Overview of Anatomy and Physiology of

musculoskeletal systems
 A. Bone
 Bones have three mechanical functions:
 1. Support of body tissues as provided by the
skeletal framework
 2. Protection of body organs
 3. Movement, affected by contraction of muscles
 4. Storage of calcium
 5. Hematopoiesis (production of RBC)
 Types of osseous tissue
 1. Compact bone- dense and looks smooth and homogeneous.
 2. Spongy bone- composed of small needlelike pieces of bone
and lots of open spaces.
·
Microscopic Anatomy of
Bone
· Osteon (Haversian System
· Central (Haversian) canal
· Opening in the center of an
osteon
· Carries blood vessels and
nerves
· Perforating (Volkman’s) canal
· Canal perpendicular to the
central canal
· Carries blood vessels and
nerves
 Microscopic Anatomy of Bone
· Lacunae
· Cavities containing bone cells
(osteocytes)
· Arranged in concentric rings
· Lamellae
· Sites of lacunae
· Canaliculi
· Tiny canals
· Radiate from the central canal
to lacunae
· Form a transport system-
connects all the bones cells to
the nutrients supply throught Figure 5.3
the hard bone matrix
pyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings
 Bone classification
 1. Long bone- (femur, humerus, radius)
 2. Short bone- (tarsal, carpals)
 3. Flat bone-( skull, sternum, ribs, ilium)
 4. Irregular bone- mandible, vertebrae, ear ossicle)
 Ligaments- strong fibrous connective tissues that bind
bones.
 Tendons- strong fibrous nonelastic connective tissue
extending from muscle sheaths, binds muscle to bone.
 Cartilage- nonvascular supporting connective tissue
composed of various cell and fibers. Provides absorp-
tion of weight, stress and strain. Protection of bones
and joints. Reduce friction.
 Joints- holds bone together securely but give the rigid
skeleton mobility.
 A. Synarthroses-immovable joints, e.g. skull
 B. Amphiarthorses- slightly movable, e.g vertebral joints
 C. Synovial joints(Diarthoses)- highly movable
 -e.g. ball and socket joint- permit full freedom of move-
ment( hip, shoulder)
 - hinge joint- permits bending in one direction only (el-
bows, knees)
 - saddle joint- allow movement in two planes at right an-
gles to each other (base of the thumb)
 - synovial fluid- located in the joint capsule provides shock
absorber.
 Fractures
 A disruption or break in the continuity
of the structure of bone.

 Occurs when the bone is subjected to

stress greater than it can absorb
(Buckley & Panaro, 2012)

 Described and classified according to:

Type
Communication or non-
communication with external
environment
Anatomic location
 Types of fracture
 1. Closed (also called simple)- do not cause a break in the skin
 2. Open (also called compound)- involves trauma to
surrounding tissue and a break in the skin.
 Types of fracture
 3.Incomplete fractures- partial cross sectional breaks with
incomplete bone disruption
 4. Complete fractures- complete cross sectional breaks.
 5. Comminuted – produce several breaks(fragments) of the
bone.

 6. Greenstick- breaks in one side of a bone and bend the other

 7. Spiral(torsion) fracture- a fracture twisting around the shaft
of the bone.
 8. Transverse- occur straight across the bone
 9. Oblique- occur at an angle across the bone
 Types of fracture
 10.Avulsed- fragment of bone tears away from the main mass of
bone
 11. Pathologic- due to other systemic diseases like osteoporo-
sis
 12. Impacted- one bone ends enter the intramedullary space
of another bone
 Types of fracture
 13. Displaced-fractured bone are separated and out of their
normal positions.
 Types of fracture
 14. Stress- prolonged repeated use of the bone
 15. Longitudinal- fracture that follows the long axis of the bone.
Types of Fractures

Fig. 61-4
 Grade of Fracture
 Open frac-
ture grade
according
to ff criteria
(Schaller,
2012)
Classification by Fracture Location

Fig. 61-6
 Etiology
 Clinical Manifestations
 1. Fracture results from
Immediate localized
crushing force
pain
 2. Pathologic fracture
 Function
occurs from weakness in
bone tissue which may Inability to bear
be caused by neoplasm weight or use affected
part
Guarding
May or may not see
obvious bone
deformity
 Reparative process of self-healing
(union) occurs in the following stages: Fracture Healing
1.
1. Fracture hematoma (d/t bleeding,
edema)
2.
2. Granulation tissue → osteoid(own
repair) (3 – 14 days post injury)
3.
3. Callus formation (minerals
deposited in osteoid)
4.
4. Ossification(forming of a new
bone) (3 wks – 6 mos) bony callus.
5.
5. Consolidation-state of becoming
solid.
6.
6. Remodeling (union completed;
remodels to original shape.
 Diagnosis

 Physical Exam
Palpate the bones
Crepitus- grating sound heard
Related
Skin
Neurovascular exam
 X-ray
 What’s the diagnosis in this case?
 Nursing Assessment for Fractures
 Neurovascular assessment
Color and temperature
 Brief history of
the accident cyanotic and cool/cold:
arterial insufficiency
 Mechanism of
injury Blue and warm: venous
insufficiency
 Special
Capillary refill (want < 2 sec)
emphasis
Peripheral pulses (↓ indicates
focused on the vascular insufficiency)
region distal to Edema
the site of Sensation
injury Motor function
Pain
LIFE SAVING MEASURES
A Airway and cervical spine immobilization

B Breathing

C Circulation (treatment and diagnosis of cause)

D Disability (head injury)

E Exposure (musculo-skeletal injury)

 Fracture
Initial Treatment
 Splint
 Analgesia
 Elevation
 Follow-up
 First-aid for closed fracture:
 Immobilize the injured part
(splint the fracture): to reduce
pain, prevent shock and
prevent further soft tissue
injury.

 Effective splints can be made

from rolled-up
newspapers,magazines,
blankets, cardboard or a stick.

 The general rule is to splint a

joint above and below the
fracture.
 Place the splint around the
injured limb and hold it in place
with a necktie, strip of cloth or
belt.
 Do not try to set a broken bone yourself . The
exceptions to this rule are when there is severe
deformity or ischemia distal to the fracture.

 Apply ice (wrapped in cloth) to the injured area to

help reduce swelling and inflammation (not in
open fracture).
 For a broken arm make a sling out of a triangular
piece of cloth.
 Do not give anything to eat or drink in case an
operation is necessary.

 Give analgesic anti-inflammatory drugs.

 Watch out for signs of shock.-

 Continue to apply pressure as long as the wound

bleeds. Add new dressings over existing ones.

 Do not try to push a protruding bone back under

the skin.
 First-aid for open fractures:

 Have the victim lie flat.

