MUSKULOSKELETAL DISORDERS
allow the body to move. The muscles
The musculoskeletal system includes:
• Bones- rigid body tissue consisting of
cells embedded in an abundant, hard
intercellular material.
• Joints - area where bone ends meet;
provides for motion and flexibility
• Muscles – is a soft tissue found in most
animals. Its cells contain protein
filaments of actin and myosin that slide
past one another, producing a
contraction that changes both the
length and the shape of the cell.
• Tendons – are cord of fibrous tissue
connecting muscle to bone
• Ligaments – are fibrous band
connecting bones
• Bursae - fluid-filled sac found in
connective tissue, usually in the area of
joints
Anatomic and Physiologic Overview
• The health and proper functioning of
the musculoskeletal system is
interdependent with that of the other
body systems.
• The bony structure provides protection
for vital organs, including the brain,
heart, and lungs.
• The bony skeleton provides a sturdy
framework to support body structures.
The bone matrix stores calcium,
phosphorus, magnesium, and fluoride.
• More than 98% of the total body
calcium is present in bone
• In addition, the red bone marrow
located within bone cavities produces
red and white blood cells in a process
called hematopoiesis.
• Joints hold the bones together and
attached to the skeleton contract,
moving the bones and producing heat,
which helps to maintain body
temperature.
Muscular system
• Muscles are attached by tendons(cords
of fibrous connective tissue) or
aponeuroses (broad, flat sheets of
connective tissue) to bones, connective
tissue, other muscles, soft tissue, or
skin.
• The muscles of the body are composed
of parallel groups of muscle cells
(fasciculi) encased in fibrous tissue
called fascia or epimysium.
• Muscle is contractile tissue and is
derived from the mesodermal layer of
embryonic germ cells.
• Its function is to produce force and
cause motion, either locomotion or
movement within internal organs.
• The muscular system is an organ system
consisting
of skeletal, smooth and cardiac muscles
• Muscles vary in shape and size
according to the activities for which
they are responsible.
• There are approximately 640 skeletal
muscles in the human body.
• There are three distinct types of
muscles: skeletal muscles, cardiac or
heart muscles, and smooth (non-
striated) muscles. Muscles provide
strength, balance, posture, movement
and heat for the body to keep warm.
1. Cardiac muscle / Heart muscle
• are distinct from skeletal muscles
because the muscle fibers are laterally
connected to
each other.
• Furthermore just as with smooth
muscles, they are not controlling
themselves.
• Heart muscles are controlled by the
sinus node influenced by autonomic
nervous system.
2. Visceral muscle
• Are controlled directly by the
autonomic nervous system and are
involuntary, meaning that they are
incapable of being moved by
conscious thought.
• Functions such as heart beat and lungs
(which are capable of being willingly
controlled, be it to a limited extent) are
involuntary muscles but are not smooth
muscles.
• Visceral muscle is found inside of
organs like the stomach, intestines, and
blood vessels.
• It is the weakest of all muscle tissues
• Visceral muscle makes organs contract
to move substances through the organ.
• It is known as involuntary muscle
(because visceral muscle is controlled
by the unconscious part of the brain, it
cannot be directly controlled by the
conscious mind).
• The term “smooth muscle” is often
used to describe visceral muscle
because it has a very smooth, uniform
appearance when viewed under a
microscope. This smooth appearance
starkly contrasts with the banded
appearance of cardiac and skeletal
muscles.
3. Skeletal muscle like other striated
muscles, are composed of myocytes, or
muscle fibers, which are in turn
composed of myofibrils, which are
composed of sarcomeres, the basic
building block of striated muscle tissue.
Muscle Actions
➢ Muscles accomplish movement by
contraction. Through the coordination
of muscle groups, the body is able to
perform a wide variety of movements.
Types of Muscle Contractions
a. An isometric contraction of a muscle
generates tension without changing
length. An example can be found when
the muscles of the hand and
forearm grip an object; the joints of the
hand do not move, but muscles
generate sufficient force to prevent the
object from being dropped.
