of motion
exercises
 Nursing Management
CAST: General Nursing Care
5. Petal the edges of the cast to
prevent crumbling of the edges
6. Examine the skin for
pressure areas and Regularly
check the pulses and skin
 Nursing Management
CAST: General Nursing Care
7. Instruct the patient not to
place sticks or small objects
inside the cast
8. Monitor for the following: pain,
swelling, discoloration, coolness,
tingling or lack of sensation and
diminished pulses
 Nursing Management
CAST: General Nursing Care
 Hot spots occurring along the cast
may indicate infection under the cast
CAST REMOVAL

Cast removal is done by bivalving

(bivalve) the cast, or cutting the cast in half
longitudinally
Common Complications of Casts:

 pain in the casted extremity, including the

feeling of "pins and needles“
 Compartment syndrome
 Pressure ulcers
 Disuse syndrome
 coldness in an extremity
 a sensation that the cast is too tight
 skin irritation where the cast meets the body
 rarely, infections.
Fracture
A break in the continuity of the bone
and is defined according to its type and
extent
Fracture
 Severe mechanical Stress to bone 
bone fracture
 Direct Blows
 Crushing forces
 Sudden twisting motion
 Extreme muscle contraction
CLINICAL MANIFESTATIONS

 Pain- continuous and increase in severity until

the bone fragments are immobilized. The
muscle spasm that accompanies fracture is a
type of natural splitting designed to minimize
further movement of the fracture fragments
 Loss of Function- after a fracture, the
extremity cannot function, because normal
function of the muscle depends on the integrity
of the bones to which they are attached
 Deformity- displacement., angulation, or
rotation of the fragments causes a deformity
that is detectable when compared with the
uninjured extremity; also results from tissue
swelling
 Shortening- because of the contraction of the
muscles that are attached above and below the
site of fracture
 Crepitus- when the extremity is examined with
the hands, a grating sensation, called crepitus
can be felt. It is caused by the rubbing of the
bone fragments against each other
 Swelling and Discoloration
- localized swelling and discoloration of the skin
(ecchymosis) is a result of trauma and bleeding
into the tissues. These signs may develop for
several hours after the injury.

DIAGNOSIS

 X-rays
 CT and MRI scans may also be used.
TYPES OF FRACTURES
 Greenstick fracture - the bone sustains a small,
slender crack. This type of fracture is more common in
children, due to the comparative flexibility of their
bones.
 Comminuted fracture - the bone is shattered into
small pieces. This type of complicated fracture tends
to heal at a slower rate.
 Simple fracture - or 'closed' fracture. The broken
bone hasn't pierced the skin.
 Compound fracture - or 'open' fracture. The broken
bone juts through the skin, or a wound leads to the
fracture site. The risk of infection is higher with this
type of fracture.
 Pathological fracture - bones weakened by various
diseases (such as osteoporosis or cancer) tend to
break with very little force.
 Avulsion fracture - muscles are anchored to bone
with tendons, a type of connective tissue. Powerful
muscle contractions can wrench the tendon free, and
pull out pieces of bone. This type of fracture is more
common in the knee and shoulder joints.
 Compression fracture - occurs when two bones are
forced against each other. The bones of the spine,
called vertebrae, are prone to this type of fracture.
Elderly people, particularly those with osteoporosis,
are at increased risk.
Types of Fractures
EMERGENCY MANAGEMENT

 Immobilize the body part before moving the

patient
 Splint with pads firmly bandaged over
clothing; sling
 With an open fracture, cover wound with a
clean (sterile) dressing to prevent
contamination of deeper tissues
MEDICAL MANAGEMENT

