MUSCULOSKELETAL

SYSTEM
FUNCTIONS
Support: form the framework that supports the body and
cradles soft organs
Protection: provide a protective case for the brain, spinal cord,
and vital organs
Movement: provide levers for muscles
Storage: reservoir for minerals, especially calcium and
phosphorus
Blood cell production: hematopoiesis occurs within the
marrow cavities of bones
The skeletal system has four components: bones, cartilage, tendons, and ligaments.
§ Bone cells are categorized as osteoblasts, osteocytes, and osteoclasts.
§ Ossification or osteogenesis , is the formation of bone by osteoblasts.
Ø Bone formation that occurs within connective tissue membranes is called
intramembranous ossification
Ø Bone formation that occurs inside hyaline cartilage is called endochondral ossification
 Four types of cells are present in bone tissue

OSTEOGENIC CELLS • unspecialized stem cells derived from mesenchyme

• only bone cells to undergo cell division
• found along the inner portion of the periosteum, in the endosteum, and in the canals within bone that
contain blood vessels
OSTEOBLASTS • bone-building cells
• synthesize and secrete collagen fibers and other organic components needed to build the extracellular
• matrix of bone tissue
• initiate calcification
• do not undergo cell division
OSTEOCYTES • mature bone cells
• main cells in bone tissue and maintain its daily metabolism
• do not undergo cell division
OSTEOCLASTS • responsible for breakdown of bone extracellular matrix termed resorption
 Spongy Bone Tissue
(Spongy)
o very porous and is located in the
epiphyses of long bones and lines the
BASED ON THE HISTOLOGICAL medullary cavity of long bones
STRUCTURE o consists of delicate interconnecting rods
or plates of bone called trabeculae
o spaces between the trabeculae are filled
with marrow
Compact Bone Tissue
(Cortical)
o forms the perimeter of the diaphysis of a
long bone and the thinner surfaces of all
other bones
o has more matrix and is denser, with
fewer pores
o has a predictable pattern of repeating
units called osteons
o Each osteon consists of concentric rings
of lamellae surrounding a central canal,
or Haversian canal
Four categories of bone, based on their shape:

LONG • longer than they are wide

• function in movement of appendages
• Most of the bones of the upper and lower limbs are long bones
SHORT • approximately as wide as they are long
• help transfer force between long bones
• bones of the wrist and ankle
FLAT • a relatively thin, flattened shape
• well-suited to providing a strong barrier around soft organs
• skull bones, the ribs, the scapulae (shoulder blades), and the sternum
IRREGULAR • have shapes that do not fit readily into the other three categories
• tend to have specialized functions, such as providing protection while allowing bending and flexing of
certain body regions
Factors Affecting Bone Growth
 BONE REPAIR
o Occurs when a bone is fractured
o Two to three days after the injury, blood vessels and cells from surrounding tissues begin to invade the
clot
o network of fibers and islets of cartilage between the two bone fragments is called a callus
 JOINTS
or articulations, arthrosis , are commonly named according to the bones or portions of bones that join together

Joints are classified structurally as fibrous, cartilaginous, or synovial, according to the major connective tissue
type that binds the bones together and whether a fluid-filled joint capsule is present.

Joints can also be classified in functional categories according to their degree of motion as synarthroses
(nonmovable joints), amphiarthroses (slightly movable joints), or diarthroses (freely movable joints).

SYNARTHROSIS • Skull sutures

• Epiphyseal plates
• Joint between 1st rib and manubrium of sternum

AMPHIARTHROSIS • Vertebral joints

• Joint of the symphysis pubis

DIARTHROSIS • Joint of the extremities

• Shoulder joints
• Hip joints
 DIAGNOSTIC EXAMS

TEST PURPOSE NURSING INTERVENTIONS

Arthrocentesis • Obtain synovial fluid from a • After the procedure, apply a

joint for diagnosis or to remove compression dressing and tell
excess fluid. the patient to report any
bleeding and leakage of fluid.
 DIAGNOSTIC EXAMS

TEST PURPOSE NURSING INTERVENTIONS

Arthroscopy • Used to perform surgery and • If general anesthesia is used, tell the
diagnose diseases of the patella, patient not to eat or drink fluids after
meniscus, and synovial and extra- midnight prior to the procedure.
synovial membranes. • Following the procedure, assess for
• Fluid may be drained from the bleeding and swelling, apply ice to the area
joint and tissue removed for if prescribed, and instruct patient to avoid
biopsy. excessive use of the joint for 2 to 3 days.
 DIAGNOSTIC EXAMS

