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  1. 1. Mulugeta Emiru (MSc in Adult Health Nursing) Mizan-Tepi University,Ethiopia 2017
  2. 2. MUSCULOSKELETAL SYSTEM 🠶Consists of the bones, muscles, ligaments, tendons, and cartilage together with the joints. 🠶Human skeleton has 206 bones 🠶Bone growth and metabolism is affected by vit D, calcium and phosphorous, calcitonin, growth hormone, estrogens, testosterone, parathyroid, and glucocorticoids.
  3. 3. Figure 41-1 Bones of the human skeleton. Axial Skeleton Appendicular Skeleton
  4. 4. Figure 41-2 Classification of bones by shape.
  5. 5. Functions 1. Supports soft tissue and provides attachment for skeletal muscles 2. Assists in mov’t, along with skeletal muscles 3. Protects internal organs 4. Stores and releases minerals 5. stores fats 6. produces blood cells
  6. 6. Bone Cells 🠶The three types of bone cells are 🠶Osteoblasts –bone forming cells by secreting bone matrix. 🠶Osteocytes –bone maintaining cells, matured osteoblasts. 🠶Osteoclasts –bone resorbing cells 🠶 Bones that are in use, and are therefore subjected to stress, increase their osteoblastic activity to increase ossification. 🠶 Bones that are inactive undergo increased osteoclast activity and bone resorption.
  7. 7. Tendons 🠶 connect bone to muscles, and aids movement when muscles contract. Ligaments 🠶connect bone to bone 🠶 Provide joint stability and strength Joints (Articulations) 🠶Area where two or more bones meet 🠶 Holds skeleton together while allowing body to move
  8. 8. Types of joints 🠶Fibrous - Immovable 🠶Cartilaginous - Slightly movable 🠶Synovial - Freely mobile Synovial Joints 🠶Found at all limb articulations 🠶 Surface covered with cartilage 🠶 Joint cavity covered with tough fibrous capsule 🠶 Cavity lined with synovial membrane and filled with synovial fluid.
  9. 9. Bursa 🠶A small sac filled with synovial fluid. 🠶Inflammation of these sacs is called bursitis
  10. 10. Nursing Assessment 🠶Health History 🠶Assessment Data 🠶Pain, 🠶Tenderness, 🠶Tightness, and 🠶Altered sensations
  11. 11. 🠶 Posture 🠶 Gait 🠶 Bone Integrity 🠶 Joint Function 🠶 Muscle Strength & Size 🠶 Skin 🠶 Neurovascular Status Physical Assessment
  12. 12. 🠶 Inspect and palpate bone and joints for visible deformities, tenderness or pain, swelling, warmth, and ROM 🠶 Assess and compare corresponding joints 🠶 Palpate each joint for any crepitus 🠶 Never attempt to move a joint past normal ROM or past point where patient experiences pain 🠶 Bulge sign and ballottement sign used to assess for fluid in the knee joint.
  13. 13. 1. Arthrocentesis: A needle is inserted through the joint capsule and fluid is aspirated. Diagnostic: done to obtain synovial fluid Therapeutic: to remove excess fluid. 2. Arthroscopy: is the internal inspection of a joint using an instrument called an arthroscope. Arthroscope is a thin fiber-optic viewing instrument that is inserted into the joint through a small incision in the knee. Diagnostic Tests
  14. 14. Arthroscopy
  15. 15. Nsg mgt. After the procedure, 🠶Leg is elevated without flexing the knee. 🠶 A cold pack is placed over the bulky dressing covering the site where the arthroscope was inserted. 🠶Administer analgesic as necessary. 3. Dual energy x-ray absorptiometry (DEXA)- bone density examinations are done to evaluate bone mineral density (BMD) and to evaluate degree of osteoporosis.
  16. 16. 4. SKELETAL X-RAY, CT and MRI: help to identify traumatic disorders, such as fractures and dislocations, and other bone disorders, such as malignant bone lesions, joint deformities, calcification, degenerative changes, osteoporosis, and joint disease. 5. Bone Scan 🠶 Uses the intravenous injection of a radionuclide to detect the uptake of the radioactive substance by the bone. 🠶The radionuclide is taken up in areas of increased metabolism, which occur in osteosarcoma, metastatic bone disease, and osteomyelitis (bone infection).
  17. 17. 🠶 CBC- to detect infection, inflammation, or anemia. 🠶 Alkaline phosphatase (ALP)- to identify bone diseases. Increased in bone cancer, Paget’s disease, healing fractures, rheumatoid arthritis, osteomalacia. 🠶 Calcium (Ca): Decreased with lack of Ca++ and vit D intake, and malabsorption from the GIT which leads to softening of the bones (osteomalacia) and resulting pain and weakness. 🠶 Increased in bone cancer and multiple fractures. BLOOD TESTS
  18. 18. 🠶 RHEUMATOID FACTOR (RF) To diagnose rheumatoid arthritis (RA) (positive for RA) 🠶 URIC ACID To diagnose and monitor the treatment of gout.  Panic level considered > 12 mg/dl.