Reduction- restoration of the fragments to

anatomical alignment and rotation

1. Closed Reduction- accomplished by bringing

the bone fragments apposition through
manipulation and manual traction. The
extremity is held in the desired position while
the physician applies a cast, a splint, or other
devices. X-rays are obtained to verify that the
bone fragments are correctly aligned.
2. Open Reduction- through a surgical
approach; internal fixation devices (metallic
pins, wires, screws, plates, nails, or rods) may
be used to hold the bone fragments in position
until solid bone healing occurs. These devices
may be attached to the sides of the bone, or
they may be inserted through the bony
fragments or directly into the the medullary
cavity of the bone
Immobilization

1. Internal Fixation- achieved through

the use of screws and plates specifically
designed for stability and fixation

2. External Fixation- methods of external

fixation include bandages, casts, splints,
continuous traction, and external fixators
Internal Fixation
External Fixations
TYPES OF FRACTURE
 1. Complete fracture
 Involves a break across the entire cross-
section
 2. Incomplete fracture
 The break occurs through only a part of the
cross-section
TYPES OF FRACTURE
 1. Closed fracture
 The fracture that does not cause a break in
the skin
 2. Open fracture
 The fracture that involves a break in the
skin
General Nursing MANAGEMENT
For CLOSED FRACTURE
 1. Assist in reduction and immobilization
 2. Administer pain medication and muscle
relaxants
 3. teach patient to care for the cast
 4. Teach patient about potential complication
of fracture and to report infection, poor
alignment and continuous pain
General Nursing MANAGEMENT
For OPEN FRACTURE
 1. Prevent wound and bone infection
 Administer prescribed antibiotics
 Administer tetanus prophylaxis
 Assist in serial wound debridement
 2. Elevate the extremity to prevent edema
formation
 3. Administer care of traction and cast
 FRACTURE COMPLICATIONS
 Early
 1. Shock
 2. Fat embolism
 3. Compartment syndrome
 4. Infection
 5. DVT
 FRACTURE COMPLICATIONS
 Late
 1. Delayed union
 2. Avascular necrosis
 3. Delayed reaction to fixation devices
 4. Complex regional syndrome
 FRACTURE COMPLICATIONS: Fat
Embolism
 Occurs usually in fractures of the long
bones
 Fat globules may move into the blood
stream because the marrow pressure is
greater than capillary pressure
 Fat globules occlude the small blood
vessels of the lungs, brain kidneys and
other organs
 Onset is rapid, within 24-72 hours
 ASSESSMENT FINDINGS
 1. Sudden dyspnea and respiratory
distress
 2. tachycardia
 3. Chest pain
 4. Crackles, wheezes and cough
 5. Petechial rashes over the chest, axilla
and hard palate
 Nursing Management
 1. Support the respiratory function
 Respiratory failure is the most common
cause of death
 Administer O2 in high concentration
 Prepare for possible intubation and
ventilator support
Nursing Management
 2. Administer drugs
 Corticosteroids
 Dopamine
 Morphine
Nursing Management
 3. Institute preventive measures
 Immediate immobilization of fracture
 Minimal fracture manipulation
 Adequate support for fractured bone during
turning and positioning
 Maintain adequate hydration and electrolyte
balance
 Early complication: Compartment
syndrome
 A complication that develops when
tissue perfusion in the muscles is less
than required for tissue viability
ASSESSMENT FINDINGS
1. Pain- Deep, throbbing and UNRELIEVED
pain by opiods
 Pain is due to reduction in the size of the
muscle compartment by tight cast
 Pain is due to increased mass in the
compartment by edema, swelling or
hemorrhage
 2. Paresthesia- burning or tingling sensation
 3. Numbness
 4. Motor weakness
 5. Pulselessness, impaired capillary refill
time and cyanotic skin
Medical and Nursing management
 1. Assess frequently the neurovascular
status of the casted extremity
 2. Elevate the extremity above the
level of the heart
 3. Assist in cast removal and
FASCIOTOMY
Strains

