The musculo-skeletal system consists
Arthroscopy
of the muscles, tendons, bones and
cartilage together with the joints
The primary function of which is to
produce skeletal movements
Three types of muscles exist in the
body
1. Skeletal Muscles
Voluntary and striated
2. Cardiac muscles
Involuntary and striated
3. Smooth/Visceral muscles
Involuntary and NON-striated
Tendons: Bands of fibrous connective
tissue that tie bones to muscles
Ligaments: Strong, dense and flexible
bands of fibrous tissue connecting
bones to another bone
Bones: Variously classified according
to shape, location and size
Functions
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
Joints: The part of the Skeleton where
two or more bones are connected
Cartilages: A dense connective tissue
that consists of fibers embedded in a
strong gel-like substance
Bursae: Sac containing fluid that are
located around the joints to prevent
friction
1. BONE MARROW ASPIRATION
Usually involves aspiration of the
marrow to diagnose diseases like
leukemia, aplastic anemia
Usual site is the sternum and iliac
crest
Pre-test: Consent
Intratest: Needle puncture may be
painful
Post-test: maintain pressure dressing
and watch out for bleeding
2.
SELF-CARE DEFICITS
A direct visualization of the joint cavity
Pre-test: consent, explanation of
procedure, NPO
Intra-test: Sedative, Anesthesia, incision
will be made
Post-test: maintain dressing, ambulation
as soon as awake, mild soreness of joint
for 2 days, joint rest for a few days, ice
application to relieve discomfort
BONE SCAN
Imaging study with the use of a contrast
radioactive material
Pre-test: Painless procedure, IV
radioisotope is used, no special
preparation, pregnancy is contraindicated
Intra-test: IV injection, Waiting period of 2
hours before X-ray, Fluids allowed, Supine
position for scanning
Post-test: Increase fluid intake to flush out
radioactive material
DXA- Dual-energy XRAY absorptiometry
Assesses bone density to diagnose
osteoporosis
Uses LOW dose radiation to measure
bone density. Painless procedure, non-
invasive, no special preparation. Advise to
remove jewelry
PAIN
These can be related to joint inflammation,
traction, surgical intervention
1. Assess patient’s perception of pain
2. Instruct patient alternative pain
management like meditation, heat and
cold application, TENS and guided
imagery
3. Administer analgesics as prescribed
Usually NSAIDS
Meperidine can be given for severe pain
4. Assess the effectiveness of pain
measures
IMPAIRED PHYSICAL MOBILITY
1. Instruct patient to perform range of
motion exercises, either passive or active
2. Provide support in ambulation with
assistive devices
3. Turn and change position every 2 hours
4. Encourage mobility for a short period
and provide positive reinforcements for
small accomplishments
Use the trapeze
1. Assess functional levels of the patient
2. Provide support for feeding problems
Place patient in Fowler’s position
Provide assistive device and supervise
mealtime
Offer finger foods that can be handled by
patient
Keep suction equipment ready
3. Assist patient with difficulty bathing and
hygiene
Assist with bath only when patient has
difficulty
Provide ample time for patient to finish activity
Traction
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
Traction: General principles
1. ALWAYS ensure that the weights hang
freely and do not touch the floor
2. NEVER remove the weights
3. Maintain proper body alignment
4. Ensure that the pulleys and ropes are
properly functioning and fastened by tying
square knot
Traction: General principles
5. Observe and prevent foot drop
Provide foot plate
6. Observe for DVT, skin irritation and
breakdown
7. Provide pin care for clients in skeletal
traction- use of hydrogen peroxide
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
CAST
Immobilizing tool made of plaster of Paris or
fiberglass
Provides immobilization of the fracture
CAST: types
1. Long arm, Short arm, Short leg, Long
leg, Spica , Body cast
Plaster of Paris
Drying takes 1-3 days
If dry, it is SHINY, WHITE, hard and resistant
Fiberglass
Lightweight and dries in 20-30 minutes
Water resistant
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
CAST: General Nursing Care
1. Allow the cast to air dry (usually 24-72
hours)
2. Handle a wet cast with the PALMS not the
fingertips
3. Keep the casted extremity ELEVATED
