Nurse Licensure Examination Review

The musculo-skeletal system consists of the muscles, tendons, bones and cartilage together with the joints The primary function of which is to produce skeletal movements

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

Bands of fibrous connective tissue that tie bones to muscles

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

Variously classified according to shape, location and size Functions 1. Locomotion 2. Protection 3. Support and lever 4. Blood production 5. Mineral deposition

The part of the Skeleton where two or more bones are connected

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

Sac containing fluid that are located around the joints to prevent friction

 The

nurse usually evaluates this small part of the over-all assessment and concentrates on the patients posture, body symmetry, gait and muscle and joint function

1. HISTORY 2. Physical Examination

Perform a head to toe assessment Nurses need to inspect and palpate The special procedure is the assessment of joint and muscle movement Usually, a tape measure and a protractor are the only instruments

Gait Posture Muscular palpation Joint palpation Range of motion Muscle strength

LABORATORY PROCEDURES 1. BONE MARROW ASPIRATION

Usually involves aspiration of the marrow to diagnose diseases like leukemia, aplastic anemia Usual site is the sternum and iliac crest Pre-test: Consent Intratest: Needle puncture may be painful Post-test: maintain pressure dressing and watch out for bleeding

LABORATORY PROCEDURES 2. Arthroscopy

A direct visualization of the joint cavity Pre-test: consent, explanation of procedure, NPO Intra-test: Sedative, Anesthesia, incision will be made Post-test: maintain dressing, ambulation as soon as awake, mild soreness of joint for 2 days, joint rest for a few days, ice application to relieve discomfort

LABORATORY PROCEDURES 3. BONE SCAN Imaging study with the use of a contrast radioactive material Pre-test: Painless procedure, IV radioisotope is used, no special preparation, pregnancy is

contraindicated Intra-test: IV injection, Waiting period of 2 hours

before X-ray, Fluids allowed, Supine position for scanning Post-test: Increase fluid intake to flush out radioactive material

LABORATORY PROCEDURES 4. DXA- Dual-energy XRAY absorptiometry Assesses bone density to diagnose osteoporosis Uses LOW dose radiation to measure bone density Painless procedure, non-invasive, no special preparation Advise to remove jewelry

The Nursing Management

PAIN These can be related to joint inflammation, traction, surgical intervention 1. Assess patients perception of pain 2. Instruct patient alternative pain management like meditation, heat and cold application, TENS and guided imagery

PAIN 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

SELF-CARE DEFICITS 1. Assess functional levels of the patient 2. Provide support for feeding problems
Place patient in Fowlers position Provide assistive device and supervise mealtime Offer finger foods that can be handled by patient Keep suction equipment ready

SELF-CARE DEFICITS 3. Assist patient with difficulty bathing and hygiene

Assist with bath only when patient has difficulty Provide ample time for patient to finish activity

 Traction
Cast

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
Skeletal traction

Pulling force exerted on bones to reduce or immobilize fractures, reduce muscle spasm, correct or prevent 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

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

CAST: types 1. Long arm 2. Short arm 3. Spica

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: General Nursing Care 1. Allow the cast to 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

CAST: General Nursing Care 5. Petal the edges of the cast to prevent crumbling of the edges 6. Examine the skin for pressure areas and Regularly check the pulses and skin

CAST: General Nursing Care 7. Instruct the patient not to place sticks or small objects inside the cast 8. Monitor for the following:

pain, swelling, discoloration, coolness, tingling or lack of sensation and diminished pulses

Nursing management

Osteoporosis A disease of the bone characterized by a decrease in the bone mass and density with a change in bone structure

Osteoporosis: Pathophysiology Normal homeostatic bone turnover is altered rate of bone RESORPTION is greater than bone FORMATION reduction in total bone mass reduction in bone mineral density prone to FRACTURE

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

Osteoporosis Nursing Interventions Take calcium supplements with meals Take alendronate with an EMPTY stomach with water Instruct on intake of Hormonal replacement

Osteoporosis Nursing Interventions 2. Relieve the pain

Instruct the patient to rest on a firm mattress

Suggest that knee flexion will cause relaxation of back muscles Heat application may provide comfort Encourage good posture and body mechanics Instruct to avoid twisting and heavy lifting

Osteoporosis Nursing Interventions 3. Improve bowel elimination Constipation is a problem of calcium supplements and immobility Advise intake of HIGH fiber diet and increased fluids

Osteoporosis Nursing Interventions 4. Prevent injury Instruct to use isometric exercise to strengthen the trunk muscles AVOID sudden jarring, bending and strenuous lifting Provide a safe environment

