NCM 104

MUSCULOSKELETAL DISORDERS

METABOLIC DISORDERS I. OSTEOMALACIA - 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. RISK FACTORS Chronic diarrhea GIT malabsorption Lack of exposure to sunlight Pregnancy Avoidance of milk Sedentary lifestyle Renal disease Use of strong sunscreen CLINICAL/DIAGNOSTIC MANIFESTATION Fractures Persistent and diffuse skeletal pain Progressive deformities of bones 1. Bowed legs 2. Knock knees 3. Rachitic rosary 4. Enlarged wrists and ankles 5. Pigeon breast Progressive muscle weakness Decreased serum levels of Calcium (44-107 IU/L) Looser zones on X-ray. Roentgenograms shows bone demineralization and multiple bone deformities. (white: more dense; otherwise: black) Elevated serum alkaline phosphatase. NURSING INTERVENTIONS 1. Assess posture and gait, note ability to walk with or without aid. 2. Note ability to walk requested distances. 3. Check bony prominence for pressure sores. 4. Assess shapes of bones throughout the body. 5. Administer prescribed diet. Rich in Calcium Rich in Vitamin D (tuna, salmon, mackerel) 6. Discuss purpose of physical therapy. 7. Assist to a position of comfort. 8. Administer prescribed analgesics. 9. Gentle back massage. 10. Instruct regarding home safety. 11. Teach family the effects of Calcium and Vitamin D on the body and the factors affecting absorption. 12. Teach client on the signs of fracture. 13. Follow up care as needed. II. OSTEOPOROSIS - 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. TYPES: a. Primary advanced age post-menopausal b. Secondary Steroids use will inhibit formation of bones decrease absorption of Calcium increase urine Calcium loss Alcohol overuse Renal failure

NCM 104

MUSCULOSKELETAL DISORDERS

RISK FACTORS Sedentary lifestyle Age Diet: caffeine, alcohol, low Calcium and Vitamin D Post-menopausal Genetics : Caucasian and Asian Immobility ASSESSMENT FINDINGS Low stature (stooping) Fracture (usually long bones) Bone pain MEDICAL MANAGEMENT 1. Diet therapy with Calcium and Vitamin D. 2. Hormone replacement therapy. 3. Moderate weight bearing exercise. 4. Management of fractures. NURSING INTERVENTIONS 1. Promote understanding of osteoporosis and the treatment regimen. Provide adequate dietary supplement of Calcium and Vitamin D. Instruct to employ a regular program of moderate exercises and physical activity. Manage the constipating side effect of Calcium supplements. Take Calcium supplements with meals. Avoid alcohol and coffee if under Calcium Therapy. Instruct on intake of hormonal replacement. Other medications: a. Selective Estrogen Receptor Modulators [SERMs] (Evista) Drugs that block the naturally circulating estrogen in breast tissues and other estrogensensitive tissues in the body. b. Alendrolate sodium A synthetic drug analog of pyrophosphate that acts primarily on bone to inhibit its resorption and is used to treat and prevent osteoporosis in postmenopausal women. Used together with vitamin D. c. Calcitonin 2. Relieve pain. Suggest that knee flexion will cause relaxation of back muscles. Heat application may provide comfort. Encourage good posture and body mechanics. Instruct to avoid twisting and heavy lifting. 3. Improve bowel elimination. Constipation is a problem of Calcium supplements and immobility. Advise intake of high fiber diet and increase fluids. 4. Prevent injury. Instruct to use isometric exercise to strengthen the trunk muscles. Avoid sudden bending strenuous lifting. Provide a safe environment.

INFLAMMATORY CONDITIONS I. OSTEOMYELITIS - 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 ETIOLOGIES Escherichia coli Neisseria gonorrhea Salmonella typhi Staphylococcus aureus (most common)

NCM 104

MUSCULOSKELETAL DISORDERS

CLINICAL & DIAGNOSTIC FINDINGS Fever (systemic and local) Pain and lack of desire to use affected limb Culture of drainage revealing infectious microorganism Elevated WBC and neutrophils(WBC: 500010000/mm3; Neutrophils: 50-70 %) Weakness, headache, nausea and vomiting Redness, edema and inflammation History of trauma

NURSING INTERVENTIONS 1. Assess site of inflammation. 2. Assess drainage from irrigating tube. 3. Assist in positioning to comfort. 4. Maintain bed rest. 5. Assist in obtaining blood specimen for culture. 6. Administer antibiotics and pain medications. 7. Offer fluids and monitor fluid status. 8. Provide divertional activities. II. BURSITIS - Inflammation of the bursa. ETIOLOGIES Excessive trauma Excessive friction Rheumatoid arthritis MANIFESTATIONS Point tenderness Limited ROM Calcified bursa History of repeated trauma NURSING INTERVENTIONS 1. Assess bursal area and surrounding tissues for ROM limitations. 2. Apply moist compress to the area. warm: decrease swelling cold: prevent swelling 3. Support inflamed tissues. 4. Arm support/sling if shoulder bursa is affected. 5. Administer prescribed medications. 6. Arrange follow up visits. 7. Refer to physical therapist for exercise regimen.