TEST PURPOSE NURSING INTERVENTIONS

Bone Density • Evaluate bone mineral density and • Instruct patient to remove all
• Dual energy x-ray to evaluate degree of osteoporosis. metal objects from the area to
absorptiometry (DEXA) DEXA can calculate the size and be scanned.
• Quantitative ultrasound thickness of bone.
(QUS) • Normal Value: 1 standard deviation
• Bone mineral density (BMD) below peak bone mass.
• Bone absorptiometry
 DIAGNOSTIC EXAMS

TEST PURPOSE NURSING INTERVENTIONS

Bone scan • Uptake is increased in • No special preparation is

(Nuclear medicine scans ) osteomyelitis, osteoporosis, needed; tell patient to increase
cancers of the bone, and in some oral fluids after the test to aid
fractures. in excretion of the radioisotope
• Uptake is decreased in avascular
necrosis.
 CONTUSION STRAIN SPRAIN
Cause bleeding into soft tissue stretching injury to a stretch and/or tear of one or
muscle or a muscle more ligaments surrounding a
tendon unit joint

Etiology Blunt force Mechanical overloading Forces going in opposite

directions

Manifestations Swelling and discoloration of the skin Pain, limited ROM, Loss of function, feeling of pop
muscle spasms, swelling or tear, discoloration, pain and
and possible muscle rapid swelling
weakness
MANAGEMENT

Diagnostics X-ray, MRI

Medication NSAIDs
Treatment

Immobilize with cast or

splint; surgery to repair torn
ligaments, PT for
rehabilitation
Nursing Care for Contusions, Sprains and Strains

Acute Pain
• Teach the patient to use RICE (rest, ice, compression, elevation) therapy to care for the injury.

Impaired Physical Mobility

•Teach the correct use of crutches, walkers, canes, or slings if prescribed.
•Encourage follow-up care.
 JOINT TRAUMA
HISTORY TAKING • circumstances of injury if known;
• pain, including location, character, timing, and activities or movements that aggravate or
relieve it
• history of prior musculoskeletal injuries;
• chronic illnesses;
• medications

PHYSICAL ASSESSMENT • Compare the position, color, size, and temperature of the affected joint to the corresponding
unaffected joint.
• Palpate for tenderness, crepitus, temperature, and swelling.
• Instruct the patient or assist to move the joint through its normal range of motion, stopping
and noting where pain is experienced.
• When a joint dislocation is suspected, assess color, temperature, pulses, movement, and
sensation of the limb distal to the affected joint.

NURSING DIAGNOSIS AND Risk for Injury

INTERVENTIONS • Monitor neurovascular status by assessing the 5 “P’s”:
Pain, Pulses, Pallor, Paralysis, Paresthesia
• Maintain immobilization as ordered after reduction.
Acute Pain
• Encourage use of an appropriate splint or joint immobilizer.
• Teach safe application of ice or heat to the affected joint as indicated.
• Instruct about using NSAIDs as ordered.
Carpal Tunnel Syndrome • term for a group of symptoms located in the carpal tunnel of the wrist, a narrow, inelastic canal through which the
carpal tendons and median nerve pass.
CLINICAL MANIFESTATIONS
Using computers
Post menopausal women • Pain
• Numbness
• Tingling of the thumb and index
finger, and lateral ventral surface of
the middle finger
PATHOPHYSIOLOGY
Entrapment of median nerve in carpal tunnel
(between transverse carpal ligament and
carpal bones)
nerve compression
paresthesia, pain, and numbness in
distribution of median
nerve.
MANAGEMENT
Diagnostics
• Phalen’s Test
• Tinel’s Test
• ultrasound
• magnetic resonance imaging (MRI)
• electromyography (EMG) nerve conduction
studies
• RICE for the first 24-48 hours
• Resting the hands when possible and
splinting the hand and wrist.
• NSAIDs and periodic injections of a
corticosteroid preparation may relieve the
inflammation and discomfort.
• Surgery to release the pressure of the
ligament
 Bursitis • an inflammation of the bursa, a fluid-filled sac that cushions bone ends to enhance a gliding
movement.
• elbow, shoulder, and knee are common sites
Etiology CLINICAL MANIFESTATIONS PATHOPHYSIOLOGY MANAGEMENT
• Trauma is the most common cause of acute
bursitis. • hot, red, edematous Trauma; RA, gout, infection Diagnostics
• Other causes include overuse, stress, infection, • tender extension and flexion of the • X-ray study
and secondary effects of gout and RA. joint near the bursa produce pain • Aspiration of fluid
• Typical of any inflammation, pain and swelling • history and physical examination
Tissue damage • MRI
occur with compromised function.