 Excessive stretching of a muscle or

tendon
 Nursing management
 1. Immobilize affected part
 2. Apply cold packs initially, then heat
packs
 3. Limit joint activity
 4. Administer NSAIDs and muscle
relaxants
Sprains
 Excessive stretching of the LIGAMENTS
 Nursing management
 1. Immobilize extremity and advise rest
 2. Apply cold packs initially then heat packs
 3. Compression bandage may be applied to
relieve edema
 4. Assist in cast application
 5. Administer NSAIDS
Heat or Cold Application in
Trauma

Cold Application  Heat Application

• first 24 hours
 After 24 hours
 To relieve pain from
• To decrease
muscle spasms
hemorrhage  To reduce swelling
• To relieve pain by increasing
• To reduce
circulation
inflammation  To promote healing
by increasing
oxygenation
Common Musculoskeletal
conditions

Nursing management
METABOLIC BONE
DISORDERS
Osteoporosis
 A disease of the bone characterized by
a decrease in the bone mass and
density with a change in bone structure
METABOLIC BONE
DISORDERS
Osteoporosis: Pathophysiology
 Normal homeostatic bone turnover is
altered rate of bone RESORPTION is
greater than bone FORMATION
reduction in total bone mass
reduction in bone mineral density
prone to FRACTURE
METABOLIC BONE
DISORDERS
Osteoporosis: TYPES
 1. Primary Osteoporosis- advanced
age, post-menopausal
 2. Secondary osteoporosis- Steroid
overuse, Renal failure
METABOLIC BONE
DISORDERS
RISK factors for the development of
Osteoporosis
 1. Sedentary lifestyle
 2. Age
 3. Diet- caffeine, alcohol, low Ca and Vit D
 4. Post-menopausal
 5. Genetics- caucasian and asian
 6. Immobility
METABOLIC DISORDER
ASSESSMENT FINDINGS
 1. Low stature
 2. Fracture
 Femur

 3. Bone pain
METABOLIC DISORDER
LABORATORY FINDINGS
 1. DEXA-scan
 Provides information about bone mineral
density
 T-score is at least 2.5 SD below the young
adult mean value
 2. X-ray studies
METABOLIC DISORDER
Medical management of Osteoporosis
 1. Diet therapy with calcium and Vitamin D
 2. Hormone replacement therapy
 3. Biphosphonates- Alendronate, risedronate
produce increased bone mass by inhibiting
the OSTEOCLAST
 4. Moderate weight bearing exercises
 5. Management of fractures
METABOLIC DISORDER
Osteoporosis Nursing Interventions
1. Promote understanding of osteoporosis and
the treatment regimen
 Provide adequate dietary supplement of
calcium and vitamin D
 Instruct to employ a regular program of
moderate exercises and physical activity
 Manage the constipating side-effect of
calcium supplements
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 Take calcium supplements with meals
 Take alendronate with an EMPTY
stomach with water
 Instruct on intake of Hormonal
replacement
METABOLIC DISORDER
Osteoporosis Nursing Interventions
2. Relieve the pain
 Instruct the patient to rest on a firm
mattress
 Suggest that knee flexion will cause
relaxation of back muscles
 Heat application may provide comfort
 Encourage good posture and body
mechanics
 Instruct to avoid twisting and heavy lifting
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 3. Improve bowel elimination
 Constipation is a problem of calcium
supplements and immobility
 Advise intake of HIGH fiber diet and
increased fluids
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 4. Prevent injury
 Instruct to use isometric exercise to
strengthen the trunk muscles
 AVOID sudden jarring, bending and
strenuous lifting
 Provide a safe environment
OSTEOMALACIA