  19. 19. 🠶 Regardless of the type of diagnostic test, the nurse is responsible for: o explaining the procedure and any special preparation needed, o assessing for medication use that may affect the outcome of the tests, o supporting the patient during the examination as necessary, o documenting the procedures as appropriate, o ensuring the consent form is signed (if required) and o Monitoring the results of the tests.
  20. 20. The management of musculoskeletal injuries and disorders frequently includes the use of 🠶Casts 🠶T raction, 🠶Braces 🠶Splints 🠶Surgery, or a combination of these. Cast 🠶 Is a rigid external immobilizing device that is molded to the contours of the body. 🠶 It permit mobilization of the patient while restricting movement of a body part.
  21. 21. 🠶Uses 🠶To immobilize a body part in a specific position 🠶To immobilize a reduced fracture 🠶To apply uniform pressure on encased soft tissue 🠶To correct a deformity 🠶To support and stabilize weakened joints 🠶 Generally, the joints proximal and distal to the area to be immobilized are included in the cast.
  22. 22. Types of Casts 🠶 Short arm cast: Extends from below the elbow to the palmar crease and is secured around the base of the thumb. 🠶Long arm cast: Extends from the upper level of the axillary fold to the proximal palmar crease. The elbow is usually immobilized at a right angle. 🠶Short leg cast: Extends from below the knee to the base of the toes. 🠶 Long leg cast: Extends from the junction of the upper and middle third of the thigh to the base of the toes.
  23. 23. Others 🠶Body cast, Shoulder Spica cast, Hip spica cast
  24. 24. 🠶Nursing Management - Carry cast with palms of the hands when WET - Elevate with pillow support - Should be exposed to circulating air to dry - Keep clean and dry - Maintain skin integrity, observe for signs of inflammation - Neurovascular assessment meticulously and regularly - Move patient every 2 hours to relieve pressure - In turning, use of trapeze or railings can be helpful
  25. 25. Potential complicationsof cast and their mg’t Compartment Syndrome 🠶 Occurswhenthere is increased tissue pressure within a limited space that compromises the circulation and the function of the tissue within the confined area. 🠶 The patient complains of deep, throbbing, unrelenting pain, which continues to increase despite the administration of opioids and seems out of proportion to the injury. 🠶 Thelower leg is most frequently involved, but forearm is also at risk. 🠶 Pain is the hallmark sign that occurs or intensifies with passive ROM.
  26. 26. 🠶P ain can be caused by : 1.a reduction in the size of the muscle compartment because the enclosing muscle fascia istoo tight or a cast or dressing is constrictive. 2. an increase in compartment contents because of edema or hemorrhage from the fracture site. 🠶Within 4 to 6 hr. after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless.
  27. 27. 🠶Injury to theperoneal nerve asa resultof pressure is a causeof foot drop(the inability to maintain thefoot ina normally flexed position). Consequently,the patient drags the foot when ambulating.
  28. 28. Management: T o relieve the pressure, the cast must be bivalved while maintaining alignment, and theextremity mustbe elevated nohigher than heart level. 🠶 If pressure is not relieved and circulation is not restored, fasciotomy may be necessary. 🠶 Thenurserecords neurovascularresponsesand promptly reports changes to the physician.
  29. 29. Pressure Ulcers 🠶 Pressureof thecastonsoft tissuesmaycausetissueanoxia and ulcers. Symptoms 🠶pain and tightness 🠶Warmarea on the cast 🠶Drainage stain the cast and emit an odor
  30. 30. Management: Toinspect the pressure area, the physician may bivalve the cast or cut an opening (window) in the cast. • If the physician elects to create a window to inspect the pressure site, a portion of the cast is cut out. • The portion of the cast is replaced and held in place by an elastic compression dressing or tape. • This prevents the underlying tissue from swelling through the window and creating pressure areas around its margins.
  31. 31. Disuse Syndrome 🠶 Immobilization ina castor splint can cause muscle atrophy and loss of strength 🠶 While ina cast,thepatient needs to learn to tense or contract muscles (e.g., isometric muscle contraction) without moving the part. 🠶 This helps to reduce muscle atrophy and maintain muscle strength. 🠶After removal of a cast, the formerly immobilized body part is weak from disuse, is stiff, and may appear atrophied.
  32. 32. 🠶Support is needed when the cast is removed. 🠶 Theskinneedsto be washedgently and lubricated with an emollient lotion. 🠶The nurse and physical therapist teach the patient to resume activities gradually within the prescribed therapeutic regimen. 🠶 Exercisesprescribed to help thepatient regain joint motionare explained and demonstrated.
  33. 33. Traction 🠶 Traction is the application of a pulling force to part of the body. T raction is used: o to minimize muscle spasms; o to reduce, align, and immobilize fractures; o to reduce deformity; and o to increase space between opposing surfaces. 🠶 Fortraction to achieve its purpose,it requires countertraction, a force opposite to themechanicalpull usually issupplied by the client’sown weight.