 Remove clothing
covering the wound.
 Apply direct pressure to
the wound to stop
bleeding
 Cover the wounded area
with a clean cloth or
dressing.
 Watch out for signs of
shock.

if present:
- elevate the victims feet.
- cover the victim with a
blanket
to keep him or her warm.
 Fracture Treatment
OPTIONS
 Closed
Non-operative- closed reduction
Splint
Cast
Traction
 Collaborative Care
 Overall goals of treatment:
Anatomic realignment of bone
fragments (reduction)
Immobilization to maintain
alignment (fixation)
Restoration of normal function
Fracture Reduction
 Closed reduction
Nonsurgical, manual
realignment
 Open reduction
Correction of bone alignment
through a surgical incision
 Collaborative Care
Fracture Reduction
 Traction (with simultaneous
counter-traction)  Purpose of traction:
Application of pulling force Prevent or reduce
to attain realignment muscle spasm
Application of a pulling force Immobilization
to an injured part of the body Reduction-
while countertraction pulls in realligning
the opposite direction.
Treat a pathologic
Skin traction (short-term: condition
48-72 hrs)
Skeletal traction (longer
periods)
BUCK’S TRACTION: a running
skin traction, use to immobilize
a fractured hip/femur until it is
possible to do surgery.
- Stabilizes the knee and
reduces muscle spasm for knee
injuries.

skin traction: 4.5-8lb

skeletal: upto 25lb
 CERVICAL TRACTION
 - Use for neck pain, neck
strain and whiplash
injury
 - Traction can be applied
to the cervical spine by
means of a head halter.
 - The pull of the cervical
traction should be felt as
an upward pull on the
back of the neck.
 NURSING CONSIDERATION IN CLIENTS WITH
TRACTION
 1. Monitor for complications of
fracture reduction
 - INFECTION
 - NERVE COMPRESSION
SYNDROME
 - KIDNEY STONES
 - PULMONARY EMBOLI
 - CIRCULATORY IMPAIRMENT
 - FAT EMBOLISM/THROMBUS
FORMATION
 - CONSTIPATION/ BONE
DEMINERALIZATION
 NURSING CONSIDERATION IN CLIENTS WITH
TRACTION
 2. Keep cast or other appliance clean and dry. infection
 3. Monitor bowel sounds, assess for abdominal
distention.-constipation
 4. Neurovascular assessment every 1 to 2 hrs after
application of the device.-nerve compression syndrome
 5. Reposition every 2 hrs encourage mobility.-thrombus
 6. Prevent skin breakdown
 7. Maintain hydration- kidney stones
 8. Provide ROM exercises-
 Footplate to prevent footdrop
 NURSING CONSIDERATION IN
CLIENTS WITH TRACTION

 9. Traction must be continuous to be effective.

 10. Weights are not removed until intermittent
traction is prescribed. Weights must hang freely.
 11. Rope must be uninterrupted.
 12. Knots in the rope or the footplate must not
touch the pulley or foot of the bed.
 13. Client must be in body alignment in the
center of the bed.
 Collaborative Care
Fracture Immobilization
 Casts A cast holds a broken bone in

Temporary place as it heals. Casts also help

to prevent or decrease muscle
circumferential
contractions, and are effective at
immobilization
providing immobilization,
device
especially after surgery.
Common Casts immobilize the joint
following above and the joint below the
closed area that is to be kept straight
reduction and without motion.
 What are the different types of casts?
Type of Cast Location Uses

Short arm cast: Applied below the elbow to the hand. Forearm or wrist fractures. Also used
to hold the forearm or wrist muscles
and tendons in place after surgery.

Long arm cast: Applied from the upper arm to the Upper arm, elbow, or forearm
hand. fractures. Also used to hold the arm or
elbow muscles and tendons in place
after surgery.

Arm cylinder cast: Applied from the upper arm to the To hold the elbow muscles and tendons
wrist. in place after a dislocation or surgery.
Type of Cast Location Uses

Shoulder spica cast: Applied around the trunk of the Shoulder dislocations or after surgery
body to the shoulder, arm, and on the shoulder area.
hand.

Minerva cast: Applied around the neck and After surgery on the neck or upper
trunk of the body. back area.

Short leg cast: Applied to the area below the
knee to the foot.
Lower leg fractures, severe ankle
sprains/strains, or fractures. Also used
to hold the leg or foot muscles and
tendons in place after surgery to allow
healing.

Leg cylinder cast: Applied from the upper thigh Knee, or lower leg fractures, knee
to the ankle. dislocations, or after surgery on the leg
or knee area.
SHOULDER SPICA CAST MINERVA CAST
Type of Cast Location Uses

Unilateral hip spica cast: Applied from the chest to the foot Thigh fractures. Also used to hold the
on one leg. hip or thigh muscles and tendons in
place after surgery to allow healing.

One and one-half hip Applied from the chest to the foot
spica cast: on one leg to the knee of the other
leg. A bar is placed between both
legs to keep the hips and legs
immobilized.
Thigh fracture. Also used to hold the
hip or thigh muscles and tendons in
place after surgery to allow healing.

Bilateral long leg hip Applied from the chest to the feet. A Pelvis, hip, or thigh fractures. Also
spica cast: bar is placed between both legs to used to hold the hip or thigh muscles
keep the hips and legs immobilized. and tendons in place after surgery to
allow healing.
Type of Cast Location Uses

Short leg hip spica Applied from the chest to To hold the hip muscles and
cast: the thighs or knees. tendons in place after surgery
to allow healing.
Type of Cast Location Uses

Abduction boot Applied from the upper thighs to the To hold the hip muscles
cast: feet. A bar is placed between both and tendons in place after
legs to keep the hips and legs surgery to allow healing.
immobilized.
 Cast care instructions:
 Keep the cast clean and dry.(wet cast can easily be destroyed)
 Check for cracks or breaks in the cast.
 Rough edges can be padded to protect the skin from
scratches.
 Do not scratch the skin under the cast by inserting objects
inside the cast.
 Can use a hairdryer placed on a cool setting to blow air under
the cast and cool down the hot, itchy skin. Never blow warm
or hot air into the cast.
 Do not put powders or lotion inside the cast.
 Cover the cast while your child is eating to prevent food
spills and crumbs from entering the cast.
 Prevent small toys or objects from being put inside the
cast.
 Elevate the cast above the level of the heart to decrease
swelling.
 Encourage your child to move his/her fingers or toes to
promote circulation.
 Do not use the abduction bar on the cast to lift or carry
the child.
 .
 - Support the cast during hardening,
handle hardening cast with the palms
of hands, not fingers.
 - Support the cast on a firm, smooth
surface.
 - Leave the cast uncovered and
exposed to the air. Reposition the
client every 2 hours.
 - Cast will totally dry in 24-72 hrs.
 Nursing Implementation: Cast care
 The 6 P’s to report
 Casts can cause
neurovascular  Paresthesia
complications if
Too tight  Pallor
Edematous
 Frequent neurovascular  Pain
checks
 Pulselessness
 Ice and elevation during
early phase  Poikilothermia (cold to touch)

 Paralysis
 COMPLICATION OF CAST
 1. COMPARTMENT
SYNDROME
 2. PRESSURE ULCER
 3. DISUSE
SYNDROME- muscle
atrophy
 4.
THROMBOEMBOLIC
COMPLICATIONS
 CAST CHANGES AND ADAPTATION
 1. BIVALVING- cutting the cast horizontally into two pieces.

