Joyce Y.

Visitacion NCM 104

BSN-4AJ SY 2008-
2009

MUSCULOSKELETAL SYSTEM

Review of Anatomy & Physiology

• The musculoskeletal system consists of the:
• Muscles
• Tendons
• Ligaments
• Bones
• Joints
• Cartilages
• Bursae

• Primary function: to produce skeletal movements

• Functions of the musculoskeletal system:

1. Provides protection for the vital organs including
the brain, heart and lungs.
2. Provides a sturdy framework to support body
structures.
3. Makes mobility possible.
4. Joints hold the bones together and allow the
body to move.
5. Muscles attached to the skeleton contract,
moving the bones and producing heat that helps maintain
body temperature.
6. Serves as reservoir for immature blood cells and
essential minerals, including:
• Calcium – 98% of total body Calcium is present in
bone.
• Phosphorus
• Magnesium
• Fluoride

Hematopoiesis
• A process in which the red bone marrow located
within bone cavities produces red blood cells, white blood cells,
and platelets.
• The formation of blood cellular components.

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MUSCLES
• Characteristic of Muscles:
• Muscles are made up of bundles of muscle
fibers.

• Functions:
• Provide the force to move bones.
• Assist in maintaining posture.
• Assist with heat production.

• Process of contraction and relaxation:

• Muscle contraction and relaxation require
large amounts of Adenosine Triphosphate.
• Contraction also requires Calcium, which
functions as a catalyst.
• Acetylcholine released by the motor end
plate of the motor neuron initiates an action potential.
• Acetylcholine then is destroyed by
acetylcholinesterase.
• Calcium is required to contract muscle fibers
and acts as catalyst for the enzyme needed for the sliding
together action of actin and myosin.
• Following contraction, Adenosine
Triphosphate transports Calcium out to allow actin and
myosin to separate and allow the muscle to relax.

• 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 lie bones to
muscles

LIGAMENTS
• Strong, dense and flexible bands of fibrous tissue
connecting bones to another bone.

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 • Ligaments hold bone and joint in the correct position.

BONES
• Variously classified according to shape, location and
size.
• Bones are constructed cancellous (trabecular) or
cortical (compact) bone tissue.

• Characteristics of Bones:
• Bones support and protect the structures of
the body.
• Bones provide attachment for muscles,
tendons and ligaments.
• Bones contain tissue in the central cavities,
which aids in the formation of blood cells.
• Bones assist in regulating Calcium and
Phosphate concentrations.

• Bone Growth:
• The length of bone growth results from
the ossification of the epiphyseal cartilage at the ends of the
bones.
• Bone growth stops between the ages of 18
and 25 year.
• The width of the bone growth results
from the activity of the osteoblasts (bone forming cell)
and occurs throughout life but slows down with aging.
• As aging occurs, osteoclasts (bone
resorption) accelerates, decreasing bone mass and
predisposing the client to injury.

• Functions:
• Locomotion
• Protection
• Support and lever
• Blood production
• Mineral deposition / storage

• Bone is composed of:

• Cells
• Protein matrix
• Mineral deposits

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 • Three basic types of bone cell:
1. Osteoblasts
• Bone forming cell.
• Function in the bone formation by
secreting bone matrix.
• Matrix consists of:
a. Collagen fibers
b. Ground substances (glycoprotein
& proteoglycans)
• Minerals deposited in the matrix are
Calcium and Phosphorus.

2. Osteocytes
• Mature bone cell.
• Involved in bone maintenance.
3. Osteoclasts
• Bone resorption cell.
• Involved in dissolving and resorbing
bone.

• Bone formation:
• Osteogenesis (bone formation) begins long
before birth.
• Ossification is a process by which the bone matrix
(collagen fibers and ground substances) is
formed and hard mineral crystals (Calcium
and Phosphorus) are bound to the collagen
fibers.

The Skeletal System

• The adult body has 206 bones.