Pathophysiology
 Deficiency of activated Vitamin D (calcitrol)
which promotes calcium absorption from the GI
tract and facilitates mineralization of the bone
 The supply of calcium and phosphate in the
extracellular fluid is low
 Without adequate Vit.D, calcium and phopshate
are not moved to calcifiaction site in bones
 Osteomalacia may result from failed
calcium absorption or from excessive loss
of calcium from the body
 Renal insufficiency results in acidosis. The
body uses available calcium to combat the
acidosis,and PTH stimulates the release
of skeletal calcium in an attempt to
establish pH. Thus bony fibrosis occurs
and bony cysts form
Diagnosis
 X-ray
 Labs show low calcium and phosphorus levels
and moderately elevated alkaline phosphatase
Medical Management
 If osteomalacia is caused by malabsorption,
increase Vit.D intake, along w/ supplemental
calcium
 Exposure to sunlight
 If dietary in origin, a diet w/ adequate protein,
increased calcium and Vit.D (e.g. fortified milk
and cereals, eggs, chicken livers)
 Frequently, skeletal problems associated
with osteomalacia resolve themselves
when the underlying nutritional deficiency
or pathologic process is adequately
treated
 Some persistent orthopedic deformities
may need to be treated with braces or
surgery
 Paget’s Disease
 Also called osteitis deformans, Paget’s disease is
a disorder of localized bone turnover
 Incidence: 2% to 3% of the population over age 50
 More common in men and risk increases with
aging; familial predisposition has been noted
 Pathophysiology: excessive bone resorption by
osteoclasts is followed by increased osteoblastic
activity; bone structure disorganized, weak, and
highly vascular
 Patients are at risk for fractures, arthritis, and
hearing loss
 Paget’s Disease
 Manifestations include skeletal deformities, mild
to moderate aching pain, and tenderness and
warmth over bones; symptoms may be insidious
and may be attributed to old age or arthritis
although most patients do not have symptoms
 Pharmacologic management
 NSAIDs for pain
 Calcitonin

 Biphosphonates (etidronate: Didronel)

 Plicamycin (Mithracin): a cytotoxic antibiotic
that may be used for severe disease resistant
to other therapy
 Osteomyelitis
 Infection of the bone occurs due to:
 Extension of soft-tissue infection
 Direct bone contamination

 Bloodborne spread from another site of

infection
 This typically occurs in an area of bone that has
been traumatized or has lowered resistance
 Causative organisms
 Staphylococcus aureus (70% to 80%)
 Other: Proteus, Pseudomonas, and E. coli
 Osteomyelitis (cont.)
 Prevention of osteomyelitis is the goal

 Early detection and prompt treatment of osteomyelitis

are required to reduce potential for chronic infection
and disability
Assessment of the Patient With
Osteomyelitis
 Risk factors
 Signs and symptoms of infection, localized pain,
edema, erythema, fever, and drainage
 With chronic osteomyelitis, fever may be low
grade and occur in the afternoon or evening
 Signs and symptoms of adverse reactions and
complications of antibiotic therapy include signs and
symptoms of superinfections
 Ability to adhere to prescribed therapeutic regimen:
antibiotic therapy
 Interventions
 Relieve pain
 Immobilization
 Elevation
 Handle with great care and
gentleness
 Administer prescribed analgesics

 Improve physical mobility

 Activity is restricted
 Perform gentle ROM to joints above
and below the affected part
 Interventions (cont.)
 Promote good nutrition including vitamin C and
protein
 Encourage adequate hydration
 Administer and monitor antibiotic therapy
 Patient and family teaching
 Long-term antibiotic therapy and management
of home IV administration
 Mobility limitations
 Safety and prevention of injury
 Follow-up care
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS
 The most common form of degenerative
joint disorder
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS
 Chronic, NON-systemic disorder of
joints
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Pathophysiology
 Injury, genetic, Previous joint
damage, Obesity, Advanced age 
Stimulate the chondrocytes to
release chemicals chemicals will
cause cartilage degeneration,
reactive inflammation of the synovial
lining and bone stiffening
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Risk factors
 1. Increased age
 2. Obesity
 3. Repetitive use of joints with previous
joint damage
 4. Anatomical deformity
 5. genetic susceptibility
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
 1. Joint pain
 2. Joint stiffness
 3. Functional joint impairment limitation
 The joint involvement is ASYMMETRICAL
 This is not systemic, there is no FEVER, no
severe swelling
 Atrophy of unused muscles
 Usual joint are the WEIGHT bearing joints
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
1. Joint pain
 Caused by
 Inflamed cartilage and synovium
 Stretching of the joint capsule