using a pillow
4. Turn the extremity for equal drying. DO
NOT USE DRYER for plaster cast
Encourage mobility and range of motion
exercises
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
CAST: General Nursing Care
Hot spots occurring along the cast may
indicate infection under the cast
Osteoporosis
A disease of the bone characterized
by a decrease in the bone mass and
density with a change in bone
structure
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
Osteoporosis: TYPES
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
3. Diet- caffeine, alcohol, low Ca and
Vit D
4. Post-menopausal
5. Genetics- caucasian and asian
6. Immobility
ASSESSMENT FINDINGS
1. Low stature
2. Fracture Femur
3. Bone pain
LABORATORY FINDINGS
1. DEXA-scan
Provides information about bone
mineral density
T-score is at least 2.5 SD below the
young adult mean value
2. X-ray studies
Medical management of Osteoporosis
1. Diet therapy with calcium and
Vitamin D
2. Hormone replacement therapy
3. Biphosphonates- Alendronate,
risedronate produce increased bone
mass by inhibiting the OSTEOCLAST
4. Moderate weight bearing exercises
5. Management of fractures
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 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 back
muscles. Heat application may provide
comfort. Encourage good posture and
body mechanics .Instruct to avoid twisting
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. 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 cause.
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 9-12 y.o.
Systemic JRA: fever, salmon pink rash,
five or more joints, anorexia, anemia, and
fatigue.
Pauci-articular: Mild joint pain and
swelling, iridocyclyitis, less than 4 joints,
very good prognosis
POlyarthritis: Moming joint and stiffness
and fever. Weight bearing joints, five or
more joints, poor prognosis
JRA: Symptoms may decrease as child
enters adulthood. With periods of
remissions and exacerbation.
Medical Management: Aspirin and
NSAIDS - mainstay treatment; slow acting
anti rheumatic drugs, corticosteroids
Nsg Management: Encourage normal
performance of ADL; Assist child in ROM
exercises; Administer Medications; encourage
social and emotional development.
Nsg Management: during acute attact: splint
the joints. Neutral positioning, Warm or cold
packs.
Osteoarthritis: the most common form of
degenerative joint disorder
Osteoarthritis: Patho: Injury, genetic, obesity,
advanced age--> stimulate the chondrocytes
to release chemicals-> chemicals will cause
cartilage degeneration reactive inflammation
of the synovial lining and bone stiffening
Risk factors: Increased age, obesity,
repetitive use of joints with previous joint
damage, anatomical deformity, genetic
susceptibility
Assessment Findings: joint pain, joint
stiffness, functional joint impairment limitation.
The joint involvement is assymetrical. This is
not systemic, there is no fever, no severe
swelling. Atrophy of unused muscles. Usual
joint are the weight bearing joints.
Joint Pain: caused by inflamed cartilage and
synovium, stretching of the joint capsule.
irritation of nerve endings.
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.
Dx Findings: 1. X-ray: narrowing of the joint
space, loss of cartilage, osteophytes. 2. Blood
tests will show no evidence of systemic
inflammation and are not useful.
Medical Management: 1. Weight reduction. 2.
Use of splinting devices to support joints. 3.
Occupational and physical therapy. 4.
Pharmacologic management: use of
paracetamol, nsaids, use of glucosamine and
chondroitin; topical analgesics, intra-articular
to decrease inflammation
Nsg Intervention: 1. Provide relief of Pain:
Administer prescribed analgesics; Application
of heat modalities. ICE packs may be used in
the early acute stage. Plan daily activitites
when pain is less severe. Pain meds before
exercising. 2. Advise pt to reduce weight:
aerobic exercise and walking. 3. Administer
prescribed meds: NSAIDS. 4. Position the
client to prevent flexion deformity: Use of foot
board, splints, wedges, and pillows.
Rheumatoid Arthritis: A type of chronic
systemic inflammatory arthritis and
connective tissue disorder affecting more
women ages 35-45 than men.
Factors: Genetics: autoimmune connective
tissue disorders. Fatigue, emotional stress,
cold, infection.