Example of this is when one pushes against an
immovable wall
b. Isotonic contraction, the tension in the
muscle remains constant despite a
change in muscle length. This occurs
when a muscle's force of contraction
matches the total load on the muscle.
Example of this is flexion of the forearm.
• During walking, isotonic contraction
results in shortening of the leg, and
isometric contraction causes the stiff
leg to push against the floor.
Muscle Tone
• Relaxed muscles demonstrate a state of
readiness to respond to contraction
stimuli. This state of readiness, known
as muscle tone (tonus)
• Muscle tone is produced by the
maintenance of some of the muscle
fibers in a contracted state.
Flaccid – is a muscle that is limp
and without tone.
Spastic - a muscle with greater-than-normal
tone.
Atony – a muscle that is denervated becomes
soft and flabby.
Body Movements Produced by Muscle
Contraction
1. Flexion—bending at a joint (eg, elbow)
2. Extension—straightening at a joint
3. Abduction—moving away from midline
4. Adduction—moving toward midline
5. Rotation—turning around a specific axis
(eg, shoulder joint)
6. Circumduction—cone-like movement
7. Supination—turning upward
8. Pronation—turning downward
9. Inversion—turning inward
10. Eversion—turning outward
11. Protraction—pushing forward
12. Retraction—pulling backward
Skeletal System
• it is the framework of the body
• all of the bones in the body and the
tissues such as tendons, ligaments and
cartilage that connect them.
• also helps protect your internal organs
and fragile body tissues. The brain,
eyes, heart, lungs and spinal cord are all
protected by your skeleton
• The body system that consists of the
bones, their associated cartilages, and
the joints, and supports and protects
the body, produces blood cells, and
stores minerals.
Five major functions of the skeletal system
1. Support
The skeleton provides the framework
for the body. Bones provide the basic
shape and structure for the body
2. Protection
The skeleton protects organs in the body.
Bones can cover and protect many of our major
organs. They are like an armor that protects our
insides.
• cranium: protects the brain
• ribs/sternum: protects the lungs, heart
and some digestive organs
• pelvis: protects and supports the
digestive and reproductive organs
• spinal column: protects the spine
3. Movement.
The bones are the levers that help the body
move in different directions and in different
ways. The bones by themselves can't move
without the muscles that are connected to
them.
4. Blood Cell Production.
Inside of the long bones in our bodies, there is a
cavity that is filled with a substance called Bone
Marrow. In this tissue, new blood cells are
produced, and damaged blood cells are
repaired. Red bone marrow produces red blood
cells, white blood cells and other blood
elements.
5. Mineral Storage.
Mineral is a substance that the body needs to
carry out all of our bodily functions like thinking,
breathing and moving around. One of the
minerals that the body needs is calcium.
Calcium is a major part of bone, and this is
where the body stores its calcium. It is very
important to make sure you eat enough calcium
each day because if you don't get enough
calcium, your body will take the calcium it
needs from your bones. The less calcium the
bone has, the weaker it will become.
Types of bones
There are five types of bones in the human
body
1. Long
2. Short
3. Flat
4. Irregular
5. Sesamoid.
Nursing Process Overview
Assessment
Health history
A. Elicit a description of the client’s present
illness and chief complaint, including onset,
course, duration, location, and precipitating and
alleviating factors. Cardinal signs and symptoms
indicating altered musculoskeletal function
include:
• Moderate to severe pain
• Inability to move body part
• Localized edema
• Altered sensation to affected area
• Contour deformity and asymmetry
• Contusions.
b. Explore the client’s health history for
risk factors associated with
musculoskeletal disorders, such as:
• Medical conditions or medications that
would cause dizziness falls, or injuries.
• Environmental or physical conditions or
unsafe behavior that would cause
injuries.
• Decreased dietary intake of essential
nutrients for bone formation.
• History of infrequent exercise and
sedentary lifestyle
• Family history of musculoskeletal
problems
2. Physical examination
A. Inspection
• Note upright body alignment, including
posture.
• Assess bone discrepancies, including
contour, length, alignment, and
symmetry.