 Irritation of nerve endings

DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
2. Stiffness
 commonly occurs in the morning
after awakening
 Lasts only for less than 30 minutes
 DECREASES with movement, but
worsens after increased weight
bearing activitry
 Crepitation may be elicited
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Diagnostic findings
1. X-ray
 Narrowing of joint space
 Loss of cartilage
 Osteophytes
2. Blood tests will show no evidence of
systemic inflammation and are not
useful
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Medical management
 1. Weight reduction
 2. Use of splinting devices to support joints
 3. Occupational and physical therapy
 4. Pharmacologic management
 Use of PARACETAMOL, NSAIDS

 Use of Glucosamine and chondroitin

 Topical analgesics

 Intra-articular steroids to decrease inflam

DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing
Interventions
1. Provide relief of PAIN
 Administer prescribed analgesics
 Application of heat modalities. ICE
PACKS may be used in the early acute
stage!!!
 Plan daily activities when pain is less
severe
 Pain meds before exercising
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing
Interventions
2. Advise patient to reduce weight
 Aerobic exercise
 Walking

3. Administer prescribed medications

 NSAIDS
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing
Interventions
4. Position the client to prevent flexion
deformity
 Use of foot board, splints, wedges and
pillows
Rheumatoid arthritis
A type of chronic systemic inflammatory
arthritis and connective tissue disorder
affecting more women (ages 35-45)
than men
Rheumatoid arthritis
FACTORS:
Genetic
Auto-immune connective tissue
disorders
Fatigue, emotional stress, cold, infection
Rheumatoid arthritis
Pathophysiology
 Immune reaction in the synovium 
attracts neutrophils  releases
enzymes  breakdown of collagen 
irritates the synovial liningcausing
synovial inflammation edema and
pannus formation and joint erosions and
swelling
Rheumatoid arthritis
ASSESSMENT FINDINGS
 1. PAIN
 2. Joint swelling and stiffness-
SYMMETRICAL, Bilateral
 3. Warmth, erythema and lack of
function
 4. Fever, weight loss, anemia, fatigue
 5. Palpation of join reveals spongy tissue
 6. Hesitancy in joint movement
Rheumatoid arthritis
ASSESSMENT FINDINGS
 Joint involvement is SYMMETRICAL
and BILATERAL
 Characteristically beginning in the
hands, wrist and feet
 Joint STIFFNESS occurs early morning,
lasts MORE than 30 minutes, not
relieved by movement, diminishes as
the day progresses
Rheumatoid arthritis
ASSESSMENT FINDINGS
 Joints are swollen and warm
 Painful when moved
 Deformities are common in the hands
and feet causing misalignment
 Rheumatoid nodules may be found in
the subcutaneous tissues
Rheumatoid arthritis
Diagnostic test
 1. X-ray
 Shows bony erosion
 2. Blood studies reveal (+)
rheumatoid factor, elevated ESR
 3. Arthrocentesis shows synovial fluid
that is cloudy, milky or dark yellow
containing numerous WBC and
inflammatory proteins
Rheumatoid arthritis
MEDICAL MANAGEMENT
 1. Therapeutic dose of NSAIDS and
Aspirin to reduce inflammation
 2. Chemotherapy with methotrexate,
antimalarials, gold therapy and steroid
 3. For advanced cases- arthroplasty,
synovectomy
 4. Nutritional therapy
Rheumatoid arthritis
MEDICAL MANAGEMENT
GOLD THERAPY:
 IM or Oral preparation
 Takes several months (3-6) before
effects can be seen
 Can damage the kidney and causes
bone marrow depression
Rheumatoid arthritis
Nursing MANAGEMENT
1. Relieve pain and discomfort
 USE splints to immobilize the affected
extremity during acute stage of the
disease and inflammation to REDUCE
DEFORMITY
 Administer prescribed medications
 Suggest application of COLD packs during
the acute phase of pain, then HEAT
application as the inflammation subsides
Rheumatoid arthritis
Nursing MANAGEMENT
2. Decrease patient fatigue
Schedule activity when pain is
less severe
Provide adequate periods of rests
3. Promote restorative sleep
Rheumatoid arthritis
Nursing Management
4. Increase patient mobility
 Advise proper posture and body
mechanics
 Support joint in functional position
 Advise ACTIVE ROME
Rheumatoid arthritis
Nursing Management
5. Provide Diet therapy
 Patients experience anorexia,
nausea and weight loss
 Regular diet with caloric
restrictions because steroids
may increase appetite
 Supplements of vitamins, iron
and PROTEIN
Rheumatoid arthritis
6. Increase Mobility and prevent
deformity:
 Lie FLAT on a firm mattress
 Lie PRONE several times to
prevent HIP FLEXION contracture
 Use one pillow under the head
because of risk of dorsal kyphosis
 NO Pillow under the joints because
this promotes flexion contractures
Hot versus Cold
HOT Cold