• Joint rest usually is recommended.

injury • Salicylates or NSAIDs may be prescribed
• If infection is the cause, antibiotics will be
ordered.
Inflammation of bursa
• RICE for the first 24-48 hours
• Review the prescribed medication and
exercise regimens with the client and
allows time for questions and answers.
• Advise the client not to traumatize or
overuse the recovering joint but to use it
normally.
• Failure to use the joint after pain and
inflammation are controlled may result in
partial limitation of joint motion
 Epicondylitis • is a painful inflammation of the elbow
• Inflammation of the tendon to microvascular trauma

It can be: CLINICAL MANIFESTATIONS PATHOPHYSIOLOGY MANAGEMENT

• Medial epicondylitis: (golfer’s elbow) • pain radiating down the dorsal • Tears, bleeding and edema; calcification of Diagnostics
surface of the forearm the tendon • history and physical examination
• Lateral epicondylitis: (tennis elbow) • weak grasp • ultrasound
• magnetic resonance imaging (MRI)

• RICE for the first 24-48 hours

• Applications of cold (ice) and heat, exercise
• Steroidal anti-inflammatory medications
local injection of corticosteroids
• Analgesics, NSAIDs
TRAUMATIC INJURIES OF THE BONE (FRACTURE)
 Fracture • a break in the continuity of the bone caused by trauma, twisting as a result of muscle spasm or indirect loss of leverage, or bone decalcification and
disease that result in osteopenia

CLINICAL MANIFESTATIONS PATHOPHYSIOLOGY MANAGEMENT

Etiology
• direct blow • Deformity Diagnostics
• crushing force • Swelling X-ray
(compression) • Pain/tenderness MRI
• sudden twisting motion • Numbness CT scan
(torsion) • Guarding
• severe muscle contraction • Crepitus • Assess extent of injury and immobilize the
• stress or pathologic • Hypovolemic shock affected
fracture • Muscle spasms • extremity.
• Ecchymosis • If a compound fracture exists, cover the wound
with a sterile dressing (apply a clean dressing if a
sterile dressing is unavailable).
• Elevate the injured extremity.
• Apply cold to injured area.
• Continue to monitor neurovascular status.
• Transport to the nearest emergency department
Reduction
• Restoring the bone to proper alignment
• Closed reduction: Accomplished by manual
alignment of the fragments, followed by
immobilization
• Open reduction: Surgical insertion of internal
• fixation devices, such as rods, wires, or pins,
• that help maintain alignment while healing
• occurs
• Retention: Application of traction or a cast to
maintain alignment until healing occurs
 COMPLICATIONS OF FRACTURES
COMPLICATIONS DESCRIPTION NURSING IMPLICATIONS

Shock • Hypovolemic shock related to blood • Administer blood and fluid volume
loss and loss of extracellular fluid from replacements as prescribed to prevent
damaged tissue. further losses.
• If untreated, the client’s condition will
deteriorate.

Fat embolism • Fat globules released after fractures of • Monitor client for symptoms, which
pelvis or long bones, or after multiple usually occur within 48–72 hours.
injuries or crushing injuries. • To prevent fatty emboli, provide early
• Globules combine with platelets to respiratory support, ensure rapid
form emboli. Onset is rapid, with immobilization of fracture, and
client experiencing respiratory distress observe client closely for signs of
and cerebral disturbances respiratory and nervous system
problems

Pulmonary embolism • Thromboembolism may occur after • Promote circulation and prevent
fracture or surgery to repair fractures. venous stasis to avoid pulmonary
These lead to pulmonary emboli in embolism.
some clients and can be fatal • Administer low-dose heparin
subcutaneously as prescribed to
prevent clot formation
 COMPLICATIONS OF FRACTURES
COMPLICATION DESCRIPTION NURSING IMPLICATIONS

Compartment syndrome • Tissue perfusion in the muscle • Monitor client for signs and symptoms
compartment (muscle covered by of compartment syndrome such as
inelastic fascia) is compromised unrelenting pain, unrelieved by
secondary to tissue swelling, analgesics.
hemorrhage, or a cast that is too tight. • Elevate the extremity, apply ice, and
• If circulation is not restored, ischemia perform neurovascular checks to help
and tissue anoxia lead to permanent prevent this complication.
nerve damage, muscle atrophy, and • As indicated, relieve pressure by
contracture. loosening cast or preparing the client
for a fasciotomy (surgical incision of
fascia and separation of muscles).

