MR. ALETH M.

TIBI, RN, MAN

Overview of the Skeletal System
y Hambone as a cross-

section of a typical bone y The center of the bone is filled with marrow y Surrounded by the hardened bone tissue

y The extracellular matrix of the bone is composed of

collagen with Ca3(PO4)2 (superphosphate of lime) deposited in it. y Bone tissue is composed of repeating, circular units called Haversian Systems. y In each Haversian system, there is a central canal where blood vessels and nerves can be found.

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vertebrae in the neck region b. coccyx.bones which make up the spine. lumbar vertebrae. sacrum. not including the face bones y mandible.bones of the skull surrounding the brain.five fused as one vertebra which are joined to the pelvis e. cervical vertebrae . so the hinge of the jaw is joined by the temporal bone by the temporo-mandibular joint y vertebrae.vertebrae with ribs attached c. which include: a.Bones of the Skeletal System y cranium. thoracic vertebrae.jaw bone.four fused as one vertebra which comprise the tailbone .vertebrae in the lower back d.

wrist bones metacarpals.y y y y y y y y y y ribs.bones protecting the chest cavity (twelve pairs) sternum.top of the arm ulna.collar bone scapula.palm of the hand phalanges.little finger side of the lower arm which also forms the elbow radius.thumb side of the lower arm carpals.breastbone clavicle .fingers .shoulder blade humerus.

hip bones y ilium.big bone on top that we think of as the hip y ischium.bones on which we sit y pubis.lower front hip bone .y (os) coxa.

inside (big-toe side) shinbone fibula. the sole y phalanges.thick.thin.toes .kneecap y tibia. outer (little-toe side) shinbone y tarsals.arch of the foot.heel bones y metatarsals.y femur.thigh bone y patella.

.The Muscular System y more than 650 individual muscles which are attached to the skeleton. providing the pulling power for movement.

Function of the Muscles y Provide movement for the body .

Types of Muscle Tissues y Voluntary muscles: muscles controlled by the will y Involuntary muscles: muscles not controlled by the will .

Types of Muscle Tissues y Cardiac Muscles: found in the heart a. many of the skeletal muscle contractions are automatic . striated b. controlled by the nervous system during contraction e. or striations b. contracts through the sliding filament c. involuntary y Skeletal Muscles: makes up about 40 % of an adult body weight. biceps. triceps a. composed of long muscle fibers c. e. it has stripe-like markings. muscle fiber has a cell which contains several nuclei d. it forms branching fibers d.g.

e. non-striated b.Smooth Muscles: the internal organs are made up of smooth muscles. bronchi a. controlled by the nervous system and hormones y .g. bladder.

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Joints. . y Tendons: fibrous connective tissues that connects to the periosteum of the bones. it is where two bones meet. it enables the bones to move when skeletal muscles contract. Ligaments and Tendons y Joints: also known as articulations. y Ligaments: dense bands of connective tissue that connect bones to bones.

first rib and munubrium of the sternum Vertebral joint. symphysis pubis joint Shoulder. hip and limb joints Amphiarthroses Diarthroses Slightly movable joints Freely movable joints .Functional Classification of Joints Type Synarthroses Description Immovable joints Examples Skull.

Skull short connective tissue Immovable Intervertebral Discs Freely movable. synovial Limbs fluids and filtrate of blood plasma .Structural Classification of Joints Type Fibrous Cartilaginous Synovial Description Example Permit little movement.

tenderness. Palpation: deviation/limitation in ROM. muscle size and strength. and body temperature . masses.ssessment y Chief Complaint and History y Physical Examination: focus on a. discharge . and movement (ADL) b. muscle strength. Inspection: color. warmth. c. swelling. deformity. and presence of subcutaneous nodules. Palpation: turgor. crepitation on joint movement. deformity of joints. symmetry. tenderness. atrophy. posture and gait.

Pott s Disease Osteomyelitis .