• Axial
1. Head - 22
• Cranial bone – 8
• Facial bone - 14
2. Breastbone / sternum - 1
3. Ribs – 24
• True ribs – 7 pairs (14); joined directly to the
sternum.

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 • False ribs – 3 pairs (9); joined to the sternum
by cartilage.
• Floating ribs – 2 pairs; not connected to the
sternum at all, connected to the
diaphragm.
4. Spine / Vertebrae - 33
• Cervical vertebrae – 7
• Thoracic vertebrae – 12
• Lumbar vertebrae – 5
• Sacrum – 5
• Coccyx – 4

• Appendicular
• Upper extremities
1. Collar bone / clavicle – 2
2. Shoulder blade / scapula – 2
3. Humerus – 2
4. Radius, ulna / forearms – 4
5. Carpals (8): scaphoid, lunate, triquetrum, pisiform,
trapezium, trapezoid, capitate,
hamate
Metacarpals (5)
Phalanges (14) each hand
Hands – 54

• Lower extremities
1. Hip bone / Ilium – 2
2. Femur – 2
3. Kneecap / patella - 2
4. Tibia, fibula / legs – 4
5. Tarsals (7): calcaneus, talus, navicular bone,
medial cuneiform bone, intermediate
cuneiform bone, lateral cuneiform
bone, cuboidal bone
Metatarsals (5)
Phalanges (14) each foot
Feet - 52

• Four categories of bones:

1. Long bones
Shaped like rods or shafts with rounded ends.
Designed for weight bearing and movements.

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A typical long bone has a shaft (diaphysis) primarily
cortical bone, proximal and distal diaphysis.
Diaphysis is a hollow cylinder of compact bone that
surrounds the medullary cavity.
Epiphyses are the ends of long bones, are primarily
cancellous bones.
piphyseal plate separates the epiphyses from the diaphysis
and is the center for longitudinal growth in children.
Bone growth stops between the ages of 18 and 25 years.
Articular cartilage covers the ends of long bones at the
joints.

• Humerus – “funny bone”; upper arm bone.

• Radius – outer and shorter bone of the forearm;
aligned to your thumb.
• Ulna – inner and longer bone of the forearm; aligned to
your pinky.
• Femur – “thigh bone”; strongest, largest and longest
bone in the body.
• Tibia – “shin bone”; inner and larger bone of the leg;
connects to the femur to form the knee joint
and with the foot bone (talus) to allow the
ankle to flex and extend.
• Fibula – outer bone of the leg; serves as an area of
muscle attachment.
• Metatarsals – bones of the feet.
• Metacarpals – bones of the palms or hands.
• Phalanges – finger and toes bones.

2. Short bones
Consist of cancellous bone covered by a layer of
compact bone.

• Carpals – wrist bones

• Tarsals – ankle bones

3. Flat bones
Are important sites of Hematopoiesis and
frequently provide vital organ protection.
Made of cancellous bone layered between
compact bones.

• Ribs – bones that form a protective cage around the

organs of the upper body.

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 • Sternum / Breastbone (manubrium, body, xiphoid
process) – bones located in the middle of the
chest.
• Cranium (frontal, parietal, temporal, occipital,
sphenoid, ethmoid) – bones protecting the
brain.
• Scapula – shoulder blades
• Portions of the pelvic girdle / hip girdle

4. Irregular bones
ave unique shapes related to their function.

• Vertebrae of ear ossicles (hammer, anvil, stirrup)

• Facial bones (turbinate, lacrimal, mandible, maxilla,
nasal, palatine, vomer, zygomatic)
• Pelvis

JOINTS
• The part of the skeleton where 2 or more
bones are connected.

• Characteristics of the Joints:

Joints allow the movement between bones.
Joints are formed when 2 bones join.
Joint surfaces are covered with cartilage.
Joints are enclosed in a capsule.
Joint contains a cavity filled with synovial fluid.
Ligaments hold the bone and joint in the correct position.
Articulation is the meeting point of 2 or more bones.