 INDICATION:
 - Swelling/Compartment syndrome
 - Infection or discomfort
 2. Windowing- cutting a square or diamond shaped section
from the cast to allow for the observation and care of the skin
underneath.
 Collaborative Care
Fracture Immobilization
 External fixation
Metallic device composed of pins that are inserted into the bone
and attached to external rods
 Collaborative Care
Fracture Immobilization
 Internal fixation- ORIF
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
 Nursing Management
Nursing Diagnoses
 Risk for peripheral neurovascular dysfunction related to edema,
swelling, tight cast, blood clots
 Acute pain related swelling
 Risk for infection related broken skin, presence of pins,
immunocompromised patient, compromised circulation
 Risk for impaired skin integrity related immobility
 Impaired physical mobility
 Ineffective therapeutic regimen management related to poor
nursing care, poor assessment.
 Nursing Management
Nursing Implementation

 General post-op care

Assess dressings/casts for bleeding/drainage
Prevent complications of immobility
Measures to prevent constipation
Frequent position changes/ ambulate as permitted
(weight bearing status, partial 30%-50% weight)
ROM exercised of unaffected joints
Deep breathing- pneumonia
Trapeze bar if permitted
Pain medication
Increase fluid intake(2,000-3,000ml/day)
Decrease calcium intake
 Complications of Fractures
Infection
 Open fractures and soft tissue injuries have 
incidence
 Osteomyelitis can become chronic
 Collaborative Care
Open fractures require aggressive surgical
debridement
Post-op IV antibiotics for 3 to 7 days
(prophylactic)
 Complications of Fractures
Compartment Syndrome
Limb threatening Condition in which elevated
intercompartmental pressure within a confined myofascial
compartment compromises the neurovascular function of
tissues within that space.

Causes capillary perfusion to be reduced below a level

necessary for tissue viability.

Perfusion pressure falls below tissue pressure within a

closed anatomic compartment (Bueche, 2010)
 Compartment Syndrome-is a
painful condition that occurs when
pressure within the muscles
build to dangerous levels. This
pressure can decrease blood flow,
which prevents nourishment
and oxygen from reaching nerve
and muscle cells.
 Two basic etiologies create
compartment syndrome:
Decreased compartment size
(dressings, splints, casts)
Increased compartment content
(bleeding, edema)
 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Six Ps
1. Paresthesia (unrelieved by narcotics) early sign
1.

2. Pain (unrelieved by narcotics)

2.

3. Pressure
3.

4. Pallor (loss of normal color, coolness)

4.

5. Paralysis
4. Pulselessness (decreased/absent pulses)-late
4.
sign
5. Tissue death occur in 6-8hrs
5.
 Collaborative Care
Prompt, accurate diagnosis is critical
Early recognition is the key
Do not apply ice or elevate above heart level
Remove/loosen the bandage and bivalve the cast
Reduce traction weight
Surgical decompression (fasciotomy)
fasciotomy
 Complications of Fractures
Venous Thrombosis
 Veins of the lower extremities and pelvis are highly susceptible to
thrombus formation after fracture, especially hip fracture
 Precipitating factors:
Venous stasis caused by incorrectly applied casts or traction
Local pressure on a vein
Immobility
S/S:edema, redness
 Prevent with
anticoagulant medications
 ROM exercises
 Antiembolic stocking
 Vena cava filter
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Characterized by the presence of fat globules in tissues and
organs after a traumatic skeletal injury.
 Fractures that most often cause FES:
Long bones
Ribs
Tibia
Pelvis
 Clinical Manifestations
Usually occur 24-48 hours after injury
Produce symptoms of ARDS
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Collaborative Care
Treatment directed at prevention
Careful immobilization of a long bone fracture
Most important preventative factor
 Collaborative Care (treatment)
Symptom management
Fluid resuscitation
Oxygen
Mechanical ventilation- if pulmonary embolism
Steroids- to counteract inflammation in the lungs
Antibiotics- to prevent infection
 Fractures
Local Complications
 Nonunion
Failure to heal
3% overall
50% of some
particular fractures
Related to
treatment, local
problems, systemic
problems (e.g. Smoking)
Treatment: New fixation,
bone graft..
 Osteoporosis
Systemic skeletal disease characterized by low
bone mass leading to enhanced bone fragility
and consequent increase risk of fracture.
Chronic, progressive metabolic bone disease
characterized by
Porous bone
Structural deterioration of bone tissue
Increased bone fragility
 Osteoporosis
The Most Common Bone Disease
 Characterized by low bone mass
and deterioration of bone
structure(bone resorption is
greater than bone formation)
 Not a natural part of aging
 Increased risk for women, post-
menopausal, over age 65
 All races, sexes, and ages are
susceptible
 Preventable and treatable!
 The “silent disease”
 Often called the
“silent disease”
 Bone loss occurs
without symptoms
First sign may be a
fracture due to
The most common breaks in weakened bones
weak bones are in the wrist, (National
spine and hip. Osteoporosis
Foundation, NOF,
2010)
A sudden strain or
bump can break a
bone
Why Are Healthy Bones Important?
 Strong bones support us
and allow us to move
 Bones are a storehouse for
vital minerals
 Strong bones protect our
heart, lungs, brain and
other organs
 After mid-30’s, you begin to
slowly lose bone mass.
 Women lose bone mass
faster after menopause.
 Men lose bone mass too.
 Etiology
Risk factors
Female gender
Increasing age
Family history
White or Asian ethnicity
Small stature
Early menopause
Excess alcohol intake
Cigarette smoking
Anorexia
Oophorectomy-(estrogen is linked to calcium reuptake and building of
bone tissue.)
Sedentary lifestyle
Insufficient calcium intake
glucocorticoids therapy, anticonvulsants (Dilantin)- NOF, 2013),
REGULAR alcohol usage, smoking, sedentary lifestyle, BMI <19
 Pathophysiology
Bone resorption exceeds bone
deposition
Bones become weakened and
prone to fracture, loss of
height(2-3 inches), and kyphosis.
 Diseases associated with
osteoporosis
Intestinal malabsorption
Rheumatoid arthritis
Hyperthyroidism
Chronic alcoholism
Cirrhosis of the liver
Diabetes mellitus
 Diagnostic Studies
Diagnosis
1 Bone Mineral Density (BMD)
2 Dual-energy x-ray absorptiometry (DEXA)- avoid
calcium before the test.
3 History and physical
4 Quantitative ultrasound
Undetected on routine x-ray
 2002 Definitions: BMD Results
Status 1, 2 T-score
Normal +2.5 to −1.0, inclusive
Osteopenia Between −1.0 and −2.5
Osteoporosis ≤−2.5
Severe osteoporosis ≤−2.5 + fragility fracture
Simple Prevention Steps

The Surgeon General

recommends five
simple steps to bone
health and osteoporosis
prevention …
 Step 1
Get your daily
recommended
amounts of calcium
and vitamin D.