  34. 34. Types of traction 🠶 Straight or runningtraction: applies thepulling force ina straight line with the body part resting on the bed. 🠶 Balanced suspension traction: supports theaffected extremity off the bed and allows for some patient movement without disruption of the line of pull. Lines of pull are known as the vectors of force.
  35. 35. 🠶 Skin traction: Is an indirect traction which is applied on the skin. 🠶Usedto control musclespasmsand to immobilize an area before surgery. 🠶is not used for long period of time 🠶 Amountof weight applied mustnot exceed 2 to 3.5 kg for extremities. Nursing Interventions 🠶 Monitor and manage potential complications 🠶Skin Breakdown 🠶Nerve Damage 🠶Circulatory Impairment
  36. 36. Skeletal Traction 🠶 Applied directly to the bone by use of a metal pin or wire that is inserted through the bone distal to the fracture. 🠶 Used occasionally to treat fractures of the femur, the tibia, and the cervical spine. 🠶 Used for long period of time and used to apply high weight. 🠶 Skeletal traction frequently uses 7 to 12 kg to achieve the therapeutic effect (usually 10% the patient’s body weight). 🠶 The weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture, dislocation and to promote healing. 🠶 Manual traction: traction temporarily applied with the hands.
  37. 37. Nursing Interventions 🠶 Maintaining effective traction 🠶Preventing skin breakdown 🠶Monitoring neurovascular status 🠶Providing pin site care 🠶Promoting exercise 🠶 Monitor and manage immobility-related complications pressure ulcers, atelectasis, pneumonia, constipation, loss of appetite, urinary stasis, urinary tract infections, and venous thromboembolism formation.
  38. 38. Management of patients with Musculoskeletal Trauma
  39. 39. 1. Contusions, Strains, and Sprains Contusions 🠶 Is a soft tissue injury produced by blunt force, such as a blow, kick, or fall. 🠶 Many small blood vessels rupture and bleed into soft tissues (ecchymosis, or bruising). 🠶A hematoma develops when the bleeding is sufficient to cause an appreciable collection of blood. 🠶 Local symptoms includes pain, swelling, and discoloration 🠶Most contusions resolve in 1 to 2 weeks.
  40. 40. Strains 🠶Is a “muscle pull” caused by overuse, overstretching, or excessive stress. 🠶 Strains are microscopic, incomplete muscle tears with some bleeding into the tissue. 🠶 The patient experiences soreness or sudden pain, with local tenderness on muscle use.
  41. 41. Sprains 🠶 Is an injury to the ligaments surrounding a joint that is caused by a wrenching or twisting motion. 🠶 The function of a ligament is to maintain stability while permitting mobility. A torn ligament loses its stabilizing ability. 🠶 Blood vessels rupture and edema occurs; the joint is tender, and movement of the joint becomes painful.
  42. 42. 🠶 The degree of disability and pain increases during the first 2 to 3 hours after the injury because of the associated swelling and bleeding. 🠶 An x-ray should be obtained to rule out bone injury. 🠶 Avulsion fracture (in which a bone fragmented is pulled away by a ligament or tendon) may be associated with a sprain.
  43. 43. Management 🠶 Treatment of contusions, strains, and sprains includes RICE 🠶 Rest prevents additional injury and promote healing. 🠶 Ice applied intermittently for 20 to 30 minutes during the first 24 to 48 hours after injury produces vasoconstriction, which decreases bleeding, edema, and discomfort. 🠶 Care must be taken to avoid skin and tissue damage from excessive cold. 🠶 After 24 to 48 hours of injury heat may be applied intermittently (for 15 to 30 minutes, QID) to relieve muscle spasm, promote vasodilation, absorption, and repair.
  44. 44. 🠶 An elastic compression bandage controls bleeding, reduces edema, and provides support for the injured tissues. 🠶 Elevation controls the swelling. 🠶 If the sprain is severe (torn muscle fibers and disrupted ligaments), surgical repair or cast immobilization may be necessary so that the joint will not lose its stability. 🠶 The neurovascular status (circulation, motion, sensation) of the injured extremity is monitored frequently.
  45. 45. 2. Joint Dislocations 🠶 A dislocation of a joint is a condition in which the articular surfaces of the bones forming the joint are no longer in anatomic contact. 🠶The bones are literally “out of joint.” 🠶 A subluxation is a partial dislocation of the articulating surfaces. 🠶 Dislocations may be congenital, spontaneous or pathologic or traumatic.
  46. 46. 🠶 Traumatic dislocations are orthopedic emergencies because the associated joint structures, blood supply, and nerves are distorted and severely stressed. 🠶 If the dislocation is not treated promptly, avascular necrosis (AVN) (tissue death due to anoxia and diminished blood supply) and nerve palsy may occur.