• Synovial fluid
• Is found in the joint capsule.
• Formed by a synovial membrane
which lines the joint capsule.
• Lubricates the cartilage.
• Provides a cushion against shocks.

• Different types of joints:

1. Amphiarthrosis
Cartilaginous and slightly movable joints.

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 Ex. symphysis pubis

2. Condyloid
Freely movable joints.
They allow frictionless, painless movements.
Ex. wrists

3. Diarthrosis
Synovial joints
Ball and socket joints
Ex. hips, elbows

4. Synarthrosis
Fibrous or fixed joints.
No movement associated with these joints.

CARTILAGES
• A dense connective tissue that consists of
fibers embedded in a strong gel-like substance.

BURSAE
• A sac connecting fluid that is located around
the joints to prevent friction.

ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM

• The nurse usually evaluates this small part
of the over-all assessment and concentrates on the:
• patient’s posture
• body symmetry
• gait
• muscle and joint function

NURSING ASSESSMENT
1. Health History
• Pain
Bone – dull, deep ache “boring in nature.

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 Function – sharp and piercing, relieved by
immobility.
Muscle - soreness
• Paresthesia
Burning, tingling sensation or numbness
• Diet
High purine diet
• Family History
• Allergy

2. Physical Examination
• Posture
Kyphosis – outward curvature of the spine.
Lordosis – inward curvature of the spine.
Scoliosis – lateral curvature of the spine.
• Gait
Smoothness and rhythm
Shuffling gait - characterized by
short steps, with feet barely leaving
the ground, producing an audible
shuffling noise.
Ataxic gait – unsteady,
uncoordinated walk with a wide base
of support and the feet thrown
outward.
Festinating gait - walks on the
toes as if being pushed. Steps start
slowly and increase in speed. The
upper part of the body advances
ahead of the lower part.
Antalgic gait – consists of a limp
adopted so as to avoid pain on
weight-bearing structures (as in hip,
knee, or ankle injuries)

• Bone integrity
Deformities and alignment

• Joint function
Range of motion
Effusion – excess fluid in joint.
Crepitus – grating or crackling sound or
sensation. May occur with movement of ends
of a broken bone or irregular joint surface.

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 • Muscle strength
• Neurovascualr function

LABORATORY PROCEDURES
1. Bone Marrow Aspiration
• Usually involes aspiration of the bone marrow to diagnose
diseases like leukemia, aplastic anemia.
• Usual site is the sternum and iliac crest.
• Pre-test:
1. Consent
2. Explanation of the procedure.
• Intratest: Needle puncture may be painful.
• Post-test:
1. Maintain pressure dressing.
2. Watch out for bleeding.

2. Arthroscopy
• A direct visualization of the joint cavity.
• Pre-test:
1. Consent
2. Explanation of the procedure.
3. NPO 8-12 hours
• Intratest:
1. Sedative
2. Anesthesia
3. Incision will be made.
• Post-test:
1. Maintain dressing.
2. Ambulation as soon as awake.
3. Mild soreness of joint for 2 days.
4. Joint rest for a few days.
5. Ice application to relieve discomfort.
6. Administer pain medication as
prescribed.
7. An elastic wrap should be worn for 2-4
days as prescribed.
8. Instruct patient that walking without
weight-bearing usually is permitted after sensation
returns but to limit activity for 1-4 days as prescribed.

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 9. Elevate the extremity as often as
possible for 2 days and place ice on the site to minimize
swelling.
10. Reinforce instructions regarding the use
of crutches, which may be used for 5-7 days post
procedure for walking.
11. Notify the doctor if fever or increased
knee pain occurs or if edema continues for more than 3
days.

3. Bone Scan
• Imaging study with the use of a contrast radioactive
material.
• Pre-test:
1. Painless procedure.
2. IV radioisotope is used.
3. No special preparation.
4. Pregnancy is contraindicated.
• Intratest:
1. IV injection.
2. Waiting period for 2 hours before x-ray.
3. Fluids allowed.
4. Supine position for scanning.

• Post-test:
1. Increase fluid intake to flush out
radioactive material.