Calcium Requirements
for 50+ Years
Over 50 years 1,200 mg
 Nutrition labels & calcium
 FDA uses “Percent Daily Value” (%
DV) to describe amount of calcium
needed by general U.S. population
daily

 120% DV for calcium

= 1,200 mg

 Look for this label:

“Nutrition Facts” on foods
“Supplement Facts” on
vitamin/mineral supplements
 You need more vitamin D as you age

Daily adult
vitamin D
needs 1,000-
1,300 IU ((U.S.
Preventive
Services Task
Force-USPSTF,
2013)
Over 50 years old
(800-1,000-
Ducharme 2010)
 Calcium & vitamin D recommendations
 51 - 70 years
1,200 mg calcium (120% DV)
400 IU vitamin D (100% DV)

 70 and older
1,200 mg calcium (120% DV)
600 IU vitamin D (150% DV)
 % DV calcium: Milk group
 Yogurt
1 cup (8 oz.) = 30% DV
 Milk
1 cup = 30% DV
 Cheese
1 ½ oz. natural/2 oz. processed = 30% DV
 Milk pudding
1/2 cup = 15% DV
 Frozen yogurt, vanilla, soft serve
½ cup = 10% DV
Choose fat-free Ice cream, vanilla
or low fat ½ cup = 8% DV
most often
 Soy or rice milk, calcium-fortified
1 cup = varies—check label
% DV calcium: Vegetable group

 Broccoli, raw
1 cup = 9% DV
 Collards
1/2 cup = 20% DV
 Turnip greens, boiled
1/2 cup = 10% DV
 % DV calcium:
Meat & Beans Group
 Baked beans
1 cup = 14% DV
 Salmon, canned, with edible bones
3 oz. = 18% DV
 Sardines, canned, in oil, with edible
bones
3 oz. = 32% DV
 Soybeans, cooked
1 cup = 26%
 Tofu, firm, with calcium
½ cup = 20% DV; check label
 What about Vitamin D?

Main dietary sources of vitamin D are:

Fortified milk
•
(400 IU per quart)
Vitamin D is like a key
that unlocks the door • Some fortified cereals
and lets calcium
into the body. • Cold saltwater fish
(Example: salmon, halibut, herring,
tuna, oysters and shrimp)

• Some calcium and vitamin/mineral

supplements
 Vitamin D from sunlight exposure
 Vitamin D is manufactured in your skin
following direct exposure to sun.

 Amount varies with time of day, season,

latitude and skin pigmentation.

 10–15 minutes exposure of hands, arms and

face 2–3 times/week may be sufficient
(depending on skin sensitivity).

 Clothing, sunscreen, window glass and pollution

reduce amount produced.
Calcium supplement
considerations
 Calcium carbonate vs. citrate

Calcium carbonate Calcium citrate

TUMS, CALTRATE
• Needs acid to dissolve
and for absorption
• Less stomach acid as we
age
• Doesn’t require stomach
acid for absorption
• May be taken anytime—
check with your
healthcare provider

• May cost more

• Often taken at
meals when more
stomach acid
Limit calcium to 500 mg at a time
Our bodies can best
handle about 500 mg
calcium at one time
from food and/or
supplements.

Spread your calcium

sources throughout
the day.
Increase amount slowly
 Start supplements with 500 mg
calcium daily for about a week,
gradually adding more.
 Gas and constipation can be side
effects:
Increase fluids and high fiber foods if
diet is low in whole grains and fruits
and vegetables.
Try a different type of supplement if
side effects continue.
 Step 2

Be physically active
everyday
Improve strength
and balance

Even simple activities such as

walking, stair climbing and
dancing can strengthen bones.
WEIGHT BEARING
 Step 3
Avoid smoking and
excessive alcohol.
12 oz. 5 oz.

1.5
oz.

.
Step 4

Talk to your doctor

about bone health.
 Step 5

Source of photo: USDA ARS Photo Unit Photo by Peggy Greb

Have a bone density test
and take medication
when appropriate.

Testing is a simple,
painless procedure.
 Treatment and Nursing Care
Diet Therapy

Weight bearing Exercises

Decrease Risk Factors

Quit smoking and decrease consumption of alcohol
 Drug Treatment of Osteoporosis
Calcium & Vitamin D supplements &
Biphosphonates (Fosamax, Didronel,
Actonel, Boniva, Aredia, Bonefos, Skelid)-
(Ducharme, 2010) + Vit C to promote
absorption. – increase bone mass and
decrease bone loss by decreasing
osteoclast activity (Watts et al 2010)
Selective Estrogen receptor modulator –
Evista
Calcitonin
 Medications Used in Treatment of
Osteoporosis
Calcitonin- produced by? thyroid
inhibits bone resorption by opposing the
effects of parathyroid
hormone(parathormone)
 200 IU nasally/day (alternating nares)-
watch out for nose bleeding as side effects
 Medications Used in Treatment of Osteoporosis
Bisphosphenates – (Fosamax)
Inhibit osteoclast-mediated bone resorption thereby
increasing BMD and total bone mass.

These drugs increase bone mass and reduce the incidence

of vertebral and nonvertebral fractures (even in women
who already have fractures).

Side effects – anorexia, weight loss, gastritis- with food

Patient Teaching
Should be taken in the morning without food and
other medication. Stay upright to prevent reflux. GERD
 OTHER BISPHOSPHONATES
 Residronate (Actonel)
Approved for osteoporosis prevention &
treatment of osteoporosis: 5 mg / day
GI side effects

 Zolindronic acid(Aclasta)
Only infusible drug approved for treatment
of osteoporosis and the most strong
members.
Use for idiopathic osteoporosis only if
other treatments are ineffective or
conterindicated.
102
Bisphosphonates: Contraindications
 Renal failure
 Esophageal erosions
GERD, benign strictures, most benign GI
problems are NOT a contraindication
Concern for esophageal irritation/erosions
from direct irritation, recommendations to
drink water after and not lie down at least
30 minutes
They can have antacids 30 after the drug
Medications Used in Treatment of Osteoporosis
Selective Estrogen Receptor Modulators(SERMs)
 Raloxifene(EVISTA)
Mimic effect of estrogen on bone by reducing bone
resorption without stimulating the breasts or uterus.
estrogen activity in bone and, therefore, prevent bone
loss, improve bone mineral density (BMD), and decrease
the risk of vertebral fracture.
Potential for preventing osteoporosis without the
increased risk of breast or uterine cancer.
Side effects
Leg cramps- vein thrombosis
Hot flashes
Contraindicated for women with DVT (Watts et al 2010)
 Nursing Diagnosis for Osteoporosis