TEACHINGS 1. Teach self-care. 2. Wound care. 3. Self-administration of antibiotics analgesics. 4. Use of ambulatory aids. 5. Complete continuity of care.

and

JOINT DISORDERS I. GOUTY ARTHRITIS - Deposition of urate crystals in the joint spaces. - Build up is caused by lack of enzymes to complete purine metabolism. - Common in males. ETIOLOGIES Buildup of uric acid crystals due to incomplete metabolism of purine. Increased production of uric acid secondary to increased cell destruction. GOUT - Metabolic disorder of a defect in purine metabolism. - Purine is stored in the body tissues and joints. TOPHI - Deposit of urates in tissues (as cartilage) that is characteristics of gout.

NCM 104

MUSCULOSKELETAL DISORDERS

CLINICAL MANIFESTATION Appearance of tophi. Arthritic joint deformities. Pain on the large toe on other joints. DIAGNOSTIC FINDING Elevated serum uric acid. Joint tenderness. Red hot swollen joint. Joint fluid analysis shows characteristic of urate crystals. NURSING INTERVENTIONS 1. Assess severity and duration of pain. 2. Place on bed rest; keep covers off the inflamed joint. 3. Ice bag on inflamed joints. 4. Avoid ASA (Aspirin) because it will increase uric acid. 5. Administer prescribed medications. Example: Uricosuricagents : urinal excretion of uric acids. a. Probenecid b. Sulfinpyrazone Allopurinol: inhibit/prevent uric acid formation. 6. Monitor side effects of medications. 7. Teach client and family to control gout through diet therapy. 8. Increase fluid intake (prevent formation of renal stones). PURINE CONTAINING FOOD A. HIGH (150-1000mg/100mg) sardines liver and kidney sweet bread mussels meat soups brain and heart B. MODERATE (50-150 mg/100mg) chicken crab and salmon bacon and pork beef and ham whole grain rice beans and spinach asparagus cauliflower

II. OSTEOARTHRITIS - Most common form of degenerative joint disorder. - Chronic, NON-systemic disorder of joints. RISK FACTORS Increased age Obesity Repetitive use of joints with previous joint damage Anatomical deformity Genetic susceptibility ASSESSMENT FINDINGS Joint pain caused by: a. commonly occurs inflamed cartilage and synovium b. stretching of the joint capsule c. irritating of nerve endings Stiffness a. commonly occurs in the morning after awakening b. last only for less than 30 minutes c. decreases with movement, but worsens after increased weight bearing activity d. crepitation may be elicited DIAGNOSTIC FINDINGS X-ray narrowing joint space loss of cartilage osteophytes (spurs)

NCM 104

MUSCULOSKELETAL DISORDERS

MANAGEMENT 1. Weight reduction 2. Occupational and physical therapy 3. Pharmacologic management Use of NSAIDS Topical analgesics Intra-articular steroids to decrease inflammation NURSING INTERVENTIONS 1. Provide relief of pain. Administer prescribed analgesics. Application of heat modalities. ICE packs maybe used in the early acute stage. Plan daily activities when pain is less severe. Pain medications before exercising. 2. Advise patient to reduce weight. Aerobic exercises Walking 3. Administer medications. NSAIDS Mefenamic Acid Ibuprofen Naproxen Endometacin 4. Position the client to prevent flexion deformity. Use of foot board, splints and pillows. III. RHEUMATOID ARTHRITIS - Type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more women (ages 3545) than men3:1. FACTORS Genetic Autoimmune connective tissue disorders Fatigue, emotional stress, cold, infection ASSESSMENT FINDINGS Joint involvement is symmetrical and bilateral. Characteristically beginning in the hands, wrist and feet. Joint stiffness occurs early morning, lasts more than 30 minutes, not relieved by movement, and diminishes as the day progresses. Joints are swollen and warm. Painful when moved. Deformities are common in the hands and feet causing misalignment. Rheumatoid nodules may be found in the subcutaneous tissues. DIAGNOSTIC TESTS 1. X-ray shows a marked deformity. 2. Blood studies reveal (+) elevated ESR and CRP. ***also ANA and RF 3. Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing numerous WBC and inflammatory proteins. MEDICAL MANAGEMENT 1. Therapeutic dose of NSAIDS and Aspirin to reduce inflammation. 2. Chemotherapy with methotrexate and gold therapy. IM or oral preparation Takes several months (3-6) before effects can be seen. May cause bone marrow depression.

NCM 104

MUSCULOSKELETAL DISORDERS NURSING MANAGEMENT 1. Relieve pain and discomfort. Use splints to immobilize the affected extremity during acute stage of the disease and inflammation to reduce deformity. Suggest application of COLD PACKS during the acute phase of pain, and then HEAT application as the inflammation subsides. 2. Decrease patients fatigue. Scheduled activity when pain is less severe. Provide adequate periods of rests. 3. Promote restorative sleep. 4. Increase patient mobility. Advise proper posture and body mechanics. Support joint in functional position. Advise active ROM. 5. Provide diet therapy. Patients experience anorexia, nausea and weight loss Gluten free diet Oats, wheat, cucumber Supplements of vitamins, iron and protein

Definition Definition

Population Etiology Affected Hallmark Sign

Gouty Arthritis Uric acid build up in blood and causes joint swelling and pain Male Metabolic Lower extremities Tophi

Rheumatoid Arthritis Inflammation of joints and surrounding tissue Female Autoimmune Upper extremities Mirror Image Ankylosis

Osteoarthritis Due to aging, wear and tear on a joint Both Degenerative Weight bearing joints Heberdens Nodes Bouchards Crepitus