• Assess the client’s ability to move each
joint through its range of motion, noting
smoothness, pain, crepitus, and clicks.
• Note the client’s gait, including
coordination, rhythm, stride, and
balance.
• Assess the joint alignment, including
symmetry, size, shape, contour,
stability, tenderness, heat, and edema.
• Note muscle discrepancies, including
hypertrophy, atrophy, fasciculation, and
spasms.
B. Palpation
• Palpate muscle mass, including shape,
size, contour, symmetry, and firmness.
• Palpate muscle strength, including
symmetry, resistance, and contractility.
3. Laboratory and diagnostic studies
a. Roentgenography (e.g., radiography,
radiographs, photographic images) detects
musculoskeletal structure, integrity,
texture, or density problems. It also allows
evaluation of disease progression and
treatment efficacy.
c. A bone scan detects skeletal trauma
and disease by determining the degree
to which the matrix of the bone “takes
up” a bone-seeking radioactive isotope.
d. Arthroscopy (also called arthroscopic or
keyhole surgery) is a minimally invasive
surgical procedure on a joint in which
an examination and sometimes
treatment of damage is performed
using an arthroscope, an endoscope
that is inserted into the joint through a
small incision.
e. Arthrocentesis allows analysis of
synovial fluid, blood, or pus aspirated
from a joint cavity.
f. Myelography is injection of a contrast
agent into the subarachnoid space of
the spine to detect herniation, tumor,
and congenital or degenerative
condition of the spinal canal.
g. Electromyography measures muscle
electrical impulses for diagnosis of
muscle or nerve disease.
h. Biopsy (i.e., aspiration, punch, needle,
or incision) studies bone, synovium, or
muscle tissue.
i. Computed Tomography scans show soft
tissue, bone, and the spinal cord in
three-dimensional, cross-sectional
images.
j. Magnetic Resonance Imaging allows
study of soft tissue in multiple planes
of the body.
k. Complete blood count analysis
identifies anemias, hemorrhage,
infections, neoplastic conditions, lupus
erythematosus, blood dyscrasias,
allergies, stress, and other conditions.
l. Alkaline phosphatase studies identify
increases in osteoblastic activity and
inflammatory conditions.
m. Creatinine phosphokinase elevation
may identify skeletal muscle necrosis,
atrophy, or trauma.
n. Lactate dehydrogenase evaluation may
identify skeletal muscle damage.
o. Serum calcium studies may help to
identify bone loss density.
p. C-reactive protein test is used for
evaluating the severity and course of an
inflammatory process, such as a
bacterial infection or rheumatic disease.
q. Rheumatoid factor measures the
presence of a macroglobulin type of
antibody found in rheumatoid arthritis
and other connective tissue diseases.
Nursing diagnoses
1. Acute or chronic pain
2. Ineffective peripheral tissue perfusion
3. Impaired physical mobility
4. Risk for infection
5. Risk for injury
6. Self-care deficit
7. Deficient knowledge
8. Anxiety
Planning and outcome identification.
The goals of the client diagnosed with a
musculoskeletal disorder include pain relief,
maintenance of adequate tissue perfusion,
improved physical mobility, prevention of the
infection and injury, achievement of maximum
level of self-care, understanding the treatment
regimen, and decreased anxiety.
Implementation
1. Perform a neurovascular assessment
A. Assess pain, which signals the beginning of
muscle ischemia.
• Assess the pain scale.
• Rule out complications that require
medical intervention.
• Take an action: Medicate; use
nonpharmacologic interventions, such
as relaxation, massage, and guided
imagery; or call the health care
provider.
• Institute appropriate safety measures.
• Evaluate the effectiveness of the
medication or nursing intervention.
B. Assess pulses; pulselessness indicates
disruption of arterial blood flow.
• Assess various locations, including
radial, brachial, pedal, posterior tibial,
popliteal, and femoral pulses. Always
mark pulses with an X.
• Document pulse strength using a scale
of 0 to 4+: 0, no pulse; 1+, weak; 2+,
normal; 3+, strong; 4+, bounding.