  47. 47. 🠶Signs and symptoms of dislocation are: o acute pain, o change in positioning of the joint, o Shortening of the extremity, o loss of normal mobility, and o deformity 🠶X-rays confirm the diagnosis and demonstrate any associated fracture.
  48. 48. Medical Management ⦁ The affected joint needs to be immobilized while the patient is transported to the hospital. ⦁ Analgesia, muscle relaxants, and possibly anesthesia are used to facilitate closed reduction. ⦁ The dislocation is promptly reduced (i.e. displaced parts are brought into normal position) to preserve joint function. ⦁ The joint is immobilized by bandages, splints, casts, or traction and is maintained in a stable position. ⦁ Neurovascular status is monitored.
  49. 49. ⦁ After reduction, if the joint is stable, gentle, progressive, active and passive movement is begun to preserve range of motion (ROM) and restore strength. ⦁ The joint is supported between exercise sessions. Nursing Management 🠶Providing comfort, 🠶Evaluating the patient’s neurovascular status, and 🠶 Teaching the patient how to manage the immobilizing devices and how to protect the joint from reinjury.
  50. 50. 3. Fractures 🠶Is a break in the continuity of bone when it is subjected to stress greater than it can absorb. 🠶causes • A metabolic bone disease /pathological such as osteoporosis • An endocrine disorder E.g. Hyperparathyroidism • Direct force/ trauma or crushing force • Sudden twisting motion • Powerful muscle contraction pulls against the bone • Bone tumors, which weaken the bone structure
  51. 51. 🠶 When the bone is broken, adjacent structures are also affected, 🠶 Resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels.
  52. 52. Types of Fractures ⦁ Based on cross-section of the bone involved: 1. Complete fracture: involves a break across the entire cross-section of the bone and is frequently displaced (removed from normal position). 2. Incomplete fracture (eg, greenstick fracture): the break occurs through only part of the cross-section of the bone. 3. Comminuted fracture: is one that produces several bone fragments.
  53. 53. ⦁ Based on involvement of the skin: 1. Closed (simple fracture): does not cause a break in the skin. 2. Open (compound, or complex, fracture): the skin or mucous membrane wound extends to the fractured bone. Open fractures are graded according to the following criteria: A. Grade I: is a clean wound less than 1 cm long. B. Grade II: is a larger wound without extensive soft tissue damage. C. Grade III: is highly contaminated, has extensive soft tissue damage, and is the most severe.
  54. 54. Clinical Manifestations ⦁ Pain ⦁ loss of function ⦁ Deformity ⦁ shortening of the extremity ⦁ crepitus (a grating sensation palpation) ⦁ swelling and discoloration. ⦁ False movement ⦁ Note: all of these clinical manifestations may not present in every fracture.
  55. 55. Emergency Management of Fractures 🠶 Immediately after injury, whenever a fracture is suspected, immobilize the body part before the patient is moved. 🠶Splints are applied for immobilization. 🠶 If an injured patient must be removed from a vehicle before splints can be applied, the extremity is supported above and below the fracture site to prevent rotation as well as angular motion. 🠶 With an open fracture, the wound is covered with a clean (sterile) dressing to prevent contamination of deeper tissues. 🠶Do not attempt to reduce the fracture, even if one of the bone fragments is protruding through the wound.
  56. 56. Medical and surgical Management 1. REDUCTION ⦁ Reduction refers to restoration of the fracture fragments to anatomic alignment and rotation. 1. Closed Reduction: closed reduction is accomplished by bringing the bone fragments into apposition (ie, placing the ends in contact) through manipulation and manual traction. 2. Open Reduction: Through a surgical approach, the fragments are reduced. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position.
  57. 57. 2. IMMOBILIZATION 🠶After the fracture has been reduced, the bone fragments must be immobilized, or held in correct position and alignment, until union occurs. 🠶Immobilization may be accomplished by external or internal fixation.
  58. 58. 3. MAINTAINING AND RESTORING FUNCTION ⦁ Swelling is controlled by elevating the injured extremity and applying ice as prescribed. ⦁ Neurovascular status (circulation, movement, sensation) is monitored, and the orthopedic surgeon is notified immediately if signs of neurovascular compromise are identified. ⦁ Isometric and muscle-setting exercises are encouraged to minimize disuse atrophy and to promote circulation.
  59. 59. Nursing Management 🠶 Instruct the patient regarding the proper methods to control edema and pain 🠶 Teach exercises to maintain the health of unaffected muscles and how to use assistive devices such as crutches, walkers. 🠶 Teach about selfcare, medication information, and monitoring for potential complications. 🠶 In an open fracture, there is a risk for osteomyelitis, tetanus, and gas gangrene. Intravenous antibiotics are administered immediately upon the patient’s arrival in the hospital along with tetanus toxoid if needed.
  60. 60. Complications of Fracture 🠶 Complications of fractures fall into two categories 🠶Early complications include: 🠶Shock, 🠶Fat embolism, 🠶Compartment syndrome, 🠶Deep vein thrombosis, 🠶Thromboembolism (pulmonary embolism), 🠶Disseminated intravascular coagulopathy (DIC), and 🠶Infection.