4. Dual-energy X-ray Absorptiometry (DXA)

• Assesses bone density to diagnose osteoporosis.
• Uses low dose radiation to measure bone density.
• Pre-test:
1. Painless procedure.
2. Non-invasive.
3. No special preparation.
4. Advise to remove jewelry.

5. Radiograph
6. Arthrocentesis
7. Arthrogram
8. Bone or Muscle Biopsy
9. Electromyography
10. Myelogram

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RISKS ASSOCIATED WITH MUSCULOSKELETAL DISORDERS:
Autoimmune disorders
Calcium deficiency
Degenerative conditions
Falls
Hyperuricemia (excess of uric acid in the
blood)
Infection
Medications
Metabolic disorders (Ex. diabetes, malnutrition,
obesity)
Neoplastic disorders (Ex. tumors)
Obesity
Post-menopausal states
Trauma and injury

Nursing Management of Common Musculoskeletal

Problems
1. Pain
These can be related to joint inflammation, traction, surgical
intervention.
a. Assess patient’s perception of pain.
b. Instruct patient alternative pain management like
mediation, heat and cold application. Transcutaneous
Electrical Nerve Stimulation (TENS) and guided
imagery.

TENS - a technique used to relieve pain in an injured or

diseased part of the body in which electrodes applied
to the skin deliver intermittent stimulation to surface
nerves and block the transmission of pain signals.

c. Administer analgesics as prescribed.

• Usually NSAIDS.
• Meperidine can be given for severe pain.

d. Assess the effectiveness of pain measures.

2. Impaired Physical Mobility

a. Instruct patient to perform ROM exercises,
either passive or active.

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 b. Provide support in ambulation with assistive
devices.
c. Turn and change position every 2 hours.
d. Encourage mobility for a short period and
provide positive reinforcements for small accomplishments.

3. Self-Care Deficits
a. Assess functional levels of the patient.
b. Provide support for feeding problems.
• Place patient in Fowler’s position.
• Provide assistive devices and supervise
mealtime.
• Offer finger foods that can be handled
by patient.
• Keep suction equipment ready.

c. Assist patient with difficulty bathing and

hygiene.
d. Assist with bath only when patient has
difficulty.
e. Provide ample time for patient to finish
activity.

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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.

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

Types of Osteoporosis:
1. Primary Osteoporosis – advanced age, post-
menopausal
2. Secondary Osteoporosis – steroid overuse, renal
failure

Risk Factors for the Development of Osteoporosis:

1. Sedentary lifestyle
2. Age – 50 years old and above
3. Diet – caffeine, alcohol, low Ca and Vit D
4. Post-menopausal – estrogen deficiency

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 5. Genetics – Caucasian and Asian
6. Immobility
7. Female – due to lower peak bone mass
8. Tobacco use
9. Low body weight – less than 70 kgs.
10. Medications – especially glucocorticoids

Assessment Findings:
1. Low stature – decreasing height (10-15 cm) due to
collapsing vertebrae.
2. Bone pain – back pain (T5-L5)
3. Dowager’s hump – curved upper back
4. Fracture – femur

Laboratory Findings:
1. DXA
• Most commonly used bone mineral density (BMD)
screening.
• T-score is at least 2.5 SD below the young
adult mean value.
2. X-ray studies

Management of Osteoporosis:
1. Diet therapy with Calcium and Vitamin
D.
2. Food supplementation – Phytoestrogen
• Beans
• Cabbage
• Rice
• Berries
• Sesame seeds
• Grains

3. Hormone replacement therapy.

4. Biphosphonates
• Alendronate, Residronate – increased bone mass
by inhibiting the osteoclast.
• These medications are best taken with full glass
of H2O after rising in the morning.
• The client should remain upright for 30 minutes
after taking the medication to prevent GI side
effects especially esophageal irritation.

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 • The client should not drink anything for 30
minutes following administration of the
medication to increase absorption of the drug.