• Use a Doppler device to verify
pulselessness.
c. Assess for pallor, which indicates disruption
of arterial blood flow. Check capillary refill time,
which should be less than 3 seconds.
d. Assess for paresthesia; nerve function may be
disrupted by nerve compression.
• Determine whether the client
experiences numbness, tingling, or the
sensation that the foot is asleep.
• Ascertain whether the client feels
pinching or touching of an extremity.
• Determine whether the client can feel
dull or sharp touch sensation.
e. Assess for paralysis; increasing edema causes
nerve compression.
• Determine whether the client can move
and lift the affected extremity.
• Ascertain whether the client can push
the affected extremity against pressure.
2. Provide pain relief.
a. Elevate the injured extremity above the level
of the client’s heart for the first 24 hours or as
directed.
b. Apply cold packs, as ordered, for the first 24
hours.
3. Promote mobility. Assist the client with
active and passive range-of-motion exercises for
unaffected body parts to help maintain
function.
4. Prevent infection. Monitor the client’s vital
signs, assess for the signs and symptoms of
infection, and monitor the white blood cell
count.
5. Protect the client from injury. Instruct the
client in and request a return demonstration of
safe transferring, ambulating, and sitting
techniques to prevent further injury from
immobilization or assistive devices.
6. Promote the client’s participation in self-care
activities within limitations of the injury and
treatment regimen.
7. Provide client and family teaching. Provide
explanations for the cause, treatment, and
expected course for the client with a
musculoskeletal disorder.
8. Minimize anxiety. Assist the client with
identifying and addressing feelings of anxiety to
include therapeutic conversation, distraction
therapy, or medication if needed.
Outcome Evaluation
1. The client reports reduced pain and states
appropriate measures to enhance comfort and
promote healing.
2. The client exhibits adequate tissue perfusion
and sensory function in the affected area.
3. The client has improved physical mobility as
evidenced by the ability to transfer himself
safely and the ability to use assistive devices
properly.
4. The client has no signs or symptoms of
systemic or local infection.
5. The client resumes normal activity without
further injury after healing.
6. The client demonstrates proper performance
of prescribed rehabilitative exercises and safety
precautions to prevent reinjury.
7. The client maintains independence in self-
care within limits of the injury and treatment
plan.
8. The client participates in self-care activities
and activities of daily living as much as possible.
9. The client verbalizes knowledge about the
prescribed medications, cast care, dietary
modifications, and other prescribed treatments.
10. The client states signs and symptoms of
further complications to watch for and report to
the health care provider.
11. The client reports a decrease in anxiety.
Sprains, Strains & Dislocations
1. A SPRAIN is a complete or incomplete tear in
the supporting ligaments surrounding a joint.
Common locations include the ankle, knee,
wrist, thumb, shoulder, neck, and lower back.
2. A STRAIN is an overstretching injury to a
muscle or tendon. Commonly affected areas are
the groin, hamstring, calf, shoulder and back
muscles, and the Achilles tendon.
Etiology
1. Sprains commonly result from a wrenching or
twisting motion that disrupts the stabilizing
action of ligaments.
2. Strains typically result from excessively
vigorous movement in understretched or
overstretched muscles and tendons
Pathophysiology
The affected ligament is unable to stabilize the
joint when the client is applying weight and
attempting to mobilize the affected joint. Blood
vessels may be ruptured and edema produced.
Assessment findings
1. Clinical manifestations
A. Sprains
• Pain and discomfort, especially on joint
movement
• Edema, possibly ecchymoses
• Decreased joint motion and function
• Feeling of joint looseness with severe
sprain
B. Strains
• Pain (In acute strain, pain may be
sudden, severe, and incapacitating.
With chronic strain, pain may be
manifested as a gradual onset of
soreness and tenderness.)
• Edema
 • Ecchymoses developing several days
after injury
2. Laboratory and diagnostic study findings.
Radiographs are commonly done to rule out
fracture or dislocation.
Nursing management
1. Administer prescribed medications, which
may include nonopioid analgesics.
2. Provide nursing care for a client who sustains
a sprain.
• Elevate or immobilize the affected joint,
and apply ice packs immediately.