Delayed bone healing • Bone fails to heal at the expected rate. • Delayed union may require surgical
• Delayed healing may result from intervention to promote bone growth,
nonunion, characterized by the ends and correct the incorrect union.
of the fractured bone failing to unite • If necessary, prepare the client for use
and heal, or it may result from of electrical stimulation measures that
malunion, characterized by the ends promote bone growth, or for a bone
of the fractured bone healing in a graft.
deformed position.
 COMPLICATIONS OF FRACTURES
COMPLICATION DESCRIPTION NURSING IMPLICATIONS

Infection • The potential for infection increases • Perform careful assessments and
with compound fractures, application maintain aseptic technique to prevent
of skeletal traction, or surgical infections.
procedures. • Monitor for early signs of infection
because early detection promotes
early correction of the problem.

Avascular necrosis • This condition occurs from • Be alert for client reports of pain and
interruption of the blood supply to the decreased function of the affected
fracture fragments after which the limb. If necessary, prepare the client
bone tissue dies; most common in the for surgery, such as bone graft, bone
femoral head. prosthesis, joint replacement, joint
fusion, or amputation.
TYPES OF TRACTION
Balanced Suspension Traction
• Balanced suspension traction is
used with skin or skeletal
traction.
• Used to approximate fractures
of the femur, tibia, or fibula
• Balanced suspension traction is
produced by a counterforce
other than client.
Nursing Intervention
• Position the client in a low Fowler’s position on either the side or the
back.
• Maintain a 20-degree angle from the thigh to the bed.
• Protect the skin from breakdown.
• Provide pin care if pins are used with the skeletal traction.
• Clean the pin sites with sterile normal saline and hydrogen peroxide or
povidone-iodine (Betadine) as prescribed or per agency policy
TYPES OF TRACTION
Skeletal Traction Nursing Intervention
Traction is applied Monitor color, motion, and sensation of the affected extremity.
mechanically to the bone Monitor the insertion sites for redness, swelling, drainage, or
with pins, wires, or tongs. increased pain.
Typical weight for skeletal Provide insertion site care as prescribed.
traction is 25 to 40 lb.
TYPES OF TRACTION
Buck’s Extension Traction Nursing Intervention
• Buck’s (extension) skin • A boot appliance is applied to attach to the traction.
traction is used to • The weights are attached to a pulley; allow the weights to
alleviate muscle spasms hang freely over the edge of bed.
and immobilize a lower • Not more than 8 to 10 lb of weight should be applied.
limb by maintaining a • Elevate the foot of the bed to provide the traction.
straight pull on the limb
with the use of weights
TYPES OF TRACTION
Russel’s Traction Nursing Intervention
• Used to stabilize a • Check the popliteal space for signs of pressure from the
fractured femur before sling such as redness, indentations, abrasions, or pain.
surgery • Check all the tape and wrappings as in Buck's traction.
• Similar to Buck’s • Keep the patient from sliding down the bed. The foot of
traction, but provides a the bed may be elevated to help prevent this.
double pull using a
knee sling that pulls at
the knee and foot
TYPES OF TRACTION
Russel’s Traction Nursing Intervention
• Used to stabilize a • Check the popliteal space for signs of pressure from the
fractured femur before sling such as redness, indentations, abrasions, or pain.
surgery • Check all the tape and wrappings as in Buck's traction.
• Similar to Buck’s • Keep the patient from sliding down the bed. The foot of
traction, but provides a the bed may be elevated to help prevent this.
double pull using a
knee sling that pulls at
the knee and foot
TYPES OF TRACTION
Halo Pelvic Traction Nursing Intervention
• To immobilize the spine • Check the popliteal space for signs of pressure from the
• To slowly correct or sling such as redness, indentations, abrasions, or pain.
reduce deformities of • Check all the tape and wrappings as in Buck's traction.
spine such as scoliosis • Keep the patient from sliding down the bed. The foot of
and tuberculosis before the bed may be elevated to help prevent this.
surgery is carried out
TYPES OF TRACTION
Bryant’s Traction (Gallows) Nursing Intervention
• Gallows traction is applied • Both legs to remain flexed at 90 degrees at the hips.
to ensure the child • The baby's buttocks are to remain slightly off the
achieves the correct mattress. You should be able to fit the palm of your hand
position for a fractured
between the mattress and baby’s buttocks. Adjust the
femur.
• Traction reduces muscle
weights to achieve extended legs and slightly flexed
spasm and maintains knees.
proper alignment of the • Supply plenty of diversional activities. If the child flips
affected limb. over, a sheet or Posey restraint may be used; avoid
• It is also used to lengthen pressure over dorsum of foot and heel
ligaments prior to
operative correction of
developmental hip
dysplasia, or post
operatively for some forms
of anal surgery.
• Is used for children under
15kgs, due to risk of
vascular complications
 Nursing Interventions for Patients in Skeletal Traction

• Never remove the weights.