1. Chronic Pain

2. Disturbed Body Image
3. Self-Care Deficit
4. Imbalanced Nutrition, Less Than Body
Requirements- 2nd
5. Impaired Physical Mobility-3rd
6. Risk for Injury- 1st priority
 Osteomyelitis
 Severe infection of the
Bone
Bone marrow
Surrounding soft tissue
 Acute or chronic most
 commonly caused by Staphy-
lococcus Aureus
 Infection may reach bone
through open wound.
 50% is caused by MRSA (Miller &
Kaplan 2009)
 Causes-Osteomyelitis
 Inflammation of bone and
marrow
 Types
1. Pyogenic osteomyelitis- Al-
ways caused by bacteria
Staphylococcus aureus in 80% to
90% of cases
 Routes of infection
 Hematogenous spread
 Extension from a contiguous
site
 Direct implantation
2. Acute osteomyelitis
3. Chronic osteomyelitis
 Organisms once localized in bone

Bacteria proliferate and induce inflammatory

reaction and cause cell death.

Bone undergoes necrosis within first 48 hours

Bacteria and inflammation spread within the

shaft of the bone and may reach the
periosteum

Subperiosteal abscess

Segmental bone necrosis sequestrum (dead

piece of bone)

Rupture of periosteum leads to an abscess in

the surrounding soft tissue and the forma-
tion of draining sinus.
 Clinical Manifestations
Acute Osteomyelitis
Initial infection
 Infection of <1 month in duration
 Both systemic and local
 Local
 Constant bone pain that worsens with activity
 Swelling, tenderness, warmth at infection site
 Restricted movement of affected part
 Later signs: drainage from sinus tracts
Clinical Manifestations
of Chronic Osteomyelitis
 Chronic – an infection that persists for
longer than 1 month
 Infection that has failed to respond to initial
course of antibiotic therapy
 Nonhealing ulcer with a connecting sinus that
spontaneously drain pus (Conterno & Silva
Filho, 2009)
 Systemic signs ______
 Signs and Symptoms
 Constant bone pain
 Swelling
 Tenderness
 Warmth at site
 Continuous Drainage
 Complications of chronic osteomyelitis:

1) Deformities of bones:
2) Pathological fractures.
3) Systemic effects such as chronic fever & fatigue.
4) Amyloidosis (starchlike gylcoprotein deposition in tis-
sues and organs).This can get further deposited in the
kidney, liver & blood vessels.
5) Squamous cell carcinoma of the skin: The skin at the
edges of the draining sinus tracts may undergo malig-
nant transformation over time.
6) Sepsis
7) Rarely sarcoma in the infected bone
 TB osteomyelitis:
 Dissemination of tuberculosis outside the
lungs can lead to the appearance of skeletal
TB:
• Skeletal Tuberculosis:
 Tuberculous osteomyelitis involves mainly the
thoracic and lumbar vertebrae (known as
Pott disease) followed by knee and hip.
 There is extensive necrosis and bony
destruction with compressed fractures
(with kyphosis) and extension to soft tissues.
Spinal tuberculosis. Magnetic resonance
imaging of the spine revealing osteomyelitis
involving T10 and T11 vertebral bodies and disc
space (A; arrow) and an adjacent multiloculated
paravertebral abscess (B; arrow).
 Diagnostic Studies
 Bone or soft tissue biopsy
Definitive way to determine causative
microorganism
 Patient’s blood and/or wound culture
Frequently positive for presence of microorganism
 Lab Studies
 WBC
 Erythrocyte sedimentation rate (ESR)
 Radiologic
 Radiologic signs
Studies
Usually do not appear until 10 days to weeks after
start of clinical symptoms
 Magnetic resonance imaging (MRI)
 Computed tomography (CT)
Help identify extent of infection, including soft tissue
involvement
 Collaborative Care
Acute Osteomyelitis
 Vigorous and prolonged intravenous (IV)
antibiotic therapy
Treatment of choice for acute osteomyelitis
As long bone ischemia has not occurred
Cultures or bone biopsy should be done if
possible
 Delaying antibiotic treatment may require
surgical debridement and decompression
 Collaborative Care
Acute Osteomyelitis
 Antibiotic therapy may be continued for
at home
 Variety of antibiotics may be prescribed
 Penicillin, nafcillin (Nafcil)
 Neomycin, vancomycin
 Cephalexin (Keflex)
 Cefazolin (Ancef)
 Collaborative Care
Chronic Osteomyelitis
 Adults with chronic osteomyelitis may be
prescribed oral therapy + fluoroquinolone
for 6 to 8 weeks instead of IV antibiotics
 Oral antibiotics may be given after acute
IV therapy to ensure resolution of infection
 Monitoring patient’s response
 Nursing Care
 Toxic effects:
 Aminoglycosides - Nephrotoxic, ototoxic, optic
neuritis, fluid retention

 Cephalosporins and Quinolones – jaundice, colitis,

photosensitivity, crystalluria
 Preventive measures:
 Keep patient well hydrated
 Avoid direct sunlight, wear sunscreen for
photosensitivity
 Monitor urinary function, hearing, vision
 Collaborative Care
Chronic Osteomyelitis
 Surgical treatment for chronic
osteomyelitis
 Removal of poorly vascularized
tissue and dead bone
(Debridement)-after immobilize
it with a cast or splint
 Extended use of antibiotics-
cause bone has poor circulation
 Antibiotic- implantation may be
used
 Collaborative Care
Chronic Osteomyelitis
 After debridement, wound may
be closed and a suction
irrigation system inserted
 Intermittent or constant
irrigation of affected bone
with antibiotics
 Protection on limb or surgical
site with casts or braces
 Negative pressure to draw
wound together
(jackson prat drain)
 Nursing Diagnoses
 Immobilization and
 Acute pain
 RT Inflammatory process secondary
to infection
 Impaired physical mobility
 RT Pain, immobilization devices
weight-bearing limitations
 Inability or unwillingness to change
positions
 Ineffective therapeutic regimen
management
 Lack of knowledge regarding
long-term management of
osteomyelitis
non-weight bearing on
affected limb will
decrease pain
 Limb should be handled
carefully to avoid
excessive manipulation
and decrease pain
 Manage patient’s pain
level using pharmacologic
and non-pharmacologic
strategies
 Instruct patient to avoid
activities that
increase circulation and
swelling and serve as
stimuli to spread infection
 Nursing Implementation
 Ambulatory and home care
 Importance of continuing antibiotics after
symptoms have subsided should be stressed
 Periodic nursing visits provide support and
decrease anxiety
 Frequent dressing changes for open wounds
 Prevention
 1. Postponed surgery if with ongoing infection
 2. During surgery give prophylactic antibiotics
( Gillespie, 2009)
 3. Removed urinary catheters and drains as
soon as possible to decrease hematogenous
spread.
Gouty Arthritis
 What is Gout?
 A condition where there is a vast accumulation of uric acid
onto the joints.
 Disorder of purine metabolism (broken down into uric acid)
 Leads to the formation of monosodium urate in various tissues
in the body.
 Male: 3.5-7.7 mg/dl
 Female: 2.5-6.6mg/dl
 What is Gouty Arthritis
 Purines are not properly processed
in our body
 Excreted through kidneys and urine
 Hyperuricemia- build-up of uric acid
in body and joint fluid
 Urate: end product of purine
metabolism