• Assist with tape, splint, or cast
application, as necessary.
• Prepare the client with a severe sprain
for surgical repair or reattachment, if
indicated.
3. Provide nursing care for a client suffering
muscle or tendon strain.
• Instruct the client to allow the muscle
or tendon to rest and repair itself by
avoiding use for approximately 1 week
and then by progressing activity
gradually until healing is complete.
• Teach appropriate stretching exercises
to be performed after healing to help
prevent reinjury.
• Prepare the client for surgical repair in
severe injury.
First aid
1. Elevation of the affected part
2. Applying cold, and using a compression
bandage.
3. RICE—Rest, Ice, Compression, Elevation
• Rest prevents additional injury and
promotes healing.
• Moist or dry cold applied intermittently
for 20 to 30 minutes during the first 24
to 48 hours after injury produces
vasoconstriction, which decreases
bleeding, edema, and discomfort.
DISLOCATIONS
Description.
Dislocation is displacement of a bone from its
normal articulation with a joint. Common sites
of dislocation include the shoulder, elbow,
wrist, digits, hip, knee, ankle, and vertebrae.
Etiology
A dislocation may be congenital (e.g., congenital
hip displacement) or may result from trauma
(e.g., abnormal twisting) or disease of
surrounding joint tissue (e.g., Paget’s disease).
Pathophysiology
Traumatic dislocation may cause severe stress
to associated joint structures, interrupting
blood supply and causing nerve damage. If
untreated, this may lead to avascular necrosis
or nerve palsy in the affected area.
Assessment findings
1. Clinical manifestations
• Pain
• Visible disruption of joint contour
• Edema
• Ecchymoses
• Impaired joint mobility
• Change in extremity length
• Change in axis of dislocated bones (i.e.,
rotation)
• In severe dislocation, circulatory or
sensory changes of the affected joint
and limb
2. Laboratory and diagnostic study findings. 7. Spiral (torsion) fractures involve a fracture
Radiographic findings may confirm the twisting around the shaft of the bone.
dislocation.
8. Transverse fractures occur straight across the
bone.
Nursing management 9. Oblique fractures occur at an angle across
the bone (less than a transverse).
1. Administer prescribed medications,
which may include opioid or nonopioid
analgesics.
Etiology
2. Prevent further injury.
1. Fractures can result from crushing force or
• Immobilize the affected joint during direct blow.
transport to medical care.
• Keep the joint immobilized as
prescribed, using bandages, splints, a
cast or traction.
3. Assist the health care provider in reducing
displaced parts as necessary.
4. Provide client teaching

Fractures
A fracture is a traumatic injury interrupting
bone continuity. Fractures are classified
according to type and extent.
1. Closed simple, uncomplicated fractures do
not cause a break in the skin.
2. Open compound, complicated fractures
involve trauma to surrounding tissue and a beak
in the skin.
3. Incomplete fractures are partial cross-
sectional breaks with incomplete bone
disruption.
4. Complete fractures are complete cross-
sectional breaks severing the periosteum.
5. Comminuted fractures produce several
breaks of the bone, producing splinters and
2. Torsion fractures can occur from a sudden
fragments.
twisting motion; persons with osteoporosis are
6. Greenstick fractures break one side of a bone at particular risk.
and bend the other
3. Extremely forceful muscle contraction can
cause fractures.
4. Pathological fractures result from a weakness Paresthesias and other sensory abnormalities
in bone tissue, which may be caused by
2. Laboratory and diagnostic study findings.
neoplasm or a malignant growth.
Radiographs and other imaging studies may
identify the site and type of fracture.
Pathophysiology
1. Fracture occurs when stress placed on a bone Nursing management
exceeds the bone’s ability to absorb it.
1. Administer prescribed medications,
2. Stages of normal fracture healing include: which may include opioid or nonopioid
analgesics and prophylactic antibiotics
1. Inflammation for an open fracture.
2. Cellular proliferation 2. Prevent infection. Cover any breaks in
3. Callus formation the skin with clean or sterile dressings.

4. Callus ossification 3. Provide care during client transfer.

5. Mature bone remodeling • Immobilize a fractured extremity with

Potential complications of fracture include:
1. Life-threatening systemic fat embolus,
which most commonly develops within 24 to 72
hours after fracture.