• Frequently assess pin insertion sites and provide
pin site care per policy.
• Report signs of infection at the pin sites, such as
redness, drainage, and increased tenderness.
• Perform neurovascular assessments frequently.
• Assess for common complications of immobility,
including pressure ulcer formation, renal calculi,
deep venous thrombosis, pneumonia, paralytic
ileus, and loss of appetite.
• If a problem is detected, assist in repositioning.
Stabilize the fracture site during repositioning.
• Teach the patient and family about the type and
purpose of the traction.
Maintain the pulling force and direction of the traction:
• The patient’s weight provides counter traction.
• Center the patient on the bed; maintain body alignment with the direction of pull.
• Ensure that weights hang freely and do not touch the floor.
• Ensure that nothing is lying on or obstructing the ropes.
• Do not allow the knots at the end of the rope to come into contact with the pulley.
Made of plaster or fiberglass to
provide immobilization of bone
and joints after a fracture or injury

CASTS
Nursing Interventions for Patients in Casts

• Perform frequent neurovascular assessments.

• Palpate the cast for “hot spots” that may indicate the presence
of underlying infection.
• Promptly report increased or severe pain; changes in
neurovascular status; or a hot spot or drainage on the cast.
• Do not use a blow dryer to speed drying; do not cover the cast
while it is drying.
• A sensation of warmth during drying is normal.
• Do not put anything into the cast.
• Keep the cast clean and dry; use plastic wrap as needed to
protect it.
• If the cast is made of fiberglass, dry it with a blow dryer on the
cool setting if it becomes wet.
• Notify your doctor immediately if you develop increased pain,
coolness, changes in color, increased swelling, and/or loss of
sensation.
• A sling may be used to distribute the weight of the cast evenly
around the neck.
• If crutches are used, arrange for physical therapist to teach
correct crutch walking.
• When the cast is removed, an oscillating cast saw will be used.
 SURGICAL MANAGEMENT OF FRACTURE

Open Reduction External Fixation

Stabilization of a fracture
by the use of an external
frame, with multiple pins
applied through the bone

Open Reduction Internal Fixation

involves the application of
screws, plates, pins, or
intramedullary rods to
hold the fragments in
alignment
AMPUTATION • Surgical removal of a limb or part of the limb.
• Complications include hemorrhage, infection, phantom limb pain, neuroma, and flexion
contractures

Postoperative interventions
• Monitor for signs of complications.
• Mark bleeding and drainage on the dressing if it occurs.
• Evaluate for phantom limb sensation and pain; explain sensation and pain to the client, and
medicate the client as prescribed.
• To prevent hip flexion contractures, do not elevate the residual limb on a pillow.
• First 24 hours: Elevate the foot of the bed to reduce edema; then keep the bed flat to prevent hip
flexion contractures, if prescribed by the HCP.
• After 24 to 48 hours postoperatively, position the client prone to stretch the muscles and prevent
hip flexion contractures, if prescribed.
• Maintain surgical application of dressing, elastic compression wrap, or elastic stump (residual limb)
shrinker as prescribed to reduce swelling, minimize pain, and mold the residual limb in preparation
for prosthesis
• As prescribed, wash the residual limb with mild soap and water and dry completely.
• Massage the skin toward the suture line if prescribed, to mobilize scar and prevent its adherence to
underlying bone.
• Prepare for the prosthesis and instruct the client in progressive resistive techniques by gently
pushing the residual limb against pillows and progressing to firmer surfaces.
• Encourage verbalization regarding loss of the body part, and assist the client to identify coping
mechanisms to deal with the loss.
Interventions for below-knee amputation

• Prevent edema.
• Do not allow the residual limb to hang over the edge of the bed.
• Discourage long periods of sitting to lessen complications of knee flexion.
• Place the client in a prone position throughout the day as prescribed by the
HCP.
Interventions for above-knee amputation

• Prevent internal or external rotation of the limb.