5. Moderate weight-bearing exercises.

• At least 30 minutes, 5 days a week, then work up
to 60 minutes.
• This increases bone mass and total body Calcium.

6. Management of fractures.
7. Avoid use of tobacco and alcohol.

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.
• Take Calcium supplements with meals.
• Take Alendronate with an EMPTY stomach with
full glass of water.
• Instruct on intake of hormonal replacement.

2. Relieve the pain.

• Instruct the patient to rest on a firm mattress.
• Suggest that knee flexion will cause relaxation of the
back muscle.
• Heat application may provide comfort.
• Encourage good posture and body mechanics.
• Instruct to avoid lifting and heavy lifting.

3. Improve bowel elimination.

• Constipation is a problem of Calcium supplements
and immobility.
• Advise intake of HIGH fiber diet and increased
fluids.

4. Prevent injury.

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 • Instruct to use isometric exercise to strengthen the
trunk muscles.
• AVOID sudden jarring, bending and strenuous
lifting.
• Provide a safe environment.

JUVENILE RHEUMATOID ARTHRITIS

Definition:
• AUTO-IMMUNE inflammatory joint disorder of
UNKNOWN disorder
• SYSTEMIC chronic disorder of connective tissue
• Diagnosed BEFORE age 16 years old

PATHOPHYSIOLOGY- UNKNOWN

• Affected by stress climate and genetics

• Common in girls 2-5 and 0-12 years old

JUVENILE RHEUMATOID ARTHRITIS

SYSTEMIC JRA PAUCI-ARTICULAR POLYARTICULAR

• FEVER • MILD joint pain • Morning joint
• Salmon-pink and swelling stiffness and
rash • IRIDOCYCLITIS fever
• Five or more • Less than 4 joints • Weight bearing
joins • Very good joints
• Anorexia, prognosis • Five or more
anemia, points
fatigue • Poor prognosis

• Symptoms may decrease as child enters adulthood

• With periods of remissions and exacerbations

Medical Management:
1. ASPIRIN and NSAIDs- mainstay treatment
2. Slow ating anti-rheumatic drugs
3. Corticosteroids

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 Nursing Management:
Encourage normal performance of daily activities
Assist child in ROM exercises
Administer medications
Encourage social and emotional development

Nursing Management during acute attack:

• SPLINT the joints
• NEUTRAL positioning
• Warm or cold packs

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS
o The most common form of degenerative joint disorder
o Chronic, NON-systemic disorder of joints
o “Wear and fear Arthritis”\

Pathophysiology:
o Injury; genetic, Previous joint damage, obesity, Advanced
age Stimulate the chondrocytes (cells in the
joints) to release chemicals chemicals will cause
cartilage degeneration, reactive inflammation of the
synovial lining and bone stiffening

Risk Factors:
3. Increased age
4. Obesity
5. Repetitive use of joints with previous damage
6. Anatomical deformity
7. Genetic susceptibility

Assessment Findings:

PRESENT IN ALL FORMS

1. Joint pain
Caused by
o Inflamed cartilage and synovium

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 o Stretching of the joint capsule
o Irritation of nerve findings

2. Joint stiffness
• Commonly occurs in the morning after
awakening
• Lasts only for less than 30 minutes
• DECREASES with movement but worsens after
increased weight bearing activity
• Crepitation may be elicited

Diagnostic Findings:
1. X-Ray
• Narrowing of joint space
• Loss of cartilage
• Osteophytes (degeneration of cartilage)

2. Blood tests will show no evidence of systemic inflammation

and are not useful

3. Functional joint impairment limitation

Joint Involvement:
The joint involvement is ASSYEMTRICAL
This is not systemic, there is no FEVER, no severe swelling
Atrophy of unused muscles
Usual joint are the WEIGHT bearing joints

Medical Management:
1. Weight reduction
2. Use of splinting devices to support joints
3. Pharmacologic management:
• Use of PARACETAMOL (ARCETAMI), NSAIDS
• Use of Glucosamine and chondroitin (retard the
destruction of cartilage)
• Topical analgesics
• Intra-articular steroids to decrease inflammation