Tuberculous Spondylitis y It is named after Percivall Pott (1714-1788). a London surgeon. David's Disease. y Most common site of bone infection in TB. y Most common site: lower thoracic and upper lumbar vertebrae . Pott s Caries. and Pott's Curvature. .Pott s Disease y Other Names: TB of the spine.

cannot receive nutrients and collapses. a dry soft tissue mass often forms known as GIBBUS .Pathophysiologic Mechanisms results from haematogenous spread of tuberculosis from other sites particularly to the spine disc tissue dies and is broken down by caseation infection then spreads from two adjacent vertebrae into the adjoining disc space vertebrae collapses and spinal damage occurs the intervertebral disc. which is avascular.

Signs and Symptoms .

or muscle weakness of the legs . tingling. sometimes associated with numbness.Signs and symptoms y back pain y fever y night sweating y anorexia y weight loss y Spinal mass.

Other Manifestations y Localized back pain y Para-vertebral swelling y Neurological signs like paraplegia .

Diagnostic Tests y Needle biopsy of bone or synovial tissue: Numbers of tubercle bacilli present are usually low but are pathognomonic y Acid-fast stain and culture for Mycobacterium Tuberculosis y Elevated Erythrocyte Sedimentation Rate .

are strongly indicative of Pott s disease as opposed to malignancy. y CT scans and Nuclear Bone Scan .Imaging y Spinal x-ray will show vertebral destruction and narrowed disc space. Bone elements visible within the swelling. y Magnetic Resonance Imaging is useful to demonstrate the extent of spinal compression and can show changes at an earlier stage than plain radiographs. or abscesses.

T R E A T M E N T Isoniazid (INH) Rifampin (Rifadin) Ethambutol (EMB) Streptomycin (SM) Pyrazinamide (PZA) Anti-infective agents .

Other Management y Spinal Immobilization with a Brace: Jewette Brace y Surgery is required if there is spinal deformity or neurological signs of spinal cord compression: debridement and fusion with bone grafting .

Complications y Severe Kyphosis y Sinus Formation y Paraplegia: Pott's Paraplegia .

causes discoloration of urine. causes peripheral neuropathy (competes with Vitamin B6 absorption). should be kept in dark containers. . y Rifampicin: Best taken with empty stomach but causes gastric irritation hence should be taken with food.Nursing Responsibilities on Drug Therapy y INH: taken before meals.

nephrotoxic. gastric irritation. skin rashes . .more on responsibilities y PZA: Hepatotoxic. ototoxic. y EMB: optic neuritis (causing red and green color indiscrimination). protect from light.

Nursing Care y Isolation y Skin Care: Braces .

Prevention .

usually caused by pyogenic bacteria or mycobacteria. .y Osteomyelitis is an infection of bone or bone marrow. and nearly 90% of cases are caused by Staphylococcus aureus. y Staphylococcus aureus is the organism most common. y Bloodstream-sourced osteomyelitis is seen most frequently in children.

Predispositions y An open injury to the bone: open fracture with the bone ends y y y y piercing the skin. leading to a secondary bone infection. which is deposited in a focal (localized) area of the bone. resulting in destruction of the bone. new bone often forms around the site. which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria. An infection from elsewhere in the body: urinary tract infection that has spread to the bone through the blood. This bacterial site in the bone then grows. However. Bacteria in the bloodstream. A chronic open wound or soft tissue infection can eventually extend down to the bone surface. A minor trauma. .

On predispositions y People with diabetes y Patients receiving hemodialysis y People with weakened immune systems y People with sickle cell disease y Intravenous drug abusers y Elderly .