 Hyperuricemia: serum urate > urate

solubility (> 6.8 mg/dl)

 Gout: deposition of monosodium

urate crystals in tissues
 Usually found in joints of feet
and legs
 GOUT RISK FACTORS
 Male
 Postmenopausal female
Organ meats,

such
Older
as liver, kidneys,
 Pharmaceuticals: intestine, and
Diuretics, ASA, cyclosporine brain
 Transplant Meats, including
 Alcohol intake bacon, beef,
Highest with beer pork, and lamb
Not increased with wine Any other meats
 High BMI (obesity) in large amounts
 Diet high in meat & seafood Anchovies, sar-
 Increase incidence with age, body mass dines, herring,
index, alcohol consumption, hypertension mackerel, and
and diuretics use (Rahman et al 2010) scallops
 Gravy
 Beer
 Cause of symptoms
When monosodium crystals
gets into joints, this illicit a
reaction from the body’s
. immune system
The body macrophages and
neutrophils attack the
monosodium urate crystals
causing inflammation of the
joint.
 SYMP-
TOMS

 Joint pain
Affects one or more joints : hip, knee, ankle, foot, shoulder,
elbow, wrist, hand, or other joints
Great toe, ankle and knee are most common
 Swelling of Joint
Stiffness
Warm and red
Possible fever
 Skin lump which may drain chalky material
The Four Stages of Gout
 Asymptomatic
 Acute or flare
 Intercritical or interval
 Chronic or advance
 1. ASYMPTOMATIC
 A- meaning without indicates
that there are no symptoms
associated
 Patient will be unaware of
what is happening
 Gout can only be determined
with the help of a physician
 2. ACUTE GOUTY FLARES
 Abrupt onset of severe joint inflammation, often nocturnal;
Warmth, swelling, erythema, & pain,
Possibly fever
 90% 1st attacks are monoarticular
 Involve one or a few joints
 Frequently starts nocturnally
 Joint is warm, red, and tender
 ACUTE OR FLARE INTERVALS

 Silent tissue deposition

& Hidden Damage
 Can occur in other
joints & tendons
 SITES OF ACUTE FLARES
 90% of gout patients
eventually have poda-
gra-(gouty pain in the
great toe.)
 3. INTERCRITICAL
 More concentration of
uric acid crystals
4. CHRONIC

 Continuous or persistent
over a long period of
time
 Not easily or quickly
resolved
 ADVANCED or chronic GOUT
 Chronic Arthritis

 X-ray Changes

 Tophi Develop

 Acute Flares continue

 TOPHI
 Solid urate deposits in
tissues

 Irregular & destructive

 Long duration of hype-
ruricemia

 Higher serum urate

 Long periods of active,

untreated gout
 Diagnosing Gout
 X-rays
 Arthrocentesis-
extraction of joint fluid-
reveals urate crystals
 Examination of joint
 Patient medical history
 Treatments
 There are many treatments for gout
 Some are used for treating the symptoms of gout,
while others are used to stop gout symptoms
from appearing.
 Because Gout is a metabolic condition, there is no
cure for it.
 TREATMENT GOALS
 Rapidly end acute flares
Protect against future flares
Reduce chance of crystal inflammation
 Prevent disease progression
Lower serum urate to deplete total body urate
pool
Correct metabolic cause
treat the acute attack of gouty arthritis before initi-
ating treatment to reduce serum uric acid levels.
 Acute Flare Med Choices

 NSAIDS
 Colchicine
 XANTHINE OXIDASE
INHIBITOR
 Uricosuric agents
 Corticosteroids
NSAIDS COLCHICINE
Oldest drug used for gout flares
 Acute treatment for gout is Prophalytic or during acute attacks
using NSAIDs use within 24 hrs of attack.
 Indomethacin Dosage: 0.5g 3 times daily
 Naproxen sodium Colchicine- reduces pain, swelling, and
 Used to alleviate the pain inflammation; pain subsides within 12
caused by inflammation hrs and relief occurs after 48 hrs
Causes low amount of neutrophils to
 Side-effects be made, decreasing
Nausea inflammation.
Vomiting Colchicine :
In extreme cases, kidney Not as effective “late” in flare
failure Cautious use in : renal or liver
Interaction with warfarin dysfunction; active infection, age > 70
Contraindicated in:
Renal disease
PUD
GI bleeding
 URICOSURIC AGENTS
 XANTHINE OXIDASE INHIBITOR
Probenecid and sulfinpyrazone-
 Zyloprim(Allopurinol), Febuxo- prevent absorption of uric acid in the
stat: tubules of kidney
 decreases the production of Increased secretion of urate into
uric acid urine
Reverses most common
 Blocks conversion of physiologic abnormality in gout .
hypoxanthine to uric acid Corticosteroids injection
 Effective in overproducers
 Can work in pts with renal
insufficiency
 Used as along term treatment
for gout
 Lowers uric acid levels
 Dosage:100mg per day
 Nursing care while on antigout
medication.. Nursing diagnosis??
 1. Antigout meds should be used cautiously in clients with
gastrointestinal, renal, cardiac or hepatic diseases.
 2. Maintain a fluid intake of at least 2,000 to 3,000 ml per
day to avoid kidney stone.
 3. Avoid alcohol and caffeine these products can increase
uric acid level.
 4. Take medication with food
 5. Eye checkup is advised for prolonged Allopurinol use
every year.
 6. Allopurinol may increase the effect of Coumadin and
oral hypoglycemic agents
 7. Apply alternating cold and warm compresses
 Diet
Rich foods have a higher
concentration of protein. This
could cause major problems
for a person afflicted with
 Watch diet for food rich in purines
 gout.
ORGAN MEATS
 SEAFOOD, ANCHOVIES
 PEAS
 ASPARAGUS, LEGUMES
 YEAST
 BEER,WINE
 SARDINES
 CHOCOLATES
 Reduce alcohol intake
 Increase water intake
 Possible treatments
 If all else fails
 Surgery may be need to remove uric acid
build up
 Osteoarthritis
Chronic, nonsystemic disorder of
the joints, characterized by dege-
naration of joint cartilage.