Nursing Interventions:
1. Provide relief of PAIN

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 • Administer prescribed analgesics
• Application of heat modalities. ICE PACKS may be used
in the early acute stage III
• Plan daily activities when pain is less severe
• Pain meds before exercising

2. Advise patient to reduce weight

• Aerobic exercise
• Walking

3. Administer prescribed medications

• NSAIDS

4. Position the client to prevent flexion deformity

• Use of foot board, splints, wedges and pillows

RHEUMATOID ARTHRITIS

Definition:
• A type of chronic systemic inflammatory arthritis and
connective tissue disorder affecting more women (ages
35-45) than men
• An inflammatory disease

Factors:
• Genetic → Auto-immune connective tissue
disorders: Fatigue, emotional stress, cold, infection

Cause: Unknown

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

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Assessment Findings:
• PAIN
• Joint swelling and stiffness- SYMETRICAL, Bilateral
• Warmth, erythema and lack of function → due to
inflammation
• SYSTEMIC MANIFESTATION: Fever, weight loss, anemia,
fatigue
• Palpation of joint reveals spongy tissue
• Hesitancy in joint movement

Joint Involvement:
• Joint involvement is SYMMETRICAL AND BILATERAL
characteristically beginning in the hands, wrist and feet
• Joint STIFFNESS occurs early morning; lasts more than 30
minutes bit relieved by movement diminished as the day
progresses.
• Joints are swollen and warm painful when moved
• Deformities are common in the hands and feet causing
misalignment
• Rheumatoid nodules may be found in subcutaneous tissues

Diagnostic Test:
8. X-Ray
• Shows bony erosion
•
9. Blood studies reveal (+) rheumatoid factor,
elevated ESR and CRP and ANTI- nuclear anti
body
10. Arthrocentesis shows synovial fluid that is cloudy,
milky or dark yellow containing numerous WBC and
inflammatory proteins

Medical Management:
1. Therapeutic dose of NSAIDS and Aspirin to reduce
inflammation
2. Chemotherapy with methotrexate (drug of choice
in rheumatoid arthritis), antimalarials, gold
therapy (aurothiglucose- given IM or oral) and
steroid (suppress immune system)
3. For advanced cases arthropology, synovectomy
(removal of synovial membrane)

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 4. Nutritional therapy

• GOLD THERAPY
o IM or Oral preparation
o Takes several months (3-6) before effects can be
seen
o Can damage the kidney and causes bone marrow
depression

Nursing Management:
Relieve pain and discomfort
• Use of splints to immobilize the affected
extremity during acute stage of the disease
and inflammation of REDUCE DEFORMITY
• Administer prescribed medications
• Suggest application of COLD packs during
the acute phase of pain, then HEAT
application as the inflammation subsides

Decrease patient fatigue

• Schedule activity when pain is less severe
• Provide adequate periods of rests

Promote restorative sleep

Increase patient mobility
• Advise proper posture and body mechanics
• Support joint in functional position
• Advise ACTIVE ROME

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

Increase Mobility and Prevent deformity

• Lie FLAT on a firm mattress
• Lie PRONE several times to prevent HIP
FLEXION contractures
• Use one pillow under the head because of
risk of dorsal kyphosis

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 • NO Pillow under the joints because this
promotes flexion contractures

HOT VERSUS COLD

HOT COLD
Use to RELIEVE joint stiffness, Use to CONTROL inflammation
pain and muscle spasm and pain

AFTER acute attack ACUTE ATTACK

OA (Osteoarthritis Arthritis)VERSUS RA (Rheumatoid Arthritis)

OA RA
Onset is EARLY Onset is LATE (over 60)

CHRONIC SYSTEMIC DISEASE DEGENERATIVE DISEASE

Involves the SYNOVIUM Involves the CARTILAGE

Involved joints are Involved joints are UNILATERAL-

SYMMETRICAL-FINGERS, WEIGHT BEARING KNEE, HIPS
CERVICAL SPINE AND SPINE

Malaise, fever, anemia (systemic No other S/SX systemic

manifestations)