Pathophysiology Predisposition like: Open wound. venous stasis. lodge and multiply Infection reaches outer surface or margin of the bone. Soft tissue infection like boils. DM Pus forms. surgery. raising the periosteum Phagocytes attempt to contain infection by releasing enzymes that destroys eventually bone tissue Disruption of blood supply and Necrosis results Bacteria adheres to damaged bone coating underlying bone with protective film . followed by edema and vascular congestion Bacteria enters.

and legs Changes in gait (walking pattern that is a painful. uneasiness. secondarily from being ill with infection General discomfort. (older people with atherosclerosis) . yielding a limp) Bacteria enter the body's tissues through a wound and travel to the bone (like after an injury or trauma) Blood supply to that area of the bone is disrupted. or ill feeling Drainage of pus through the skin Excessive sweating Chills Lower back pain Swelling of the ankles. feet.Manifestations Bacteria can travel into the bone through the bloodstream from other infected areas in the body Pain and/or tenderness in the infected area Swelling and warmth in the infected area Fever Nausea.

Typical Appearance of Osteomyelitis .

which will show if there is an increased white blood cell count 2.Diagnostic Tests y Blood tests: When testing the blood. measurements are taken to confirm an infection: 1. complete blood count (CBC). ESR (erythrocyte sedimentation rate) and/or CRP (Creactive protein) in the bloodstream. . the infectious agent can then be identified and tested against different antibiotics in hopes of finding the most effective treatment. By allowing the bacteria to grow. (NV=0-15mm/hr) y Blood culture: A blood culture is a test used to detect bacteria. A sample of blood is taken and then placed into an environment that will support the growth of bacteria. which detects and measures inflammation in the body.

the material will spread in a uniform fashion. y Bone scan: a small amount of Technetium-99 pyrophosphate. . A tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material. y Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism. which can be seen with a special camera that produces the images on a computer screen.y Needle aspiration: a needle is used to remove a sample of fluid and cells from the vertebral space. a radioactive material. is injected intravenously into the body. or bony area. If the bone tissue is healthy.

Treatment y Drainage: needle aspiration of open wound. y Medications: Antibiotics help the body get rid of bacteria in the bloodstream that may otherwise reinfect the bone. A needle is inserted into the infected area and the fluid is withdrawn. Type of antibiotics is based on culture results. . commonly used is Methacillin.

y Physiotherapy: to build up strength of the muscles .y Splinting or cast immobilization: to immobilize the affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible y Surgery: destroyed bone is scraped out.

light clothing. ensure daily fluid intake of 3L.Nursing Care y Risk for Infection related to compromised immune system: Hand washing and maintain dietary kcal and CHON intake. y Hyperthermia related to infection and inflammatory process: maintain cool environment. .

y Pain related to swelling: splint area. use of analgesics.y Impaired physical mobility related inflammation and use of immobilizers: maintain functional position. . ensure PROME. use of distraction. minimal manipulation or handling of affected area. maintain rest and avoid weight bearing activities.

Scoliosis

Scoliosis
y abnormal curvature of the spine y "S" or a "C" curvature of the spine y bones are rotated slightly, making the person's waist or

shoulders appear uneven.

and is seen more often in girls than boys y Adult: Degeneration as in osteoporosis .Predispositions y If someone in a family has scoliosis. before puberty. the likelihood of an incidence is much higher: approximately 20 percent y Children: It is usually develop in middle or late childhood.

Etiology y "idiopathic." meaning the cause is unknown. .

Manifestations y Uneven shoulders y One shoulder blade that appears more prominent than the other y Uneven waist y One hip higher than the other y Leaning to one side .

y Ribs on one side of the body to stick out farther than on the other side y Back pain and difficulty breathing .

legs and the rib cage for signs of scoliosis. Periodic X-rays are done to monitor the curve and help make treatment decisions. . hips. y X-rays: initial X-ray to confirm the diagnosis and determine the curve angle.Diagnostic Tests y Physical examination: examination of the spine as well as the shoulders.

or S-shaped curve. is at 0 degrees a straight line . y Angle: A normal spine. viewed from the back. y Location: The curve may occur in the upper back area (thoracic). the lower back area (lumbar) or in both areas (thoracolumbar) y Direction: The curve can bend to the left or to the right. The rotation of the spine causes the ribs and muscles near the spine to move out of normal alignment.Descriptions y Shape: Curves develop side-to-side as a C.