  61. 61. 🠶Delayed complications include: 🠶Delayed union and nonunion, 🠶Avascular necrosis of bone, 🠶Reaction to internal fixation devices, 🠶Complex regional pain syndrome (formerly called reflex sympathetic dystrophy).
  62. 62. Stages of Bone Healing ⚫Hematoma formation within 48 to 72 hr. after injury ⚫Hematoma to granulation tissue ⚫Callus formation and Osteoblastic proliferation ⚫Bone remodeling ⚫Bone healing completed within about 6 weeks; up to 6 months in the older person
  63. 63. Amputation 🠶 Amputation- is the removal of a body part, usually an extremity. Indications 🠶 progressive peripheral vascular disease. E.g.DM 🠶 fulminating gas gangrene 🠶 Trauma / accident- (crushing injuries, burns, frostbite, explosions, ballistic injuries) 🠶 Congenital deformity 🠶 malignant tumor 🠶 Chronic uncontrollable infections - chronic osteomyelitis , osteoarthritis
  64. 64. 🠶Types of amputation 🠶open (guillotine) 🠶closed (flap amputation) open amputation 🠶 It is a type of amputation performed during emergency condition like gas gangrene or sever trauma. 🠶The skin and the bones are at equal level. 🠶 The main purpose is to save the remaining part and extremity & reserve an emergency situation. pic
  65. 65. Closed amputation 🠶 It is a planned type . 🠶 The skin and the bone are not at equal level. 🠶 Skin closure is done surgically. 🠶 Antibiotics is administered to prevent re infection levels of amputation Amputation is performed at the most distal point that will heal successfully. If it is done at a joint it is called disarticulation. pic
  66. 66. 🠶The site of amputation is determined by two factors 1. Circulation in the part 2. Functional usefulness (muscle balance to meet the requirement of the prosthesis)
  67. 67. Complications 🠶Hemorrhage 🠶Infection 🠶 Skin breakdown - irritation due to prosthesis 🠶 Stump edema- edema of amputated limb 🠶 Phantom limb pain –it is false sensation, pain that seems to come from an amputated limb as a result of severing of the peripheral nerves 🠶 Joint contracture – caused by positioning & protective flexion withdrawal pattern associated with pain.
  68. 68. Medical Management 🠶 76 The objectives of treatment: • to achieve healing of the amputation wound • to get a non tender residual limb (stump) with healthy skin for prosthesis use 🠶Healing is enhanced by: • gentle handling of the residual limb, • control of residual limb edema through rigid or soft compression dressings • the use of aseptic technique in wound care to avoid infection.
  69. 69. 🠶 A closed rigid cast dressing is frequently used: -to provide uniform compression -to support soft tissues -to control pain -to prevent joint contractures 🠶 Immediately after surgery, a sterilized residual limb sock is applied to the residual limb. 🠶 Felt pads are placed over pressure-sensitive areas. 🠶 The residual limb is wrapped with elastic POP bandages while firm, even pressure is maintained. 🠶 Care is taken not to constrict circulation.
  70. 70. 🠶 A removable rigid dressing may be placed over a soft dressing: -to control edema -to prevent joint flexion contracture -to protect the residual limb from unintentional trauma during transfer activities. 🠶 This rigid dressing is removed several days after surgery for wound inspection and is then replaced to control edema. 🠶 The dressing facilitates residual limb shaping.
  71. 71. 🠶 A soft dressing with or without compression may be used if there is: -significant wound drainage -desire of frequent inspection of the limb 🠶 An immobilizing splint may be incorporated in the dressing. 🠶 Stump (wound) hematomas are controlled with wound drainage devices to minimize infection. 🠶 Rehabilitation- help the pt to achieve the highest possible level of function & participation in ADLs.
  72. 72. Nursing Management 🠶relieving pain 🠶minimizing altered sensory perception 🠶promoting wound healing 🠶enhancing body image 🠶self-care
  73. 73. Phantom Limb Pain 🠶 Phantom limb pain is a frequent complication of amputation. 🠶 Client complains of pain at the site of the removed body part, most often shortly after surgery. 🠶 Pain is intense burning feeling, crushing sensation or cramping. 🠶 Some clients feel that the removed body part is in a distorted position.
  74. 74. Management of Phantom Pain ⚫ Phantom limb pain must be distinguished from stump pain because they are managed differently. ⚫ Recognize that this pain is real and interferes with the amputee’s activities of daily living. ⚫ Some studies have shown that opioids are not as effective for phantom limb pain as they are for residual limb pain. ⚫ Other drugs include intravenous infusion calcitonin, beta blockers, anticonvulsants, and antispasmodics.