• Place a sandbag, rolled towel, or trochanter roll along the outside of the
thigh to prevent external rotation.
• Place the client in a prone position throughout the day as prescribed by the
HCP.
 REHABILITATION
• Instruct the client in the use of a mobility aid such as crutches or a walker.
• Prepare the residual limb for a prosthesis.
• Prepare the client for fitting of the residual limb for a prosthesis.
• Instruct the client in exercises to maintain range of motion and upper body strengthening.
• Provide psychosocial support to the client
Rheumatoid
• Rheumatoid arthritis is a chronic systemic inflammatory disease (immune complex disorder); the cause may be related
to a combination of environmental and genetic factors.
• Rheumatoid arthritis leads to destruction of connective tissue and synovial membrane within the joints.
• Rheumatoid arthritis weakens the joint, leading to dislocation and permanent deformity of the joint.

Arthritis
• Pannus forms at the junction of synovial tissue and articular cartilage and projects into the joint cavity, causing necrosis.
• Exacerbations of disease manifestations occur during periods of physical or emotional stress and fatigue.
• Vasculitis can impede blood flow, leading to organ or organ system malfunction and failure caused by tissue ischemia.

CLINICAL MANIFESTATIONS PATHOPHYSIOLOGY MANAGEMENT

• Inflammation, tenderness, Diagnostics
and stiffness of the joints • Blood test used to assist in
• Moderate to severe pain,
with morning stiffness lasting diagnosing rheumatoid
longer than 30 minutes arthritis
• Joint deformities, muscle • Reference interval: Negative or
atrophy, and decreased range
of motion in affected joints < 60 units/mL
• Spongy, soft feeling in the Meds:
joints • NSAIDs, disease modifying
• Low-grade temperature, antirheumatic drugs (DMARDs),
fatigue, and weakness and glucocorticoids
• Anorexia, weight loss, and
anemia
Surgical interventions
• Elevated ESR and positive • Synovectomy: Surgical removal of
rheumatoid factor the synovia to help maintain joint
• Radiographic study showing function
joint deterioration • Arthrodesis: Bony fusion of a joint
• Synovial tissue biopsy reveals to regain some mobility
inflammation
• Joint replacement (arthroplasty):
Surgical replacement of diseased
joints with artificial joints;
performed to restore motion to a
joint and function to the muscles,
ligaments, and other soft tissue