Milwaukee brace. The brace has a flat bar in the front and two flat bars in the back. *Also called a thoracolumbosacral orthosis (TLSO). This brace is not commonly used. This full-torso brace has a neck ring with rests for the chin and for the back of the head. b. A Milwaukee brace may be used for curves in the upper spine. . Underarm or low-profile brace: made of modern plastic materials and is contoured to conform to the body. lower back and hips. this closerfitting brace is less visible under the clothes as it fits under the arms and around the rib cage.Treatment y Braces: prevents further progression of the curve a.

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Fusion involves connecting two or more vertebrae with pieces of bone taken from the pelvis. .y Surgery: "Fusion" means joining two pieces together. the vertebrae and the pieces of bone fuse together preventing further progression of the curve. Eventually.

infection.Complications from Surgery y bleeding. arthritis and disk degeneration. pain. nerve damage. .

to avoid another surgery. .y It involves the use of metal rods. screws or wires (instrumentation) to the spine to hold the vertebrae together during the months after surgery while the bones fuse. hooks. even after the bones have fused. y The instrumentation is left in the body.

the risk of lung infections and pneumonia increases. . making it more difficult to breathe and harder for the heart to pump. Any time breathing is compromised. a curve greater than 100 degrees damage to the lungs and the heart can occur. a curve greater than 70 degrees the rib cage may press against the lungs and heart. In very severe scoliosis 2.Complications y Lung and heart damage: 1.

.y Back problems: chronic back and if untreated may develop arthritis of the spine. y Body image: child might feel isolated and develop a poor body image from wearing a brace during childhood and teenage years.

Conservative Treatment y Electrical Stimulation y Traction y Active and Passive ROME y Weight reduction .

frequent change of undergarments during warm weather. teach to avoid use of powders and lotion.Nursing Care y Risk for injury related to bracing and other related factors: Assess for skin irritation. use of undergarments to reduce friction. . loosen brace during meals and for the first 30 minutes after meals.

color and sensation. .y Risk for peripheral neurovascular dysfunction related to brace and cast application: assess for movement.

Osteoarthritis Rheumatoid Arthritis .

lower back and feet. hips. But if fingers are affected. knees.Osteoarthritis y Also known as degenerative joint disease or osteoarthrosis y characterized by the breakdown of joint cartilage those in fingers. y Initially it may strike only one joint. multiple hand joints may become arthritic. .

heredity. and muscle weakness. joint injury or stress.Causes y combination of factors: including being overweight. . the aging process.

and some people may not experience any signs or symptoms y Pain in a joint during or after use. particularly after using it y Bony lumps on the middle or end joints of the fingers or the base of the thumb known as Heberden s node y Loss of joint flexibility . or after a period of inactivity y Discomfort in a joint before or during a change in the weather y Swelling and stiffness in a joint.Manifestations y Often develops slowly.

y Nodes tend to run in families and affect more women than men. .Areas y Fingers: Bony knobs called Heberden s node can enlarge in the finger joints. creating a gnarled appearance y Painful or stiff and numb joint.

neck pain and stiffness. .y Spine: Slow deterioration of disks between the bones along the spine can lead to back.

Where bone surfaces rub together (facets).In osteoarthritis. disks narrow and spurs form. cartilage becomes worn and may be painful. .

knees and feet y As cartilage slowly deteriorates over the years.y Weight-bearing joints: The parts of the body that bear the majority of the weight like hips. chronic pain or varying amounts of discomfort when standing and walking .

The hip joint on the left is normal, but the hip joint on the right shows deterioration of cartilage due to osteoarthritis.