2. Compartment syndrome, which is a
condition involving increased pressure and
constriction of nerves and vessels within an
atomic compartment.
3. Nonunion of the fracture side
4. Arterial damage during treatment
splints in the position of the deformity
before moving the client; avoid
straightening the injured body part if a
joint is involved.
• Support the affected body part above
and below the fracture site when
moving the client.
4. Provide client and family teaching.
• Explain prescribed activity restrictions
and necessary lifestyle modifications
because of impaired mobility.
• Teach the proper use of assistive
devices, as indicated.

5. Infection and possibly sepsis 5. Provide appropriate nursing interventions

associated with prescribed treatment
6. Hemorrhage, possibly leading to shock. modalities.
Assessment findings 6. Prevent and manage potential complications.
1. Clinical manifestations • Observe for symptoms of life-
threatening fat embolus, which include
• Pain personality changes, restlessness,
• Edema dyspnea, crackles, white sputum, and
• Tenderness petechiae over the chest and buccal
• Abnormal movement and crepitus membranes. Assist with respiratory
• Loss of function support, which must be instituted early.
• Ecchymoses • Observe for symptoms of compartment
• Visible deformity syndrome, which include deep,
 unrelenting pain; hard edematous
muscles; and decreased tissue perfusion
with impaired neurovascular
assessment findings. If necessary,
discuss and assist with prescribed
treatments, including fasciotomy,
bivalve cast, or release of constrictive
dressings.
• Monitor closely for signs and symptoms
of other complications.
Medical Management
Reduction
Fracture reduction refers to restoration of the
fracture fragments to anatomic alignment and
positioning.
Closed Reduction
• Accomplished by bringing the bone
fragments into anatomic alignment
through manipulation and manual
traction.
• The extremity is held in the aligned
position while the physician applies a
cast, splint, or other device.
• Reduction under anesthesia with
percutaneous pinning may also be used.
• The immobilizing device maintains the
reduction and stabilizes the extremity
for bone healing. X-rays are obtained to
verify that the bone fragments are
correctly aligned.
• Traction (skin or skeletal) may be used
until the patient is physiologically stable
to undergo surgical fixation.
Open Reduction
• Through a surgical approach, the
fracture fragments are anatomically
aligned.
• Internal fixation devices (metallic pins,
wires, screws, plates, nails, or rods) may
be used to hold the bone fragments in
position until solid bone healing occurs.
• These devices may be attached to the
sides of bone, or they may be inserted
through the bony fragments or directly
into the medullary cavity of the bone.
• Internal fixation devices ensure firm
approximation and fixation of the bony
fragments.
Osteoporosis
Osteoporosis is a disorder of bone metabolism
in which there is a reduction of total bone mass,
making bones abnormally prone to fracture. It
affects 25% of older adults, and the greatest
incidence occurs among white females between
ages 50 and 70.
Osteopenia, by definition, is a condition of bone
that is slightly less dense than normal bone but
not to the degree of bone in osteoporosis.
Etiology
Osteoporosis may be iatrogenic or secondary to
other disorders. Predisposing factors include
postmenopausal status, long-term
corticosteroid use, prolonged immobilization,
and nutritional deficiency.
Lifestyle Risk Factors
• Diet low in Ca++ and Vit. D
• Cigarette smoking
• Use of alcohol and/or caffeine
• Lack of weight-bearing exercise
• Lack of exposure to sunlight
Pathophysiology
In osteoporosis, the rate of bone loss (i.e.,
resorption) exceeds bone formation, resulting in
a decrease in total bone mass. Bones affected
by osteoporosis lose calcium and phosphate
salts, resulting in porous, brittle bones that are
susceptible to fractures.
Age-related loss begins soon after the peak
bone mass is achieved (ie, in the fourth decade).
Calcitonin, which inhibits bone resorption and
promotes bone formation, is decreased.