Physical mobility
• Preserve joint function.
• Provide range-of-motion
exercises to maintain joint
motion and muscle
strengthening.
• Balance rest and activity.
• Splints may be used during
acute inflammation to •
prevent deformity.
• Prevent flexion contractures.
• Apply heat or cold therapy as
prescribed to joints.
• Apply paraffin baths and
massage as prescribed.
• Encourage consistency with
exercise program.
• Use joint-protecting devices.
• Avoid weight-bearing on
inflamed joints.
Self-care
• Assess the need for assistive devices •
such as raised toilet seats, self-rising
chairs, wheelchairs, and scooters to •
facilitate mobility.
• Work with an occupational therapist
or HCP to obtain assistive or
adaptive devices.
Instruct the client in alternative
strategies for providing activities of
daily living.
Nursing Management
Fatigue Disturbed body image
Identify factors that may • Assess the client’s reaction to
contribute to fatigue. the body change.
Monitor for signs of • Encourage the client to
anemia and administer verbalize feelings.
iron, folic acid, and • Assist the client with self-care
vitamins as prescribed. activities and grooming.
• Monitor for medication- • Encourage the client to wear
related blood loss by street clothes.
testing the stool for occult
blood.
• Instruct the client in
measures to conserve
energy, such as pacing
activities and obtaining
assistance when possible.
 Osteoarthritis
(Degenerative
Joint Disease)
• The cause of primary osteoarthritis
is not known. Risk factors include
trauma, aging, obesity, genetic
changes, and smoking
•
•
Osteoarthritis is marked by progressive deterioration of the articular cartilage.
Osteoarthritis causes bone buildup and the loss of articular cartilage in peripheral and axial joints.
• Osteoarthritis affects the weight-bearing joints and joints that receive the greatest stress, such as the hips, knees, lower
vertebral column, and hands.
CLINICAL MANIFESTATIONS PATHOPHYSIOLOGY MANAGEMENT
• The client experiences joint pain that Diagnostics
diminishes after rest and intensifies after
activity, noted early in the disease Osteotomy: The bone is resected to
correct joint deformity, promote
process. realignment, and reduce
• As the disease progresses, pain occurs joint stress.
with slight motion or even at rest. 2. Total joint replacement or arthroplasty
• Symptoms are aggravated by a. Total joint replacement is performed
temperature change and climate when all measures of pain relief have
failed.
humidity. b. Hips and knees are replaced most
• Presence of Heberden’s nodes or commonly.
Bouchard’s nodes (hands) c. Total joint replacement is
• Joint swelling (may be minimal), crepitus, contraindicated in the presence of
and limited range of motion infection, advanced osteoporosis, or
• Difficulty getting up after prolonged severe joint inflammation
sitting
• Skeletal muscle disuse atrophy
• Inability to perform activities of daily
living
• Compression of the spine as manifested
by radiating pain, stiffness, and muscle
spasms in 1 or both extremities
 Osteoarthritis (Degenerative Joint Disease): Management
Assessment Pain Nutrition Physical mobility
• Client experiences joint pain that
• Administer NSAIDs, muscle relaxants, • Encourage a well-balanced • Instruct the client to balance
diminishes after rest and intensifies after
and other medications as prescribed. diet. activity with rest and to
activity, noted early in the disease process.
• Prepare the client for corticosteroid • Maintain weight within participate in an exercise
• As the disease progresses, pain occurs with
injections into joints as prescribed. normal range to decrease program that limits stressing
slight motion or even at rest.
• Position joints in function position stress on the joints affected joints.
• Symptoms are aggravated by temperature
and avoid flexion of knees and hips. • Instruct the client that exercises
change and climate humidity.
• Immobilize the affected joint with a should be active rather than
• Presence of Heberden’s nodes or
splint or brace until inflammation passive and to stop exercise if
Bouchard’s nodes
subsides. pain occurs.
• Joint swelling (may be minimal), crepitus,
• Avoid large pillows under the head or • Instruct the client to limit
and limited range of motion
knees. exercise when joint
• Difficulty getting up after prolonged sitting
• Provide a bed or foot cradle to keep inflammation is severe
• Skeletal muscle disuse atrophy
linen off of feet.
• Inability to perform activities of daily living
• Instruct the client in the importance
• Compression of the spine as manifested by
of moist heat, hot packs or
radiating pain, stiffness, and muscle
compresses, and paraffin dips as
spasms in one or both extremities
prescribed.
• Apply cold applications as prescribed
when the joint is acutely inflamed.
• Encourage adequate rest,
recommending 10 hours of sleep at
night and a 1- to 2-hour nap in the
afternoon.
 Gout
Asymptomatic: Client has no
symptoms but serum uric
acid level is elevated.
Acute: Client has
excruciating pain and
inflammation of 1 or more
small joints, especially the
great toe.
Intermittent: Client has
intermittent periods without
symptoms between acute
attacks.
Chronic: Results from
repeated episodes of acute
gout
a. Results in deposits of
urate crystals under the skin
b. Results in deposits of
urate crystals within major
organs, such as the kidneys,
leading to organ dysfunction
• Gout is a systemic disease in which urate crystals deposit in joints and other body tissues.
• Gout results from abnormal amounts of uric acid in the body.
• Primary gout results from a disorder of purine metabolism.
• Secondary gout involves excessive uric acid in the blood caused by another disease.
CLINICAL MANIFESTATIONS PATHOPHYSIOLOGY MANAGEMENT
• Swelling and inflammation of the Diagnostics:
joints, leading to excruciating pain • No blood test
• Tophi: Hard, irregularly shaped • MRI, CT scan