Pathophysiology
mechanical stress imbalance of enzymes released from the cartilage cells or from the lining of the joint

joint cartilage breaks down faster

cartilage wears down completely, leaving the bone rubbing on the other bone .

damaged end of the bones

Risks
y 45 years old or older and female y hereditary conditions like defective cartilage and

malformed joints y joint injuries caused by physical activity or sports y obesity y weak thigh (quadriceps) muscles leading to osteoarthritis of the knees

magnetic resonance imaging (MRI) scans y Arthrography an image taken after dye has been injected into the joint.Diagnostic Tests y Fluid may be withdrawn from a joint for analysis (joint aspiration) y X-rays. worn-down cartilage and loss of joint space . Imaging techniques can reveal bone spurs. bone scans. computerized tomography (CT) scans.

gels. Capsaicin: a cream made from the seeds of hot chili peppers. knees and elbows. . ointments and sprays to temporarily relieve arthritic pain. Topical pain relievers: creams. methyl salicylate. may relieve pain in joints close to the skin surface. such as fingers. menthol and camphor like Icy Hot and Ben-Gay. Examples: trolamine salicylate include Aspercreme and Sportscreme.Treatment y Medications: to treat pain and mild inflammation and therefore improving joints' functioning 1.

y Side Effect: liver damage. Acetaminophen: Acetaminophen (Tylenol) can relieve pain but doesn't reduce inflammation. y It has been shown to be effective to relieve mild to moderate pain. especially if taken with alcoholic beverages .y 2.

gastrointestinal bleeding. Motrin IB) and naproxen sodium (Aleve). ketoprofen (Orudis). cardiovascular problems. y Side Effects: ringing in the ears. ibuprofen (Advil. . Voltaren) and nabumetone (Relafen).y 3. gastric ulcers. NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs): It relieves pain and fight inflammation y Examples: aspirin. y Consuming alcohol or taking corticosteroids while using NSAIDs increases the risk of gastrointestinal bleeding. diclofenac (Cataflam. and liver and kidney damage.

has been linked to an increased risk of heart attack and stroke. COX-2 inhibitors: Considered as effective for managing pain and inflammation y Example: celecoxib (Celebrex) y Side Effects: fluid retention and causing or exacerbating high blood pressure.y 4. .

given in combination with acetaminophen to increase pain relief y y Side Effect: nausea and constipation. has no anti-inflammatory effect y Used for short-term treatment of acute flare-ups.y 5. . Tramadol: (Ultram) centrally acting analgesic.

. such as hips and knees these replacement joints last at least 20 years in about 80 percent of those who had replacements. it also can improve appearance and comfort and may improve joint's mobility.Surgery y Joint replacement: (Arthroplasty): damaged joint is removed and replaces it with a plastic or metal device called a prosthesis. painfree lifestyle. hip and knee joints common sites. y Joint replacement is most successful in large joints. In smaller hand joints. y Joint replacement surgery can help resumes an active.

The artificial joint has metal alloy caps for thighbone and shinbone and high-density plastic to replace eroded cartilage within the joint and on the kneecap. .Knee replacement surgery can repair damage from osteoarthritis and other inflammatory conditions.

Implanting an artificial joint eliminates pain and restores near-normal movement .Gradual deterioration of cartilage that occurs in osteoarthritis is the most common reason for hip replacement surgery.

fluid or loose debris inside the joint. y These procedures may provide short-term pain relief and improved joint function . y Lavage involves using saline to flush out blood. y Debridement removes loose fragments of bone or cartilage inside the joint. lavage and debridement or both are done.y Arthroscopic lavage and debridement: During arthroscopy.

can then bear weight without pain. The fused joint. such as an ankle. but has no flexibility.y Repositioning bones: known as osteotomy y Fusing bones: known as arthrodesis to increase stability and reduce pain. .

Nursing Care
y Emphasize benefits of Exercise regularly: walking is a good starter exercise; stationary bicycle or do hand or arm exercises. y Instruct patient as she moves, maintain a slow, steady rhythm. No jerk or bouncing. y Instruct not to hold your breath, as this can temporarily deprive muscles of oxygen and tire them. y Maintain good posture while doing exercise. y Avoid exercising tender, injured or severely inflamed joints. y If there is new joint pain, stop!

y Control weight: Excess weight puts added stress on joints of the back, hips, knees and feet. y Eat a healthy diet: A healthy diet emphasizing fruit, vegetables and whole grains can help control the weight and maintain overall health.

y Apply heat: Heat will ease pain, relax tense, painful muscles and increase the regional flow of blood. y Instruct patient to apply heat before exercising. y One of the easiest and most effective ways to apply heat: a 15-minute hot shower or bath. y Other options: hot pack, an electric heating pad on its lowest setting or a radiant heat lamp with a 250-watt reflector heat bulb. y Precautions: If the skin has poor sensation or have poor circulation, don't use heat treatment.