Use to RELIEVE joint Use to control

stiffness, pain and inflammation and pain
muscle spasm
After acute attack ACUTE ATTACK
OA versus RA
RA OA
Onset is early Onset is late
Chronic systemic Degenerative disease
disease
Involves the synovium Involves the cartilages
Involved joints are Involved joints are
symmetrical- fingers, unilateral- weight
cervical spine bearing knee, hips
spine
Malaise, fever, anemia No other S/SX
systemic
OA versus RA
RA OA
Joint tenderness, Crepitus, stiffness in
swelling, warmth and the morning decreases
redness after activity
Subcutaneous nodules
Stiffness that dimishes
Rest the joint, cold and Rest the joints, Avoid
heat modalities, ASA, overactivity, Weight
NSAIDS, DMARDS reduction, cold and
warm modalities, ASA
Gouty arthritis
A systemic disease caused by
deposition of uric acid crystals in the
joint and body tissues
 CAUSES:
 1. Primary gout- disorder of Purine
metabolism
 2. Secondary gout- excessive uric
acid in the blood like leukemia
Gouty arthritis
 ASSESSMENT FINDINGS
 1. Severe pain in the involved joints,
initially the big toe
 2. Swelling and inflammation of the joint
 3. TOPHI- yellowish-whitish,
irregular deposits in the skin that
break open and reveal a gritty
appearance
 4. PODAGRA-big toe
Gouty arthritis
ASSESSMENT FINDINGS
 5. Fever, malaise
 6. Body weakness and headache
 7. Renal stones
Gouty arthritis
DIAGNOSTIC TEST
 Elevated levels of uric acid in the blood
 Uric acid stones in the kidney
 (+) urate crystals in the synovial fluid
Gouty arthritis
 Medical management
 1. Allupurinol- take it WITH FOOD
 Rash signifies allergic reaction

 2. Colchicine
 For acute attack
 3. Probenecid
 For uric acid excretion
in the kidney
 Gouty arthritis
Nursing Intervention
1. Provide a diet with LOW purine
 Avoid Organ meats, aged and processed foods
 STRICT dietary restriction is NOT necessary
2. Encourage an increased fluid intake (2-
3L/day) to prevent stone formation
3. Instruct the patient to avoid alcohol
4. Provide alkaline ash diet to increase urinary
pH
5. Provide bed rest during early attack of gout
Gouty arthritis
Nursing Intervention
6. Position the affected extremity in mild
flexion
7. Administer anti-gout medication and
analgesics