  75. 75. Exercise After Amputation 🠶 ROM to prevent flexion contractures, particularly of the hip and knee 🠶Trapeze and overhead frame 🠶Firm mattress 🠶 Prone position every 3 to 4 hours 🠶 Elevation of lower-leg residual limb controversial
  76. 76. Metabolic Disorders 1. Osteoporosis “porous bones” 🠶 Is a metabolic bone disorder characterized by loss of bone mass, and an increased risk of fractures. 🠶Pathophysiology • The reduced bone mass is caused by an imbalance of bone resorption and bone formation. • The total bone mass and density is reduced, resulting in bones that become progressively porous, brittle, and fragile.
  77. 77. 🠶 Although osteoporosis may result from an endocrine disorder or malignancy, it is most often associated with aging. 🠶 With aging level of calcitonin and estrogen decreases but levels of parathyroid hormone increases. 🠶 Estrogen deficiency, which occurs at menopause, is considered the leading factor in osteoporosis among aging women. 🠶Osteoporosis can be primary or secondary.
  78. 78. 🠶 Primary osteoporosis occurs in women after menopause and in men due to failure to develop optimal peak bone mass during childhood, adolescence, and young adulthood. 🠶 Secondary osteoporosis is the result of medications and diseases that affect bone metabolism. 🠶Prolonged use of medications that increase calcium excretion, such as aluminum-containing antacids and anticonvulsants, increase the risk of developing osteoporosis. 🠶Corticosteroids
  79. 79. A B
  80. 80. Assessment Findings 🠶loss of height 🠶 progressive curvature of the spine(dorsal kyphosis and cervical lordosis) / “dowager’s hump”. 🠶 low back pain, and fractures of the forearm, spine, or hip. 🠶 Radiographic examinations; X-ray and DEXA show bone loss, deformities and pathologic fractures in long bones.
  81. 81. Medical Management 🠶Oral calcium preparations with vit D 🠶Bisphosphonates- alendronate 🠶Calcitonin 🠶Hormone replacement therapy (HRT) 🠶A diet rich in calcium and vitamin D 🠶Bone pain or tenderness may respond to mild analgesics such as aspirin. 🠶Moderate weight bearing exercises 1st line
  82. 82. Nursing Interventions • Provide adequate dietary supplement of calcium and vit D • Teach patients who are able to participate in weight- bearing exercises to perform exercises at least three times a week for a sustained period of 30 to 40 minutes. • Manage constipating side-effect of calcium supplements • Relieve the pain • Prevent injury
  83. 83. 2. OSTEOMALACIA 🠶 Often referred to as adult rickets, is characterized by inadequate or delayed mineralization of bone matrix, resulting in softening of bones. 🠶 Marked deformities of weight bearing bone and pathologic fractures occur. 🠶 The two main causes of osteomalacia are • Insufficient calcium absorption in the intestine due to a lack of calcium intake or vitamin D deficiency, • Increased losses of phosphorus through the urine
  84. 84. 🠶 Bone volume unchanged, but the replaced bone consists of soft osteoid instead of rigid bone. Manifestations 🠶 Weakness, bone pain, and tenderness 🠶kyphosis and bowing of the legs 🠶 Waddling type of gait, putting them at risk for falls and fractures
  85. 85. Diagnostic Findings 🠶 x-ray- generalized demineralization 🠶low serum calcium and phosphorus 🠶elevated alkaline phosphatase 🠶 Bone biopsy demonstrates an increased amount of osteoid Medical Management 🠶 supplements of calcium, phosphorus, with vitamin D; adequate nutrition; exposure to sunlight; and progressive exercise and ambulation.
  86. 86. 3. Paget’s Disease 🠶 An imbalance of increased osteoblast and osteoclast cells; thickening and hypertrophy. 🠶 Results in bone deposits that are weak, enlarged, and disorganized 🠶 Bone pain most common symptom; bony enlargement and deformities of long bone usually bilateral, kyphosis,.
  87. 87. Rx- Analgesics, bisphosphonates and calcitonin, assistive devices, and hot/cold treatment.
  88. 88. Musculoskeletal Infections 1. OSTEOMYELITIS 🠶Is an infection of the bone. 🠶 Staph. aureus is the most common infecting organism. 🠶Classified as: 🠶Hematogenous osteomyelitis 🠶Contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (eg, gunshot wound) 🠶Osteomyelitis with vascular insufficiency eg. DM and peripheral vascular disease
  89. 89. 🠶 After entry, bacteria lodge and multiply in the bone, resulting in the inflammatory and immune system response. 🠶 If the infection reaches the outer margin of the bone, it raises the periosteum of the bone, spreading along the surface. 🠶 Lifting of the periosteum from the cortex disrupts the blood vessels that enter the bone, compromising the vascular supply and leading to ischemia and eventual necrosis of the bone. 🠶 New bone cells are deposited on the periosteum while the underlying bone becomes necrotic.