Cold also has a numbing effect and decreases muscle spasms. Precaution: Don't use cold treatments if there is poor circulation or numbness .y Choose appropriate footwear: Wearing comfortable cushioned shoes that properly support the weight y Apply cold for occasional flare-ups: Cold may dull the sensation of pain during the first day or two.

y Practice relaxation techniques: Hypnosis. y Take your medications as recommended: By taking medications regularly instead of waiting for pain to build. . will lessen the overall intensity of your discomfort. guided imagery. deep breathing and muscle relaxation can all be used to control pain.

. y a. Teaching to use a cane to take weight off the joint when walking.y Teach to use assistive devices: painful knee may need a brace for support. y How: The cane should be used in the hand opposite the affected joint. If the hands are affected. y y b. various helpful tools and gadgets are available to help maintain an active lifestyle.

Know limitations.y 2. Arthritis can make one prone to fatigue and muscle weakness A rest or short nap that doesn't interfere with night time sleep may help. . Rest when tired.

Avoid grasping actions that strains finger joints: For example. Periodically relax and stretch. Use hot water to loosen a jar lid and avoid pressure from the palm to open it. Try using a walking stick or cane. Spread the weight of an object over several joints: Use both hands.3. to lift a heavy pan. select one with a shoulder strap. . 5. Don't twist or use your joints forcefully. instead of a clutch-style purse. 4. Take a break. for example. or use a jar opener.

6. . Don't push open a heavy glass door. Use the strongest muscles and favor large joints. bend the knees and squat while keeping the back straight. To pick up an object. Lean into it.

Use of Coping Skills y Osteoarthritis can affect everyday activities and overall quality of life. it's important to adopt coping strategies for dealing with the disease 1. Make a plan for managing arthritis. As a result. . Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and function better. Keep a positive attitude.

Homeopathy d. Magnets .Complementary and Alternative Therapy y Common forms of complementary and alternative medicine for treatment of osteoarthritis include: a. Copper jewelry c. Acupuncture b.

.Rheumatoid Arthritis y an inflammatory condition causing joints to ache and throb and eventually become deformed.

Cause y unknown. but it's believed to be the body's immune system attacking the tissue that lines the joints (synovium) .

Prevalence y two to three times more common in women than in men y generally strikes between the ages of 20 and 50 .

Risk Factors y Getting older: incidence of rheumatoid arthritis increases with age y Being female y Being exposed to an infection. that may trigger rheumatoid arthritis in those with an inherited susceptibility y Inheriting specific genes y Smoking cigarettes over a long period of time. possibly a virus or bacterium. .

Pathophysiology Predisposition like Infection proteins damages cartilage. especially after sleep or after periods of rest Loss of motion of the affected joints Loss of strength in muscles attached to the affected joints Fatigue. white blood cells whose usual job is to attack unwanted invaders. bone. tendons and ligaments. especially in the smaller joints of hands and feet Generalized aching or stiffness of the joints and muscles. which can be severe during a flare-up Low-grade fever Deformity of joints over time General sense of not feeling well (malaise) . such as bacteria and viruses move from the bloodstream into the synovium joint loses its shape and alignment Inflammation of the synovial joints release of proteins that cause thickening of the synovium Pain and swelling in the joints.

especially after sleep or after periods of rest y Loss of motion of the affected joints y Loss of strength in muscles attached to the affected joints y Fatigue y Low-grade fever y Deformity of the joints over time y General sense of not feeling well (malaise) .Manifestations y Pain and swelling in the joints. especially in the smaller joints of the hands and feet y Generalized aching or stiffness of the joints and muscles.

causing pain. swelling and deformity.Rheumatoid arthritis typically strikes joints. fluid builds up and joints erode and degrade. As the synovial membranes become inflamed and thickened. .

the synovial membrane that protects and lubricates joints becomes inflamed. Joint erosion may follow. causing pain and swelling. With rheumatoid arthritis. involves the wearing away of the cartilage that caps the bones in the joints.Osteoarthritis. the most common form of arthritis. .