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 Pauci-articular

FEVER MILD joint pain and swelling

Polyarticular
Morning joint stiffness and fever

Salmon-pink rash Five or more joints

IRIDOCYCLITIS

Less than 4 joints

Anorexia, Very Good anemia, fatigue prognosis

Weight Bearing joints Five or more joints 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-acting anti-rheumatic drugs 3. Corticosteroids

Nursing Management 1. Encourage normal performance of daily activities 2. Assist child in ROM exercises 3. Administer medications 4. Encourage social and emotional development

Nursing Management During acute attack:

SPLINT the joints NEUTRAL positioning Warm or cold packs

OSTEOARTHRITIS The most common form of degenerative joint disorder

OSTEOARTHRITIS Chronic, NON-systemic disorder of joints

OSTEOARTHRITIS: Pathophysiology Injury, genetic, Previous joint damage, Obesity, Advanced age Stimulate the chondrocytes to release chemicals

chemicals will cause cartilage degeneration, reactive inflammation of the synovial lining and bone stiffening

OSTEOARTHRITIS: Risk factors 1. Increased age 2. Obesity 3. Repetitive use of joints with previous joint damage 4. Anatomical deformity 5. genetic susceptibility

OSTEOARTHRITIS: Assessment findings

1. Joint pain 2. Joint stiffness 3. Functional joint impairment limitation The joint involvement is ASYMMETRICAL This is not systemic, there is no FEVER, no severe swelling Atrophy of unused muscles Usual joint are the WEIGHT bearing joints

OSTEOARTHRITIS: Assessment findings 1. Joint pain Caused by

Inflamed synovium Stretching of the joint capsule Irritation of nerve endings

OSTEOARTHRITIS: Assessment findings 2. Stiffness

commonly occurs in the morning after awakening Lasts only for less than 30 minutes DECREASES with movement Crepitation may be elicited

OSTEOARTHRITIS: Diagnostic findings 1. X-ray Narrowing of joint space Loss of cartilage Osteophytes 2. Blood tests will show no evidence of systemic inflammation and are not useful

OSTEOARTHRITIS: Medical management 1. Weight reduction 2. Use of splinting devices to support joints 3. Occupational and physical therapy 4. Pharmacologic management
Use of PARACETAMOL, NSAIDS Use of Glucosamine and chondroitin Topical analgesics Intra-articular steroids to decrease inflam

OSTEOARTHRITIS: Nursing Interventions 1. Provide relief of PAIN

Administer prescribed analgesics Application of heat modalities. ICE PACKS may

be used in the early acute stage!!! Plan daily activities when pain is less severe Pain meds before exercising

OSTEOARTHRITIS: Nursing Interventions 2. Advise patient to reduce weight

Aerobic exercise Walking

3. Administer prescribed medications

NSAIDS

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

FACTORS: Genetic Auto-immune connective tissue disorders Fatigue, emotional stress, cold, infection

Pathophysiology

Immune reaction in the synovium attracts neutrophils releases enzymes breakdown of collagen irritates the synovial liningcausing synovial inflammation edema and pannus formation
and joint erosions and swelling

ASSESSMENT FINDINGS 1. PAIN 2. Joint swelling and stiffness-

SYMMETRICAL, Bilateral 3. Warmth, erythema and lack of function 4. Fever, weight loss, anemia, fatigue

5. Palpation of join reveals spongy tissue 6. Hesitancy in joint movement

ASSESSMENT FINDINGS Joint involvement is SYMMETRICAL and

BILATERAL

Characteristically beginning in the hands, wrist and feet Joint STIFFNESS occurs early morning, lasts

MORE than 30 minutes, not relieved by movement, diminishes as the day progresses

ASSESSMENT FINDINGS Joints are swollen and warm Painful when moved Deformities are common in the hands and feet causing misalignment

Rheumatoid nodules may be found in the subcutaneous tissues

Diagnostic test 1. X-ray

2. Blood studies reveal (+) rheumatoid

Shows bony erosion

factor, elevated ESR and CRP and ANTInuclear antibody

3. 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, antimalarials, gold therapy and steroid 3. For advanced cases- arthroplasty, synovectomy 4. Nutritional therapy

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

Nursing MANAGEMENT 1. Relieve pain and discomfort

USE splints to immobilize the affected extremity during acute stage of the disease and inflammation to REDUCE DEFORMITY
Administer prescribed medications Suggest application of COLD packs

during the acute phase of pain, then HEAT application as the inflammation subsides

Nursing MANAGEMENT 2. Decrease patient fatigue Schedule activity when pain is less severe Provide adequate periods of rests 3. Promote restorative sleep

Nursing Management 4. Increase patient mobility Advise proper posture and body mechanics Support joint in functional position Advise ACTIVE ROME

