Prepared by:

Edwin Jonathan A. Manlapas, DDM, R.N

“ Great Minds have
purposes, others have
wishes.”
Washington
Irving
“ A winner has a plan, a
loser has an excuse.”
Musculoskeletal system
2nd largest body system

Bones, joints & skeletal muscles

Anatomy & Physiology
Skeletal System
206 bones

Multiple joints
Classification of bones by shape:
Long bones – cylindrical with
rounded ends; often bear weight
Shortbones – phalanges, small
& bear little or no weight
Flat bones – scapula
Protect vital organs; often contain
blood forming cells
Irregular bones – unique shapes;
carpal bones of the wrist, bones
in the inner ear
Classification of bone by structure:
Cortex – outer dense, compact bone
tissue
Medulla – composed of spongy
cancellous bone
Epiphyses – 2 knob-like ends
Diaphysis – bone shaft
Plays a role in growth &
development
Haversian system – structural unit
of cortical, compact bone
Cancellous tissue – with trabecula;
filled with red & yellow marrow
Hematopoiesis – production of
blood cells; happen in the red
bone marrow
Yellow marrow – contains fat cells
Osteoblasts – bone forming cells
Osteoclasts – bone destroying cells
Osteon – bone matrix; consists of
collagen, mucopolysaccharides &
lipids
Function of the skeletal system:
Provides a framework for the
body.
Supports the surrounding tissues
Assists in movement (muscles,
tendons)
Protect vital organs (heart, lungs)

Production of red blood cells

Provides storage for mineral salts

(Ca & PO4)
Calcium & Phosphorus
99% Calcium

90% Phosphorus
Serum concentration of Ca &
Phosphorus maintain an inverse
relationship
Calcitonin
Decreases the serum Ca
concentration if increased above
normal levels
Inhibits bone resorption
Increases renal excretion of Ca &
Phosphorus
Vitamin D – promotes absorption
of Ca & Phosphorus from the
small intestine; enhance PTH
activity
A decreased in Vitamin D can
result in Osteomalacia among
adults & Rickets in children
Parathyroid hormone
(Parathormone, PTH) –
stimulates bone’s osteoclastic
activity & release calcium to the
blood
Growth hormone – increase bone
length; determines the amount of
bone matrix formed before
puberty
Glucocorticoids – regulate protein
metabolism; regulate intestinal
Ca & Phosphorus absorption
Estrogens & Androgens
Estrogen stimulates osteoblastic
activities & inhibit parathormone
Testosterone – increase bone mass
by promoting anabolism
Thyroxine – increase the rate of
protein synthesis
Insulin works with growth
hormones to build & maintain
healthy bone tissue
Joint – a space in which 2 or more
bones come together
Provide movement & flexibility
in the body
Types of joint:
Synarthrodial – completely
immovable joints (Ex. Joints in
the cranium)
Ampiarthrodial – slightly
movable joints (Ex. Pelvis)
Diarthrodial (Synovial) – freely
movable joint (Ex.Elbow &
knee)
Synovial joints are the only joints
lined by synovium; a membrane
that secretes synovial fluid for
lubrication & shock absorption
 consistsof elongated cells called
muscle fibers that utilizes ATP to
generate force
 produces heat, body movements &
maintains posture
1. Skeletal muscle – attached to
the bones of the skeleton;
fibers with striations, voluntary
controlled by CNS & PNS
2. Cardiac muscle – forms most
of the wall of the heart; striated;
involuntary, controlled by ANS
intercalated discs – unique
structure of cardiac muscle
3. Smooth muscle – non-striated,
involuntary, located in walls of
hollow internal structures like
blood vessels, airways of the
lungs, stomach, intestine &
gall bladder
Contraction helps constrict the
lumen of blood vessels
CARTILAGE
CostalCartilage – connects
sternum to rib cage
Yellow Cartilage – external ear,
epiglottis
Hyaline Cartilage – septum of
nose, larynx, trachea
TENDONS – bands of tough,
fibrous tissue that attach muscles to
bones