.Diagnostic Tests y Blood tests: (ESR or sedimentation rate) can indicate the presence of an inflammatory process y People with rheumatoid arthritis tend to have elevated ESRs. y The ESRs in those with osteoarthritis tend to be normal.

y Blood test for antibody called rheumatoid factor .

Differential Characteristics y 1. malaise and fatigue Inflammation sites: fingers and proximal interphalangeal joint Nodules: subcutaneous extraarticular nodules around the joints y 1. Heberden s nodes are present . 2. 3. Rheumatoid Arthritis Systemic Disease: fever. 3. 2. Osteoarthritis Local Joint Disease: no systemic symptoms Inflammation sites: distal interphlangeal joints Nodules: no periarticular of subcutaneous nodules.

4. Who are predispose: young adults to older adults 4. ESR: Elevated. ESR: normal 5. Who are predispose: adults in later years . elevated serum rheumatoid factor 5.

y Side Effects: easy bruising. reduce inflammation and pain. and slow joint damage. a round face and diabetes . weight gain. thinning of bones. cataracts.Treatment y Corticosteroids: prednisone and methylprednisolone (Medrol).

cyclosporine (Neoral. which is out of control in rheumatoid arthritis. y Side Effect: increased susceptibility to infection.y Immunosuppressants: It tames the immune system. y It attacks and eliminate cells that are associated with the disease. azathioprine (Imuran). . Sandimmune) and cyclophosphamide (Cytoxan). y Examples: leflunomide (Arava).

a type of costimulation modulator. such as pneumonia . Serious infections. Abatacept.y Abatacept (Orencia). such as upper respiratory tract infections. y Side Effects: headache. nausea and mild infections. it reduces the inflammation and joint damage caused by rheumatoid arthritis by inactivating T cells a type of white blood cell.

chills and nausea.y Rituximab (Rituxan): Rituximab reduces the number of B cells in the body. y Side effects: flu-like signs and symptoms. Rituximab is administered as an infusion into a vein in arm. such as fever. extreme reactions to the infusion: difficulty breathing and heart problems. B cells are involved in inflammation. .

assist and support during exercise. change position frequently. use of resting splints during acute pain y Impaired physical mobility related to joint destruction: encourage regular active exercise of joints.Nursing Care y Pain related to joint inflammation and stiffness: apply heat or cold prior to exercise and at bedtime. provide rest periods. avoid exercise during acute pain .

encourage ambulation with assistance. use shoes than slippers when ambulating. encourage active ROME. use ambulatory devices like cane.y Potential for injury related to weakness and impaired movement: avoid positions of flexion. teach use safety devices such as grab bars on tubs and showers .

use assistive device in dressing.y Self Care Deficits related to pain and limitation of movement: provide time for ADL. use comfort measures as needed before required activities. allow maximum independence. identify and anticipate needs . identify personal strengths. feeding and ADL y Body Image Disturbances related to deformed joints: provide opportunities to discuss feelings.

medication c. nutrition . nature of the disorder b. activity e. exercise program d.y Knowledge Deficit related to control and management of arthritis: teach the following: a.

Club Foot Congenital Hip Dysplasia .

Clubfoot
y Feet point down and inward y It does not cause pain in the newborn child y It can cause long-term abnormalities in gait y It may lead to complications such as chronic skin

ulcers

Mechanisms
y The tendons on the inside and the back of the foot are

too short. y The foot is pulled then toes point down and in, and it is held in this position by the shortened tendons.

Pathophysiology failure to keep pace with the development of the foot posterior and medial tendons and ligaments (in the back and inside) tendons and ligaments tether posterior and medial parts of the foot point downwards and the twist inwards Bones are mis-shapened .