Estrogen, which inhibits bone breakdown,
decreases with aging. On the other hand,
parathyroid hormone (PTH) increases with
aging, increasing bone turnover and resorption.
Assessment findings
1.Clinical manifestations
• Fractures, particularly vertebral
compression fractures, hip fractures,
and long bone fractures.
• Pain
• Visible deformity (e.g., kyphosis)
• Loss of height
• Constipation
2. Laboratory and diagnostic study
findings
• Radiographic and bone-density studies
reveal loss of bone density in clients
with 25% to 40% bone
demineralization.
• Serum calcium, phosphorus, and
alkaline phosphatase levels are within
normal ranges.
Nursing management1
1. Administer prescribed medications, which
may include antiresorptive therapy, nonopioid
analgesics, and calcium supplements.
2. Prevent fractures. Use caution when turning,
lifting, and transferring the client to prevent
fracture.
3. Promote spinal stability by applying a
lumbosacral corset, if indicated; avoid
appliances that can decrease mobility.
4. Provide client teaching.
• Encourage increased intake of foods
high in calcium (e.g., milk, cheese,
salmon, spinach, broccoli, rhubarb),
vitamin D, fiber, and protein.
• Teach knee flexion and muscle-relaxing
exercises.
• Teach the client to move the trunk as a
unit and maintain good posture and
body mechanics.
• Instruct the client to perform range-of-
motion exercises at least twice daily.
• Suggest that the client sleep on a firm,
nonsagging mattress.
• Encourage a regular, moderate exercise
regimen (e.g., walking, swimming, low-
impact aerobics).
• Teach the client about the disease
process and prevention of progressions.
• Teach safety measures to prevent injury
from falls.
Osteoarthritis
Description
Osteoarthritis is a slowly progressive,
degenerative joint disease characterized by
variable changes in weight-bearing joints. The
most common form of arthritis, osteoarthritis
affects both sexes about equally, with onset
usually after age 40.
Etiology
Osteoarthritis is associated with obesity, aging,
trauma, genetic predisposition, and congenital
abnormalities.
Pathophysiology
1. Osteoarthritis starts with asymmetric
cartilage loss, which leads to abnormal forces
on the joint. It causes deterioration of the joint
cartilage and formation of reactive new bone at
joint margins and in subchondral areas. Soft
tissue imbalance, joint malalignment, and bony
hypertrophy can result.
2. Disability varies from the limitation of finger
movement to severe hip and knee
degeneration.
3. Progression is also variable; joints with minor
deterioration may remain stable for years.
Assessment findings
1. Clinical manifestations
• Pain and muscle spasms, which are
pronounced after exercise, at night, and
in the early morning
• Limited motion in affected joints
• Joint “grating” with movement
• Flexion contractures, primarily in the
hip and knee
• Joint tenderness and Herbeden’s and
Bouchard’s nodes in interphalangeal
joints
2. Laboratory and diagnostic study findings.
Radiographs may reveal a narrowing of joint
space.
Nursing Management
1. Administer prescribed medications, which
may include analgesics and nonsteroidal anti-
inflammatory drugs such as COX-2 inhibitors.
2. Provide nonpharmacologic comfort
measures.
• Apply warm compresses to sore joints.
• Massage surrounding muscles, not over
inflamed joints.
• Promote adequate rest and reduction
of stress.
• Maintain nonjudgmental attitude and
respect the client’s right to choose any
alternative treatment for pain relief.
3. Position the client to prevent flexion
deformity using a foot board, splints, sandbags,
wedges, or pillows as needed. Remove splints
routinely, if used, to exercise joints.
4. Plan activities that promote optimal function
and independence.
5. Refer the client to physical and occupational
therapy, as indicated. A physical therapist may
prescribe and implement modified weight-
bearing exercises within the client’s tolerance
level. An occupational therapist may help with
self-management strategies.
6. Prepare the client for surgical treatment, as
indicated.
7. Provide referrals.
Gouty Arthritis
Description
Gouty arthritis is a metabolic disease marked by
urate crystal deposits in joints throughout the
body, causing local irritation and inflammatory
responses. For the most part, it affects men
older than age 30.