Joint TENDERNESS, SWELLING, CREPITUS, stiffness in the

WARMTH AND REDNESS morning decreases after activity
(stiffness in the morning for 30
minutes but disappear during
movement)

Subcutaneous nodules

Stiffness that diminishes

Rest the joint, cold and head Rest the joints, Avoid over
modalities, ASA, NSAIDS, activity, Weight reduction, cold
DMARDS (Disease Modifying Anti- and warm modalities, ASA
rheumatic Drugs)

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 Π Normal color of synovial fluid is yellow in color Π

GOUTY ARTHRITIS

Definition:
• A systemic disease cased by deposition of uric acid crystals
in the joint and body tissues
• “BIG TOE” is usually affected
• MAIN PROBLEM: ABNORMAL PURINE METABOLISM THAT
RESULTS TO HYPERURICEMIA

• CAUSES:
11. Primary gout- disorder of Purine metabolism
12. Secondary gout- excessive uric acid in the
blood like leukemia; side effects of medications such
as diuretics, salicylates

Assessment Findings:
1. Severe pain in the involved joints, initially
the big toe
2. Swelling and inflammation of the joint
3. TOPHI- yellowish-whittish, irregular
deposits in the skin that break open and reveals
a gritty appearance
4. PODAGRA- big toe
5. Fever, malaise
6. Body weakness and headache
7. Renal stones

Π GOUT Π

FEVER- low grade occasionally

PAIN- fingers/knees/ankles/toe (main)

JOINTS- stiffened deformed (chronic); joints tender to touch

SKIN- red, shiny, swollen, and hot skin over affected joints; tophi
deposits ≈urate leaking (advanced)

OTHER- racing heart (occasionally), chills (occasionally), malaise;

tendon inflammation
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 Diagnostic Test:
• Elevated levels of uric acid in the blood
• Uric acid stones in the kidney
• (+) Urate crystals in the synovial fluid

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
6. Position the affected extremity in mild flexion
7. Administer anti-gout medication and analgesics

Medical Management (MAIN PHARMACOLOGICAL

TREATMENT OF GOUTY ARTHRITIS):
1. Allupurinol- take it WITH FOOD
Rash signifies allergic reaction

2. Colchicine
For acute attack (usually first 24 hours)

3. Probenecid
For uric acid excretion in the kidney

FRACTURE
A break in the continuity of the bone and is defined according to its
type and extent
Severe mechanical stress to bone bone fracture
Direct blows
Crushing forces
Sudden twisting motion
Extreme muscle contraction

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 Types of Fracture:
13. Complete Fracture
Involves a break across the entire cross-section

14. Incomplete Fracture

The break occurs through only a part of the cross section

Π INCOMPLETE FRACTURE IN CHILDREN-

GREENSTICK Π

. Comminuted Fracture
A fracture that involves production of several bone
fragments

. Simple Fracture
A fracture that involves the break of a bone into 2 parts or
one

Assessment Findings:
1. Pain or tenderness over the involved area
2. Loss of function
3. Deformity
4. Shortening
5. Crepitus
6. Swelling and discoloration

PAIN
o Continuous and increases in severity
o Muscle spasm accompanies the fracture is a
reaction of the body to immobilize the fractured bone

LOSS OF FUNCTION
o Abnormal movement and pain can result to this
manifestation

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 DEFORMITY
o Displacement, angulations or rotation of the
fragments causes deformity

CREPITUS
o A grating sensation produced when the bone
fragments rub each other

Diagnostic Test:
• X-Ray

Emergency Management of Fracture:

1. Immobilize any suspected fracture
2. Support the extremity above and below when moving the
affected part from a vehicle
3. Suggested temporary splints- hard board, stick, rolled
sheets
4. Apply sling if forearm fracture is suspected or the
suspected fractured arm maybe bandaged to the chest
5. Open fracture is managed by covering a clean/sterile
gauze to prevent contamination
6. DO NOT attempt to reduce the fracture