Osteoarthritis
Osteoarthritis is a form of arthritis
(OA)
that features the breakdown and
eventual loss of the cartilage of one
or more joints. Cartilage is a protein
substance that serves as a "cush-
ion" between the bones of the
joints
 OA is the most common form of
arthritis and the most common
joint disease
 OA most often occurs at the ends of
the fingers, thumbs, neck, lower
back, knees, and hips.
 Primary osteoarthritis, os-
teoarthritis not resulting
from injury or disease, is
mostly a result of natural ag-
ing of the joint. With aging,
the water content of the car-
tilage increases, and
the protein makeup of car-
tilage degenerates..
 ( septic & rheumatoid arthritis)
 Secondary osteoarthritis is a
form of osteoarthritis that is
caused by another disease or
condition. include obesity,
repeated trauma or surgery to
the joint structures, abnormal
joints at birth (congenital
abnormalities), gout, diabetes,
and other hormone disorders.
(McPhee et al 2012)
 OA – Risk Factors
Age

 Age is the strongest risk factor for OA. Although OA can start in

young adulthood, if you are over 45 years old, you are at higher

risk.

Female gender

 In general, arthritis occurs more frequently in women than in men.

Before age 45, OA occurs more frequently in men; after age 45, OA

is more common in women. OA of the hand is particularly com-

mon among women.

 OA – Risk Factors
Hereditary gene defect

 A defect in one of the genes responsible for the cartilage component collagen
can cause deterioration of cartilage.

Joint injury or overuse caused by physical labor or sports

 Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip increases your risk for

developing OA in these joints. Joints that are used repeatedly in certain jobs may be

more likely to develop OA because of injury or overuse.

Obesity

 Being overweight during midlife or the later years is among the strongest risk factors for

OA of the knee.
 Causes
Osteoarthritis may result from wear and tear
on the joint •
The normal
cartilage lining is
gradually worn
away and the
underlying bone is
exposed. Affects
weight bearing
joints.
 OA – Signs & Symptoms
 OA usually occurs slowly -
It may be many years
before the damage to the
joint becomes noticeable
 Only a third of people
whose X-rays show OA
report pain or other
symptoms:
• Steady or intermittent pain in a joint
• Stiffness that tends to follow periods of inactivity, such as sleep
or sitting
• Swelling or tenderness in one or more joints [not necessarily
occurring on both sides of the body at the same time]
• Crunching feeling or sound of bone rubbing on bone (called
crepitus) when the joint is used
 Heberden’s node- bony overgrowth at
terminal interphalangeal joints.
 Bouchard’s node- bony overgrowth at the
proximal interphalangeal joints.
 Clinical Features
 Age of Onset > 40 years 90% even
when symptoms are absent (M-
cPhee et al. 2012)
 Commonly Affected Joints
Cervical and lumbar spine
First carpometacarpal joint
Proximal interphalangeal joint
Distal interphalangeal joint
Hip
Knee
Asymmetrical joint
involvement
 Clinical Diagnosis
 Symptoms
Pain
Stiffness

 Physical examination
Crepitus
Bony enlargement
Decreased range of motion
Malalignment
Tenderness to palpation
 The more features, the more likely the diagnosis.
 1. x-ray
 2. imaging studies
 Radiographic Features(McPhee
et al. 2012)
 Joint space narrowing
 Subchondral sclerosis
 Subchondral cyst-The cartilage tries to repair it-
self, the bone remodels, the underlying (subchondral)
bone hardens, and bone cysts form
 OA – Radiographic Diagnosis

Asymmetrical joint space narrowing from loss of

articular cartilage
The medial (inside) part of the knee is most commonly affected by osteoarthritis.
 Subchondral Sclerosis
 Increased bone density or thickening in the
subchondral layer
 Fluid-filledSubchondral Cysts
sacs in subchondral bone
Long-Term Complications
Unlike rheumatoid arthritis, osteoarthritis does not affect the body's
organs or cause illness. But it can lead to deformities that take a toll on
mobility. Severe loss of cartilage in the knee joints can cause the knees
to curve out, creating a bow-legged appearance (shown on the left).
Bony spurs along the spine (shown on the right) can irritate nerves,
leading to pain, numbness, or tingling in some parts of the body.
 OA – Disease Management
•OA is a condition which progresses slowly over a
period of many years and cannot be cured
•Treatment is directed at decreasing the symptoms of
the condition, and slowing the progress of the
condition. (Esser & Bailey, 2011)
•Functional treatment goals:
Increase range of motion
Increase muscle strength
Control pain and swelling
Minimize disability
Improve the quality of life
Prevent progression
Education
Chronic Condition and Management
Algorithm for OA Management
 OA – Non-operative Treatments
•Pain medications
•Physical therapy
•Walking aids
•Limit strain to affected areas

•A program of diet and exercise can

help minimize symptoms of OA in
patient who are obese (Brosseau,
Wells et all 2011)
 Non-pharmacologic Treatment
 Weight Loss
Ten-pound weight loss over 10 years decreased the
odds for developing knee OA by 50%
Even a modest amount of weight loss may be
beneficial
 Rest
Short period of time, typically 12-24 hours
Prolonged rest can lead to muscle atrophy and
decreased joint mobility
 Non-pharmacological Treatment
 Physical Therapy
“Manual therapy" may be
more beneficial than exercise
programs that focus on
muscle strengthening,
endurance training, and
improved coordination
May be more beneficial in
those with mild OA
There is no treatment to stop
the erosion of cartilage in the
joints, but there are ways to
improve joint function.
Pillow Squeeze
This move helps strengthen the
inside of your legs to help support
your knee. Lie on your back, both
knees bent. Place a pillow between
knees.
Squeeze knees together, squishing
pillow between them. Hold for five
seconds. Relax. Repeat 10 times.
Rest, then do another set of 10.
 Non-pharmacological Treatment
 Exercise – focus on low load exercise
Tai Chi
Yoga
Swimming
Biking
Walking
Most important aspect to counsel patients for prevention and
treatment
Even modest weight loss has been shown to reduce symptoms of
osteoarthritis by easing the strain on weight-bearing joints. Losing
weight not only cuts down on pain, but may also reduce long-term
joint damage.