Etiology
Gouty arthritis is linked to a genetic deficit in
purine metabolism.
Pathophysiology
1. Gout is characterized by formation of tophus
deposits in soft tissues and urate crystals in
joint synovia. It primarily affects joints in the
feet (especially the great toe) and legs, but it
may strike in any joint.
2. The disorder follows a variable course of
periodic attacks, often with long symptom-free
periods between attacks. Eventually, it can lead
to chronic disability and, in some cases, severe
hypertension and progressive renal failure.
Assessment findings
1. Clinical manifestations
• Sudden attacks, usually at night, with
periodic remissions and exacerbations
• Pain, usually monarticular, acute,
crushing, and pulsating
• Joint edema and inflammation
• Intolerance to the weight of bed linens
over the affected joint.
• Pruritus or skin ulceration over the
affected joint
• Signs of renal involvement (e.g.,
oliguria, low back pain, hypertension) in
severe disease
2. Laboratory and diagnostic study findings
• Arthrocentesis reveals urate crystals in
synovial fluid
• Serum uric acid level is increased.
• Radiograph may show joint damage in
advanced disease.
Nursing management
1. Administer prescribed medications,
which may include nonsteroidal
antiinflammatory drugs, uric acid
synthesis inhibitors, and uricosuric
agents.
Colchicine may be prescribed for acute attack
and used in small doses for prevention. Nausea,
vomiting, and diarrhea are toxic effects of
colchicine and should be reported to the health
care provider.
2. Promote measures to prevent exacerbations.
• Urge the client to drink 2 to 3 L of fluid
daily and to report any decrease in
urine output.
• Teach the client about dietary
modifications to limit foods high in
purine (e.g., organ meats, anchovies,
sardines, shellfish, chocolate, meat
extracts).
3. Provide measures to promote comfort and
reduce pain.
• Maintain strict bed rest for 24 hours
after an attack.
• Provide a bed cradle to keep bed linen
off affected joints to help reduce pain.
4. Provide client teaching
Osteomyelitis
Description
Osteomyelitis is a severe pyogenic bone
infection.
Etiology
1. Osteomyelitis can result from trauma or
secondary infection (most commonly with
Staphylococcus aureus). It tends to affect
persons with low resistance or with decreased
blood flow to a trauma site.
2. Blood-borne (hematogenic) osteomyelitis is
more common in children after a throat
infection. Osteomyelitis resulting from trauma
or orthopedic surgical procedures is more
common in older persons.
Pathophysiology
1. Circulation of infectious microbes through
the bloodstream to susceptible bone leads to
inflammation, increased vascularity, and
edema.
2. The organisms grow, pus forms within the
bone, and abscess may form. This deprives the
bone of its blood supply, eventually leading to • Provide a diet high in protein and
necrosis. vitamins C and D.
• Referral to a wound care clinic may be
Assessment findings
necessary.
Clinical manifestations
4. Prepare the client for surgical treatment,
1. Localized bone pain such as debridement, bone grafting, or
amputation, as appropriate.
2. Tenderness, heat, and edema in the affected
area 5. Provide additional teaching.

3. Guarding of the affected area

4. Restricted movement in affected area
5. Systemic symptoms
• High fever and chills in acute
osteomyelitis
• Low-grade fever and generalized
weakness in chronic osteomyelitis
6. Purulent drainage from a skin abscess

Laboratory and diagnostic study findings

a. White blood cell count reveals leukocytosis.
b. Erythrocyte sedimentation rate is elevated.
c. Blood culture identifies the causative
organism.
d. Radiograph and bone scan demonstrate bone
involvement in advanced disease.

Nursing Management
1. Administer prescribed medications, which
may include opioid or nonopioid analgesics and
antibiotics.
2. Protect the affected extremity from further
injury and pain by supporting the limb above
and below the affected area.
3. Promote healing and tissue growth.
• Provide local treatments as prescribed
(e.g., warm saline soaks, wet to dry
dressings).