Nursing Management 5. Provide Diet therapy Patients experience anorexia, nausea and weight loss
Regular

diet with caloric restrictions because steroids may increase appetite Supplements of vitamins, iron and PROTEIN

6. Increase Mobility and prevent deformity:

Lie FLAT on a firm mattress Lie PRONE several times to prevent HIP FLEXION contracture Use one pillow under the head because of risk of dorsal kyphosis NO Pillow under the joints because this promotes flexion contractures

HOT

Cold

Use to RELIEVE joint stiffness, pain and muscle spasm After acute attack

Use to control inflammation and pain ACUTE ATTACK

A systemic disease caused by deposition of uric acid crystals in the joint and body tissues CAUSES: 1. Primary gout- disorder of Purine

metabolism

2. Secondary gout- excessive uric acid in the blood like leukemia

ASSESSMENT FINDINGS 1. Severe pain in the involved joints,

initially the big toe

2. Swelling and inflammation of the joint 3. TOPHI- yellowish-whitish, irregular

deposits in the skin that break open and reveal a gritty appearance
4. PODAGRA

ASSESSMENT FINDINGS 5. Fever, malaise 6. Body weakness and headache 7. Renal stones

DIAGNOSTIC TEST Elevated levels of uric acid in the blood Uric acid stones in the kidney

Medical management 1. Allupurinol- take it WITH FOOD

Rash signifies allergic reaction

2. Colchicine
For acute attack

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 (23L/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

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

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 OF FRACTURE 1. Complete fracture

Involves a break across the entire cross-section

2. Incomplete fracture
The break occurs through only a part of the crosssection

TYPES OF FRACTURE 1. Closed fracture

The fracture that does not cause a break in the skin

2. Open fracture
The fracture that involves a break in the skin

TYPES OF FRACTURE 1. Comminuted fracture

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

ASSESSMENT FINDINGS 1. Pain Continuous and increases in severity Muscles spasm accompanies the fracture is a reaction of the body to immobilize the fractured bone

ASSESSMENT FINDINGS 2. Loss of function Abnormal movement and pain can result to this manifestation

ASSESSMENT FINDINGS 3. Deformity Displacement, angulations or rotation of the fragments Causes deformity

ASSESSMENT FINDINGS 4. Crepitus 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

EMERGENCY MANAGEMENT OF FRACTURE 5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination 6. DO NOT attempt to reduce the facture

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 alignment and continuous pain

General Nursing MANAGEMENT For OPEN FRACTURE 1. Prevent wound and bone infection Administer prescribed antibiotics Administer tetanus prophylaxis Assist in serial wound debridement 2. Elevate the extremity to prevent edema formation 3. Administer care of traction and cast

FRACTURE COMPLICATIONS Early 1. Shock 2. Fat embolism 3. Compartment syndrome 4. Infection 5. DVT

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

FRACTURE COMPLICATIONS: Fat Embolism Occurs usually in fractures of the long bones Fat globules may move into the blood stream because the marrow pressure is greater than capillary pressure Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs

FRACTURE COMPLICATIONS: Fat Embolism Onset is rapid, within 24-72 hours ASSESSMENT FINDINGS

1. Sudden dyspnea and respiratory distress

2. tachycardia 3. Chest pain 4. Crackles, wheezes and cough 5. Petechial rashes over the chest, axilla and hard palate

FRACTURE COMPLICATIONS: Fat Embolism Nursing Management 1. Support the respiratory function Respiratory failure is the most common cause of death Administer O2 in high concentration Prepare for possible intubation and ventilator support

FRACTURE COMPLICATIONS: Fat Embolism Nursing Management 2. Administer drugs Corticosteroids Dopamine Morphine

FRACTURE COMPLICATIONS: Fat Embolism Nursing Management 3. Institute preventive measures Immediate immobilization of fracture Minimal fracture manipulation Adequate support for fractured bone during turning and positioning Maintain adequate hydration and electrolyte balance

Early complication: Compartment syndrome A complication that develops when tissue perfusion in the muscles is less than required for tissue viability

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 to increased mass in the compartment by edema, swelling or hemorrhage

Early complication: Compartment syndrome ASSESSMENT FINDINGS 2. Paresthesia- burning or tingling sensation 3. Numbness 4. Motor weakness 5. Pulselessness, impaired capillary refill time

and cyanotic skin

Early complication: Compartment syndrome Medical and Nursing management 1. Assess frequently the neurovascular status of the casted extremity 2. Elevate the extremity above the level of

the heart

3. Assist in cast removal and FASCIOTOMY

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

Excessive stretching of the LIGAMENTS Nursing management 1. Immobilize extremity and advise rest 2. Apply cold packs initially then heat packs 3. Compression bandage may be applied to relieve edema 4. Assist in cast application 5. Administer NSAIDS