 Heat and Cold

Lack of convincing data despite being commonly used
 When osteoarthritis flares up,
many patients find relief with over-
the-counter pain and anti-
inflammatory medication, such as
aspirin, ibuprofen, or paracetamol.
Pain-relieving creams or sprays can
also help when applied directly to
the sore area. If pain persists
despite the use of pills or creams,
your doctor may suggest an
injection of steroids directly into
the joint.
 Corticosteroid injection
showed no ill effects in
comparison with pt’s receiving
placebo.
 NSAIDs
 Tend to avoid for long-term use
Rash and hypersensitivity reactions
Abdominal pain and gastrointestinal bleeding
Impairment of renal, hepatic, and bone marrow function, and platelet
aggregation
 Low dose ibuprofen (less than 1600 mg/day) may have less serious GI
toxicity
 NSAIDs are superior to acetaminophen for improving knee and hip pain in
people with OA
 Indomethacin should be avoided for long-term use in patients with hip OA
associated with accelerated joint destruction
 Topical NSAIDs were generally inferior to oral NSAIDs
 However topical route was safer than oral use
 Topical Diflofenac (1% gel or patch)
 Salicylates can be use: watch out for hearing loss esp in elderly
  Narcotics for Refractory
 COX-2 inhibitors appear Pain
 Vicodin/Oxycodone
to be as effective NSAIDs
 Safety: Medium
 Associated with less GI  Tolerability: Medium
toxicity Constipation,
 Those who are receiving somnolence, mental
status changes
low dose aspirin and a  Use of opiates indicated
COX-2 selective agent in those who are not
may benefit from candidates for surgery
antiulcer prophylaxis.. and who continue to
have moderate to
severe pain despite
being on NSAIDs or
(COX)-2 inhibitors.
Supportive Devices
Supportive devices, such as finger
splints or knee braces, can reduce
stress on the joints and ease pain. If
walking is difficult, canes,
crutches, or walkers may be
helpful. People with osteoarthritis
of the spine may benefit from
switching to a firmer mattress and
wearing a back brace or neck
collar.

For canes use it on unaffected side

Supplements
Overall studies suggest no
benefits of glucosamine and
chondroitin – supplements
available at pharmacies and
health food stores touted for
relieving pain and stiffness for
people with osteoarthritis. Check
with your doctor before using
chondroitin, especially if you
take blood-thinners.
Is Surgery for You?
If osteoarthritis interferes significantly with everyday life and
the symptoms don't improve with physical therapy or
medication, joint replacement surgery is an option. This
procedure is used on those with severe OA and replaces a
damaged joint with an artificial one. The knee and hip are
the joints that are replaced most often.
 Total Knee Replacement/Osteotomy
• The ends of the femur, tibia, and patella are shaped to accept
the artificial surfaces.
• The end result is that all moving surfaces of the knee are
metal against plastic
 Total hip replacement
 Post operative care:
 1. maintain abduction of affected limb at all
times with 2 pillows between legs while in
bed. Watch out for groin pain.
 2. prevent external rotation by placing
trochanter rolls along hip, avoid turning on
the operative side.
 3. prevent hip flexion. USE HIGH SEAT CHAIR
 4. prevent dislodgement of prosthesis by:
 A. do not cross legs
 B. avoid hip flexion and adduction
 C. do not raise legs on a chair
 D. do not bend down, avoid low chair
 E. avoid strenuous exercise for at least a
few days
 F. watch out for complications like infec-
tion and pulmonary embolism(most com-
mon)
 Education and Self-Help
 Understand the disease
 Reduce pain but remain active
 Clear Functional goals
 Cope physically, emotionally, and mentally
 Have greater control over the disease
 Build confidence
 Nursing care and diagnosis
 Pain
 Knowledge deficit
 Impaired physical mobility
 Noncompliance
Sprain / Strain
SPRAIN

 stretch and/or tear of a

ligament caused by a
sudden pull
 one or more ligaments can
be injured at the same
time
 severity of injury
—› extent of injury and
number of ligaments
involved
STRAIN

 injury to either a muscle or

a tendon as a result of
sudden pulling them too
far
 simple overstretch of mus-
cle or tendon, or result
of a partial or complete
tear
What Causes a Sprain?
 fall
 sudden twist
 blow to the body that
forces a joint out of its
normal position and
stretches or tear the
ligament
supporting that joint
 What Are the Signs and
Symptoms of a Sprain?

 pain
 swelling
 bruising
 instability
 loss of functional
ability
 sometimes a pop or
tear when the injury
happens
What Causes a Strain?

 twisting or pulling a
muscle or tendon

 acute or chronic
—› recent trauma or
result of overuse
 Strain causes
• Carrying, holding, or
restraining items.
• Lifting, pushing, holding or
pulling loads
• Working in a fixed position
with the back bent,
 sitting or standing
continuously, or driving
vehicle for long periods
• Repetitive tasks such as
reaching.
• Working in awkward
positions involving bending
or twisting your body to
reach items
 Where Do Strains Usually Occur?
 two common sites: the back and the
hamstring muscle
 hand and forearm, elbow
 What Are the Signs and Symptoms of a Strain?
 typical—›pain, limited
motion, muscle spasms,
possibly muscle
weakness
 localized swelling,
cramping, or
inflammation and, with a
minor or moderate strain,
usually some loss of
muscle function
How Are Sprains and
Strains Treated?
RICE Therapy- Na-
tional Association of Ortho-
pedic Nurses- (NAON- 2007)
Nursing diagnosis?
To reduce pain and
swelling
 Rest

 Ice

 Compression

 Elevation
 Treatments for Sprains & Strains

• FIRST STAGE – to reduce swelling and pain

• RICE therapy (Rest, Ice, Compress, Elevate) for
the first 24 to 48 hours
1. Rest the injured area (reduce regular exercise or
activities as needed)
2. Ice the injured area, 20 minutes at a time, four to
eight times a day (cold pack, ice bag, or plastic bag
filled with crushed ice and wrapped in a towel can be
used)

PPT-053-01 13
Treatments for Sprains & Strains

3. Compress the injured area, using bandages, casts,

boots, elastic wraps or splints to help reduce swelling

4. Elevate the injured area, above the level of the heart,

to help decrease swelling while you are lying or sitting
down

PPT-053-01 14
 Treatments for Sprains & Strains

• Health care provider may recommend an anti-inflammatory

drug such as aspirin (Bayer), ibuprofen (Advil, Motrin), or
acetaminophen (Tylenol) to help decrease pain and
inflammation

• If moderate sprain, may require use of mobility aids, such as

a cane, crutches, a walker or wheelchair
• If severe sprain, may need surgery to repair torn ligaments,
muscle or tendon

PPT-053-01 15
 Treatments for Sprains & Strains

• SECOND STAGE – Rehabilitation

1. Physical therapy/exercise program:

designed to help reduce swelling, prevent
stiffness and restore normal, pain-free range
of motion (during first week after injury)

PPT-053-01 16
Treatments for Sprains & Strains

2. Increase strength and flexibility (about

second week after injury); usually more
demanding exercises to improve function

PPT-053-001 17
How Much Time to Heal?

• Time needed for full recovery:

- Mild sprain/strain: three to six weeks

- Moderate sprain/strain: two to three

months

- Severe sprain/strain: eight to 12

months

PPT-053-01 20
 Can Sprains and Strains Be Prevented?
 Avoid exercising or playing sports when
tired or in pain.
 Maintain a healthy, well-balanced diet to
keep muscles strong.
 Maintain a healthy weight.
 Practice safety measures to help
prevent falls.
 Wear shoes that fit properly.
 Replace athletic shoes as soon as the tread
wears out or the heel wears down on
one side.
 Do stretching exercises
daily.
 Be in proper physical
condition to play a sport.
 Warm up and stretch
before participating in any
sports or exercise.
 Wear protective
equipment when playing.
 Run on even surfaces.