Medical Management:
1. Reduction of fracture either open or closed, immobilization
and Restoration of function
2. Antibiotics; muscle relaxants and pain medications

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 and continuous pain

General Nursing Management For OPEN FRACTURE:

1. Prevent wound and bone infection
• Administer prescribed antibiotics
• Administer tetanus prophylaxis

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 • Assist in serial wound debridement

2. Elevate extremity to prevent edema formation

3. Administer care of traction and cast

Fracture Complications:
EARLY
1. Shock
2. Fat embolism
• Occurs usually in fractures of the long bones
• Fat globes 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

3. Compartment syndrome
4. Infection
5. DVT

LATE
1. Delayed union
2. Avascular necrosis
3. Delayed reaction to fixation devices
4. Complex regional syndrome

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 oxygen in high concentration
• Prepare for possible intubation and ventilator support

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 2. Administer drugs
• Corticosteroids
• Dopamine
• Morphine

3. Institute preventive measures

• Immediate immobilization of fracture
• Minimal fracture manipulation
• Adequate support for fractures bone during turning
and positioning
• Maintain adequate hydration and electrolyte balance

Early Complication: Compartment Syndrome

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 t 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:

• Assess frequently the neurovascular status if the casted
extremity
• Elevate the extremity above the level of the heart
• Assist in cast removal and FASCIOTOMY

Musculoskeletal Modalities
• Traction
• Cast

Traction

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 • A method of fracture immobilization by applying equipments
to align bone fragments
• Used for immobilization, bone alignment and relief of muscle
spasm
• Skin traction: Buck, Bryant
• Skeletal traction
• Balanced suspension traction
• Running/straight traction
• Pulling force exerted on bones to reduce or immobilize
fractures, reduce muscle spasm, correct or prevent
deformities
• 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 a square knot
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
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

Cast
• Immobilizing tool made of plaster of Paris or fiberglass
• Provides immobilization of the fracture

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Cast Types:
1. Long arm
2. Short arm
3. Short leg
4. Long leg
5. Spica
6. Body Cast

Casting Materials:
1. Plaster of Paris
• Drying takes 1-3 days
• If dry it is SHINY, WHITE, hard and resistant

2. Fiberglass
• Lightweight and dries in 20-30 minutes
• Water resistant

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 PALMS not fingertips
3. Keep the cast 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

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
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

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 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 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
Amputation:
• Removal of body part
• Peripheral vascular disease, fulminating gas
gangrene, trauma, congenital deformities, chronic
osteomyelitis, malignant tumor
• Purpose is to relieve symptom and improve
function
• Staged amputation- gangrene and infection
• Complication are hemorrhage, infection, skin
breakdown, phantom limb pain, joint contractures

Assessment:
• Neurovascular evaluation
• Functional status of the extremity
• Diet- balance with adequate protein and vitamins
• Psychological status
o Grief response

Nursing diagnosis:
• Acute pain
• Disturbed body image

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 • Infection risk
• Ineffective coping
• Risk for disturbed sensory perception
• Self care deficit

Goals:
• Relief of Pain
o Evaluation of pain
o Opioid analgesics
o Place a light sandbag on the rosidual limb to
counteract muscle spasm

• Absence of altered sensor perception

o Phantom pain
o Acknowledge the feeling and help the patient
modify the perception
o Keep the patient active
o Early rehab and stump desensitization with
kneading massage brings relief

• Wound healing
o Change the wound dressing
o Wrap the residual limb with elastic dressing

• Acceptance of body image

• Restoration of physical mobility
o Avoid abduction, external rotation and flexion of the
lower extremity amputated
o Elevate the foot area of the bed
o Turn side to side
o Post-op rehab ROM exercise
o Discourage sitting for prolong periods

• Absence of complication
o Massive hemorrhage-most threatening
o Infection- most frequent
o Socket of prosthesis is wash with mild detergents
and dried thoroughly with a clean cloth

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