Patho: 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.
Assessment: Pain; Joint Swelling and stiffness:
symmetrical, bilateral; Warthm, erythema and
lack of function; Fever, weight loss, anemia,
fatigue; Palpation of joint reveals spongy
tissues; hesitancy in joint movement.
Assessment Findings: Joint involvement is
symmetrical and bilateral: characteristically
beginning in the hands, wrists, and feet. Joint
stiffness occurs early morning last more than
30 minutes, not relieved by movement,
dimishes 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 the subcutaneous tissues.
Dx test: 1. xray shows bony erosion. Blood
studies reveal positive rheumatoid factor,
elevated ESR and CRP and anti nuclear
antibody. Arthrocentesis shows synovial joint
that is cloudy, milky, or dark yellow containing
numerous WBC and inflammatory proteins.
Medical ManagementL: Therapeutic dose of
NSAIDS and Aspirin to reduce inflammation.
Chemotherapy with methotrexate,
antimalarials, gold therapy, and steroids. For
advanced cases - arthroplasty, synovectomy.
Nutritional therapy.
Gold therapy: IM or Oral preparation. takes
severals months 3-6 months before effects can
be seen. Can damage the kidney and causes
bone marrow depression.
Nsg Management:
1. Relieve pain and discomfort: use
splints to immobilize the affected
extremity during acute stage of the
disease and inflammation to reduce
deformity. Administer prescribed
medications. Suggest application of
Cold packs during the acute phase of
pain, then Heat application as the
inflammation subsides.
2. Decrease patient fatigue: schedule
activity when pain is less severe,
provide adequate periods of rests.
3. Promote restorative sleep.
4. Increase pt mobility: advise proper
 posture and body
mechanics. support joint in
function position. advise
Active ROM.
5. Provide Diet therapy: pts
experiences anorexia,
nausea and weight loss.
Regular diet with caloric
restrictions because steroids
may decrease appetite.
Supplements of vitamins,
iron, and proteins.
6. Increase Mobility and
prevent deformity: lie flat on
a firm mattress. Lie prone
several times to prevent HIp
flexion contractures. Use on
pillow under the head
because of risk of dorsal
kyphosis. No pillow under
the joints because this
promotes flexion
contractures.
Hot application: use to relieve joint
stiffness, pain and muscle spasm.
after acute attacks.
COld: use to control inflammation and
pain. Acute attacks.
RA: onset is early, chronic systemic
disease, involves the synovium,
involved joints are symmetrical-
fingers, cervical spine; malaise, fever,
anemia.
OA: onset is late. degenerative
disease. involves the cartilages.
involved joints are unilateral-weight
bearing knee, hips, spine. no other
systemic s/sx
Gouty arthritis: A systemic disease
caused by deposition of uric acid
crystals in the joint and body tissues.
Causes: 1. primary gout: disorder of
purine metabolis. 2. Secondary gout:
excessive uric acid in the blood like
leukemia.
Assessment" Fever low grade
occasionaly. Pain on the knees,
fingers, ankles, toes. Joints stiff and
deformed, and tender to touch. SKIN
appears red, shiny, swollen and hot
skin over affected joints. Tophi
deposits - urate leaking (advanced)
Other: racing heart, chills, malaise,
and tendon inflammation.
Assessment: 1. Severe pain in the
involved joints initially the big toel. 2.
Swelling and inflammation of the joint.
3. TOPHI - yellowish-whitish irregular
deposits in the skin that break open and
reveal a gritty appearance. 4. PODAGRA-
a big toe. 5. Fever, malaise. 6. Body
weakness and headache. 7. Renal stones.
Dx tests: Elevated levels of uric acid in the
blood. Uric acid stones in the kidneys.
Positive urate crystals in the synovial fluid.
Medical Management: 1. Allupurinol - take
it with food. Rash signifies allergic
reaction. 2. Colchicine: for acute attack. 3.
Probenecid: for uric acid excretion in the
kidney.