nodules in the skin containing chalky • Joint Fluid Analysis
deposits of sodium urate
• Low-grade fever, malaise, and • Provide a low-purine diet as prescribed, avoiding foods
headache such as organ meats, wines, and aged cheese.
• Pruritus from urate crystals in the • Encourage a high fluid intake of 2000 mL/day to
skin prevent stone formation.
• Presence of renal stones from • Encourage a weight reduction diet if required.
elevated uric acid levels • Instruct the client to avoid alcohol and starvation diets
because they may precipitate a gout attack.
• Increase urinary pH (above 6) by eating alkaline ash
foods (i.e., green beans, broccoli).
• Provide bed rest during acute attacks, with the
affected extremity elevated.
• Monitor joint range-of-motion ability and appearance
of joints.
• Position the joint in mild flexion during acute attack.
• Protect the affected joint from excessive movement or
direct contact with sheets or blankets.
• Provide heat or cold for local treatments to affected
joint as prescribed.
• Administer medications such as analgesic, anti-
inflammatory , and uricosuric agents as prescribed.
METABOLIC DISORDERS
 Osteomalacia
Risk Factors
• Chronic diarrhea
• GIT malabsorption
• Lack of exposure to sunlight
• Pregnancy
• Avoidance of milk
• Sedentary lifestyle
• Renal disease
• Use of strong sunscreen
• Decalcification and softening of bones.
• Due to a lack of vitamin D or a problem with the body's ability to break down and use
this vitamin.
• Rickets in children
CLINICAL MANIFESTATIONS PATHOPHYSIOLOGY MANAGEMENT
• Fractures Diagnostics
• Persistent and diffuse skeletal • Decreased serum levels of Calcium (44-
107 IU/L)
pain • Roentgenograms shows bone
• Progressive muscle weakness demineralization and multiple
• Progressive deformities of bone deformities. (white: more dense;
bones otherwise: black)
o Bowed legs • Elevated serum alkaline phosphatase
o Knock knees
o Rachitic rosary • Assess posture and gait, note ability to
o Enlarged wrists walk with or without aid.
• Note ability to walk requested distances.
and ankles • Check bony prominence for pressure sores.
o Pigeon breast • Assess shapes of bones throughout the
body.
• Administer prescribed diet.
Rich in Calcium
Rich in Vitamin D (tuna, salmon, mackerel)
• Discuss purpose of physical therapy.
• Assist to a position of comfort.
• Administer prescribed analgesics.
• Gentle back massage.
• Instruct regarding home safety.
• Teach family the effects of Calcium and
Vitamin D on the body and the factors
affecting absorption.
• Teach client on the signs of fracture.
• Follow up care as needed.
 Osteoporosis
Primary osteoporosis
• Most often occurs
postmenopausal women;
occurs in men with low
testosterone levels
• Risk factors include
decreased calcium intake,
deficient estrogen, and
sedentary lifestyle.
Secondary osteoporosis
• Causes include prolonged
therapy with corticosteroids,
thyroid-reducing medications,
aluminum- containing
antacids, or anticonvulsants.
• Associated with immobility,
alcoholism, malnutrition, or
malabsorption
Risk Factors
• Cigarette smoking
• Early menopause
• Excessive use of alcohol
• Family history
• Female gender
• Increasing age
• Insufficient intake of calcium
• Sedentary lifestyle
• Thin, small frame
• White (European descent) or
Asian race
•
•
Decrease in the bone mass and density with a change in bone structure.
May be ASYMPTOMATIC until the bones become fragile and a minor injury or movement causes a fracture
CLINICAL MANIFESTATIONS PATHOPHYSIOLOGY MANAGEMENT
in
• Possibly asymptomatic Diagnostics
• Back pain occurs after • bone mineral density measurement by DEXA (dual-energy X-ray
lifting, bending, or absorptiometry) at the lumbar spine
stooping. • Degeneration of lower thorax and lumber vertebrae on radiographic studies
• Back pain that increases
with palpation Promote understanding of osteoporosis and the treatment regimen.
• Provide adequate dietary supplement of Calcium and Vitamin D.
• Pelvic or hip pain,
especially with weight • Instruct to employ a regular program of moderate exercises and physical
activity.
bearing
• Problems with balance • Manage the constipating side effect of Calcium supplements.
• Take Calcium supplements with meals.
• Decline in height from
vertebral compression • AVOID ALCOHOL AND COFFEE IF UNDER CALCIUM THERAPY
• Kyphosis of the dorsal • Instruct about hormone therapy
Other medications:
spine, also known as
“dowager’s hump” Selective Estrogen Receptor Modulators [SERMs] (Evista)
Alendrolate sodium
Calcitonin
• 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.
• Improve bowel elimination.
• Constipation is a problem of Calcium supplements and immobility.
• Advise intake of high fiber diet and increase fluids.
• Prevent injury.
• Instruct to use isometric exercise to strengthen the trunk muscles.
• Avoid sudden bending strenuous lifting.
• Provide a safe environment.
Osteomyelitis
Causative Agents:
• Escherichia coli
• Neisseria gonorrhea
• Salmonella typhi
• Staphylococcus aureus (most
common)
• Infection of the bone and the bone marrow.
• Caused by direct invasion from an open wound or a systemic infection.
• Caused by lowered body resistance and decreased blood flow to the bones
CLINICAL MANIFESTATIONS
• Fever
• Pain and lack of desire to use affected limb
• Weakness, headache, nausea and vomiting
• Redness, edema and inflammation
PATHOPHYSIOLOGY MANAGEMENT
Diagnostics
• CBC: Elevated WBC and neutrophils
• Elevated ESR and CRP sensitive but
not specific
• Presence of microorganisms
• Biopsy or aspiration with culture
necessary to identify organism
• Caretakers must handle the arm or
leg or related area gently to prevent
additional pain or fracture.
• They must protect the infected area
from injury.
• The nurse instructs the client to
elevate the area and to bear weight
only as indicated.
• 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.
Ctto :Casey Mateo