  90. 90. 🠶 The pocket of necrotic bone (sequestrum) may remain sequestered for years or eventually drain by forming a sinus tract through to the skin; which leads to chronic osteomyelitis. 🠶 complications of osteomyelitis include: o Septicemia o Thrombophlebitis o muscle contractures o pathologic fractures and o nonunion of fractures
  91. 91. Assessment Findings 🠶 Acute infection: high fever, chills, rapid pulse, tenderness or pain over the affected area, redness, and swelling. 🠶Chronic infection: 🠶persistent draining sinus. 🠶elevated leukocyte count, an elevated ESR, +ve blood culture 🠶 Radiographic findings: irregular bone decalcification, bone necrosis, elevation of the periosteum, and new bone formation. 🠶Bone scans and MRI are useful in definitive diagnoses. PIC
  92. 92. Medical and Surgical Management 🠶 Immobilization to decrease pain and prevent fracture. 🠶 Apply warm saline soaks to increase circulation 🠶 Intravenous (IV) antibiotic therapy is administered for 3 to 6 weeks. Oral antibiotics then follow for as long as 3 months. 🠶 Surgical debridement of the necrotic tissue and sequestrum to remove the infected areas.
  93. 93. Nursing management 🠶Protecting the skin from breakdown, 🠶 administering the prescribed antibiotics and pain medications, 🠶 informing the client about the expected therapeutic effects and possible side effects. 🠶 Clients with chronic osteomyelitis require extensive emotional support, related to the long-term nature of this illness.
  94. 94. 2. SEPTIC (INFECTIOUS) ARTHRITIS 🠶 Joints can be infected through hematogenous spread or directly through trauma or surgical instrumentation. 🠶 Infection of the joint leads to synovitis, joint effusion and abscesses formation; can lead to destruction of the affected joint. 🠶 A single joint, often the knee, is usually affected. Manifestations 🠶 Abrupt onset, warm, painful, swollen joint with decreased ROM. 🠶 chills, fever, and leukocytosis
  95. 95. 🠶Risk factors 🠶advanced age, impaired immunity, diabetes, rheumatoid arthritis, and preexisting joint disease or joint replacement. 🠶Assessment and Diagnostic Findings 🠶Diagnostic studies include aspiration, examination, and culture of the synovial fluid. 🠶Computed tomography (CT) and MRI
  96. 96. Medical Management 🠶 Broad-spectrum IV antibiotics are started promptly and then changed to organism-specific antibiotics after culture results are available. 🠶 The IV antibiotics are continued until symptoms resolve. 🠶 The synovial fluid is aspirated and analyzed periodically for sterility and decrease in WBCs. 🠶Arthrotomy or arthroscopy is used to drain the joint and remove dead tissue.
  97. 97. Nursing Care 🠶Monitor the patient’s response to therapy, including systemic manifestations such as fever. 🠶Position the affected joint appropriately, using pillows to elevate it as needed. 🠶 Immobilize the joint using splints or traction . 🠶Warm compresses may be ordered for comfort. 🠶 Active ROM exercises preserve joint mobility and should be initiated as soon as the physician allows.
  98. 98. Joint and connective tissue diseases 1. OSTEOARTHRITIS (OA) 🠶 Degenerative Joint Disease (DJD) 🠶the most common form of arthritis. 🠶 degeneration and wearing away of the articular cartilage  exposing bone 🠶 Typically affects the weight-bearing joints and those that are repeatedly used for work. 🠶 Unlike RA, DJD has no remissions and no systemic symptoms, such as malaise and fever.
  99. 99. 🠶 Risk factors include increasing age, previous joint injury, obesity, congenital and developmental disorders, hereditary factors, and decreased bone density. 🠶Classified as: o Primary, when the etiology is unknown, or o Secondary, when OA has an underlying cause such as injury or a congenital disorder
  100. 100. 🠶 The degenerative process begins when the cartilage that covers the bone ends becomes thin, rough, and ragged. 🠶 The cartilage no longer springs back into shape after normal use. 🠶 As the cartilage wears away, the joint space decreases, so that the bone surfaces are closer and rub together. 🠶In an attempt to repair the damaged surface, new bone develops in the form of bone spurs, bone cysts, or osteophytes, which are extended margins of the joints. 🠶 The joint becomes deformed, and the client experiences pain and limited joint movement.
  101. 101. Clinical Manifestations 🠶 Often affects only one large weight-bearing joint, such as hip, spine, or knee 🠶 Joint pain occurs often after exercise or weight bearing 🠶Pain often relieved by rest 🠶 morning stiffness, aches during weather changes 🠶 Functional impairment results from pain on movement and limited motion caused by structural changes in the joints. 🠶 X-ray films demonstrate disruption of the joint cartilage and bony changes.