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Etiology y Associated with other congenital malformations such as spina bifida y No known cause of the deformity has been established .

although girls are not exempted.Prevalence y It tends to be more common in boys. y A positive family history is a predisposition .

Manifestations y It does not cause pain in the infant y If uncorrected in the older child. . and the development of chronic ulceration and infection. it is very unsightly and very crippling y Patient walks on the outside of his foot which is not meant for weight-bearing y Skin breaks down.

with manipulation before each casting. .Treatment y Manipulating the foot to get it to the best position possible. and then holding the correction in a cast. the foot is manipulated and cast applied every 2 weeks. to obtain further correction. (Ponseti Method) y The cast is changed on a weekly basis. y After the first 6 weeks surgery can be planned.

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y The lateral ligaments are released to allow a complete release. . "Flexible" means one can move the foot around freely without pain. b.Surgery y Releasing all the tight tendons and ligaments in the posterior and medial aspects of the foot. not on heels or the outside of foot. y Objective: Plantigrade and Flexible foot a. and repairing them in the lengthened position. "Plantigrade" means the child stands with the sole of the foot on the ground.

the foot needs to be casted at biweekly intervals for 6 weeks. followed by the use of a thermoplastic brace known as Wheaton Brace Purpose: to hold the correction.y After surgery. The brace is used fulltime for about 6 weeks. followed by night use only till the child starts to walk at one year of age .

Wheaton Brace .

Provide diversional activities . Check for NEUROVASCULAR Integrity How: observe for color and sensation 2.Nursing Care 1. Regularly inspect the cast for irritation 3.

.Congenital Hip Dysplasia y It is a disorder in children that is either present at birth or shortly thereafter. y During gestation. the infant's hip should be developing with the head of the thigh bone (femur) sitting perfectly centered in its shallow socket (acetabulum). y The acetabulum should cover the head of the femur as if it were a ball sitting inside of a cup.

especially when weight bearing begins. .y In congenital hip dysplasia. the development of the acetabulum in an infant allows the femoral head to ride upward out of the joint socket.

Congenital Hip Dysplasia .

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Prevalence y more females affected than males. It places the infant's hips into extreme adduction (brought together) y higher in infants born by caesarian and breech position births. . y related to common practice of swaddling and using cradleboards for restraining the infants.

y greater chance in the first born compared to the second or third child. .

y The stretch of skin between the anus and the genitals (perineum) is unusually wide.Manifestations y Reduced joint mobility y A low clunking sound can be heard when the leg is gently rotated. which is the sound of the femur engaging the socket. .

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The skin creases of the buttocks don t match. b. .y For unilateral dislocation symptoms include: a. One knee joint looks higher than the other.

. With the legs abducted (moved apart). the examiner may be able to discern a distinct clicking sound with motion. with the second and third fingers pointing down the child's thigh.Diagnostic Test y Ortolani Test: begins with each of the examiner's hands around the infant's knees. y If symptoms are present with a noted increase in abduction. the test is considered positive for hip joint instability.

Ortolani Test Barlow Test .

The hip is abducted to where it can be felt if the hip is sliding out and then back in the joint. .y Barlow Test : with the infant's hip brought together with knees in full bent position y The examiner's middle finger is placed over outside of the hipbone while the thumb is placed on the inner side of the knee.

y X rays may also be helpful in finding the proper positioning of the hip joint for treatment of casting. .y X-ray films can be helpful in detecting abnormal findings of the hip joint.

stabilization was achieved by placing rolled cotton diapers or a pillow between the thighs.Treatment y Objective: is to replace the head of the femur into the acetabulum and. to enlarge and deepen the socket. . y In the past. thereby keeping the knees in a frog like position. by applying constant pressure.

Pavlic Harness .

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Nursing Care 1. Provide diversional activities . Check for NEUROVASCULAR Integrity How: observe for color and sensation 2. Regularly inspect the cast for irritation 3.