Nsg Intervention. 1. Provide a diet with
Low Purine: avoid organ meats, age and
processed foods. Strict dietary restrictions
is not necessary. 2. Encourage an
increased fluid intake (2-3L/day) to prevent
stone formation. 3. Instruct the pt 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 gouty meds and
analgesics.
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.
Types: 1. Complete: involves a break
across the entire cross section. 2.
Incomplete fracture: the break occurs
through only a part of the cross-section.
1. Comminuted: a fracture that involves
production of several bone fragments. 2.
Simple fracture: a fracture that involves
break of bone into two parts or one.
Assessment: Pain or tenderness over the
involved area, loss of function, deformity,
shortening, crepitus, swelling, and
discoloration.
PAIN: continuous and increases in
severity. Muscle spasm accompanies the
fracture is a reaction of the body to
immobilize the fractured bone. 2. Loss of
function: abnormal movement and pain
can result to this manifestation. 3.
Deformity: displacement, angulation or
rotation of fragments causes deformity. 4.
Crepitus: a grating sensation produced
when the bone fragments rub each other.
Emergency Management of Fracture: 1.
Immobilize any suspected fracture. 2.
Support the extremity above and below when Assessment: 1. Pain: deep, throbbing and
moving the affected part from a vehicle. 3. unrelieved by pain by opoiod. Pain is due to
Suggested temporary splints: hard board, reduction in the size of the muscle
stick, rolled sheets. 4. Apply sling if forearm compartment by tight cast. Pain is due to
fracture is suspected or the suspected increased mass in the compartment by edema,
fractured arm maybe bandaged to the chest. swelliung or hemorrhage.
5. Open fracture is managed by covering a
clean / sterile gauze to prevent contamination. Medical and Nsg Management: 1. Assess
6. Do not attempt to reduce the fracture. \ frequently the neurovascular status of the
casted extremity. 2. Elevate the extremity
Medical Management: 1. Reduction of above the level of the heart. 3. Assist in cast
fracture either open or closed, immobilization removal and fasciotomy.
and Restoration of function. 2. Antibiotics,
muscle relaxants and pain medications. Strains: excessive stretching of a muscles or
tendon.
For Closed Fracture: 1. Assist in reduction
and immobilization. 2. Administer pain Nsg Management: immobilize the affected
medication and muscle relaxants. 3. Teach part. Apply cold packs initially then heat packs.
patient to care for the cast. 4. Teach pt about Limit joint activity. administer NSAIDS and
potential complication of fracture and to report muscle relaxants.
infection, poor alignment and continuous pain.
Sprains: excessive stretching of the ligaments
For Open Fracture: 1. Prevent wound and
bone infection. Administer prescribed nsg management: immobilize extremity and
antibiotics. Administer tetanus prophylaxis. advise rest. Apply cold packs initialy and heat
Assist in serial wound debridement. 2. packs. Compression bandage may be applied
Elevate the extremity to prevent edema to relieve edema. Assist in cast application.
formation. 3. Administer care of traction and Administer NSAIDS.
cast.
Early complication: shock, fat embolism,
compartment syndrome, infection, dvt.
Late complication: 1. Delayed union,
avascular necrosis, delayed reaction to
fixation devices, complex regional syndrome.
Fat Embolism: occurs usually in fractures of
the long bones. Fat globules may move into
the blood stream because the marrow
pressure is greater than capillary pressure.
Fat globules occlude the small blood vessels
of the lungs, brain, kidneys, and other organs.
Onset is rapid, within 24-72 hours
Assessment findings: sudden dyspnea and
respiratory distress, tachycardia, chest pain,
crackles, wheezes and cough, petechial
rashes over the chest, axilla, and hard palate.
Nsg management: 1. Support the respiratoty
function. Respiratory failure is the most
common cause of death. Admister o2 in high
concentration. Prepare for possible intubation
and ventilator support. 2. Administer drugs:
corticosteroids, dopamine. and morphine. 3,
Institue preventive measures: immediate
immobilization of fracture, minimal fracture
manipulation. adequate support for fractured
bone during turning and positioning. Maintain
adequate hydration and electrolyte balance.
Compartment Syndrome: A complication that
develops when tissue perfusion in the
muscles is less than required for tissue
variability.