  102. 102. Medical and Surgical Management 🠶Non-pharmacological  local rest of the affected joints, heat applied to the painful part, weight loss  Splints, braces, canes, or crutches may reduce discomfort, relieve pain, and prevent further destruction of the affected joints. 🠶Large doses of acetaminophen 🠶Aspirin and NSAIDs 🠶 Corticosteroids may be injected into inflamed joints
  103. 103. 2. Rheumatoid arthritis 🠶 Systemic autoimmune inflammatory disorder of connective tissue / joints characterized by chronicity, remissions, and exacerbations. 🠶Female-to-male ratio is 2-4:1 🠶Its cause is unknown 🠶 Particularly affect small joints of the hands and feet, 🠶can also affect large joints 🠶 Chronic inflammation begins in the synovial membrane
  104. 104. 🠶Approximately 70% to 80% of people with RA have a substance called rheumatoid factor (RF), an antibody that reacts with a fragment of immunoglobulin G (IgG). 🠶 This self-produced (autologous) antibody forms immune complexes (IgG/RF). 🠶 PMN leukocytes, monocytes, and lymphocytes are attracted to the area and cause phagocytosis of the immune complexes. 🠶 lysosomal enzymes are released and enzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation.
  105. 105. 🠶 Pannus destroys cartilage and erodes the bone. 🠶 loss of articular surfaces and joint motion. Signs and Symptoms 🠶onset of symptoms is acute. 🠶 Joint involvement usually is bilateral and symmetric. 🠶 Localized symptoms include joint pain, swelling, and warmth; erythema, stiffness in the morning; 🠶 Spongy tissue on joint palpation, and fluid on joints. 🠶Swelling and pain comes and goes
  106. 106. 🠶 Deformities of the hands and feet are common in RA 🠶 Non-tender and movable nodules may be noted in 25% of patients with more advanced RA. 🠶 Swan neck deformity—Hyperextension of the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. 🠶 Ulnar deviation—Fingers deviating laterally toward the ulna.
  107. 107. Diagnostic Findings 🠶Radiographic films 🠶 Arthrocentesis- synovial fluid usually appears cloudy, milky, or dark yellow, and contains many inflammatory cells 🠶 Arthroscopy- to visualize the extent of joint damage 🠶Positive RF
  108. 108. Medical management 🠶 Drug therapy is not curative but helps relieve pain 🠶 NSAIDs, Steroids, Immunosuppressant- methotrexate 🠶 surgery to repair or replace joints or remove tissues interfering with movement 🠶Local applications of heat and cold 🠶gait training
  109. 109. 3. GOUT 🠶 A genetic defect of purine metabolism resulting in hyperuricemia, usually affects the feet (especially the great toe), hands, elbows, ankles, and knees. 🠶 Over secretion of uric acid or a renal defect resulting in decreased excretion of uric acid, or a combination of both, occurs. 🠶 It occurs more commonly in males than females
  110. 110. 🠶 Attacks of gout appear to be related to sudden increases or decreases of serum uric acid levels. 🠶 When the urate crystals precipitate within a joint, an inflammatory response occurs and an attack of gout begins. 🠶 Collections of urate crystals, called tophi, are found in the cartilage of the outer ear (pinna), the great toe. 🠶 As these deposits accumulate, they destroy the joint, producing a chronically swollen, deformed appearance. 🠶 The uric acid also may precipitate in urine, causing renal stones.
  111. 111. Clinical Manifestations 🠶 sudden onset of acute pain and tenderness in one joint. 🠶 skin turns red and the joint swells, warm and hypersensitive to touch 🠶 The attack may last for 1 or 2 weeks 🠶 Repeated episodes in the same joint may deform the joint Diagnostic Findings 🠶Hyperuricemia 🠶arthrocentesis - urate crystals
  112. 112. 🠶 The aim of treatment is to decrease sodium urate in the ECF so that deposits do not form. 🠶 NSAIDs, such as ibuprofen and indomethacin 🠶 Acute attacks of gout also may be treated with colchicine 🠶 Other drugs used include probenced and allopurinol. Nursing Management 🠶 patients should be encouraged to decrease foods high in purines, especially organ meats, and to limit alcohol intake. 🠶 increase their fluid intake Medical Management
  113. 113. 4. Ankylosing Spondylitis 🠶 Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues. 🠶 Occasionally, the large synovial joints, may be involved. 🠶 Characteristics include spondylosis and fusion of the vertebrae 🠶 Usually begins in early adulthood and mainly affects men than women. 🠶Back pain is the characteristic feature.
  114. 114. 🠶 As the disease progresses, ankylosis (stiffness) of the entire spine may occur, leading to respiratory compromise and complications. Medical Management 🠶 Focuses on treating pain and maintaining mobility by suppressing inflammation. 🠶 Good body positioning and posture are essential, so that if ankylosis (fixation) does occur, the patient is in the most functional position. 🠶 Maintaining ROM with a regular exercise and muscle- strengthening program is especially important.
  115. 115. Pharmacologic therapy ⚫NSAIDS such as naproxen or indomethacin are usually prescribed for relieving inflammation and pain. Surgical management ⚫Surgical management may include total hip replacement. Nursing management of spondylitis ⚫The nurse administers prescribed drugs ⚫Encourages the client to perform ADLs as much as possible. ⚫Teaches the client to perform mild exercises that reduce stiffness and pain.