LIGAMENTS – attach bones to

other bones at joints
Decreased bone density
Increased bone prominence

Kyphotic posture : widened gait,

shift in the center of gravity
Cartilagedegeneration
Decreased ROM

Muscle atrophy , decreased

strength
Slowed movement
History
Demographic data:
Young men – risk for trauma R/T
motor vehicle crashes
Older adults – risk for falls
fracture, soft tissue injury
Family history and genetic risk :
Osteoporosis – age related bone
loss
Bone cancer

Osteoarthritis
Personal History :
Accidents, illnesses, lifestyle,
medication
Level of physical activity

Traumatic injuries

Participation in sports/sports injuries

Diet History :
Determine risk of inadequate
nutrition
Lactose intolerance → affect Ca
intake
Insufficient Vitamin C or D →
inhibits healing of bone and
tissue
Obesity→ places excess stress
and strain on bones and joints
Socioeconomic Status:
Computer related jobs→ carpal
tunnel syndrome ( entrapment
of median nerve in the wrist )
Construction worker, Health
care workers → back injury
Athletes → joint dislocation,
fractures
Current Health Problems:
PAIN – most common complaint
- acute or chronic
- best if client describes the
pain in his/her own words
PQRST Model
P rovoking incident
Q uality of pain
R egion, radiation and relief
S everity of pain
T ime
General Inspection
Posture – body build and alignment
when standing and walking
Gait – two phases of normal,
automatic gait
1. Stance phase
Antalgic gait – abnormality in the
stance phase of gait
 Part of one leg is painful, the
person shortens the stance phase
on the affected side
2. Swing phase
Lurch – abnormality in the swing phase
Occur when muscles in the buttocks
and/or legs are too weak to allow the
person to change weight from one foot
to the other
Mobility
Goniometer – a tool use to provide
an exact measurement of ROM
Assessment of the Head & Neck
- inspect, palpate the skull
(shape, symmetry, tenderness and
masses)
Common abnormal findings:
1. tenderness and pain
2. crepitus ( grating sound )
3. spongy swelling
Assessment of the spine
Both hands are placed over the
lumbosacral area, apply pressure
with thumb
Lordosis – in pregnancy , in
abdominal obesity
Scoliosis – client flexes forward
from the hip, inspect lateral
curve
Assessment of the Upper
Extremity
Assessment of the Lower
Extremity
genu valgum ( “knock knee “)
genu varum ( “bow-legged )
Neurovascular Assessment
Lovett’s Scale for Grading Muscle
Strength
5 Normal : ROM unimpaired
against gravity with full resistance
4 Good : can complete ROM
against gravity with some resistance
3 Fair : can complete ROM against
gravity
2 Poor : can complete ROM with
gravity eliminated
1 Trace : no joint motion and
slight evidence of muscle
contractility
0 Zero : no evidence of muscle
contractility
LABORATORY PROFILE
Serum Calcium( 9-10.5 mg/dL )

Hypercalcemia :
• Metastatic cancers of the bone

• Paget’s Disease

• Bone fractures in healing stage

Hypocalcemia:
• Osteoporosis

• Osteomalacia
Serum Phosphorus ( 3–4.5 mg/dL )
Hyperphosphatemia:
• Bone fracture in healing stage

• Bone tumors

• Acromegaly
Hypophosphatemia:
• Osteomalacia
Alkaline Phosphatase, ALP
(30-120 units/L)
Elevations may indicate :
• Metastatic cancers of the bone

• Paget’s Disease

• Osteomalacia
Serum muscle enzymes
Creatinine kinase ,CK
Men : 55-170 units/L
Women : 30-135 units/L
Elevations may indicate :
Muscle trauma ; Effects of EMG

Progressive muscular dystrophy

Lactate dehydrogenase, LDH
Total LDH: 100-190 units/L
Elevations may indicate:
• Skeletal muscle necrosis

• Extensive cancer

• Progressive muscular dystrophy

Aspartate aminotransferase, AST
( 0-35 units/L )
Elevations may indicate:
• Skeletal muscle trauma

• Progressive muscular dystrophy

Aldolase, ALD ( 3-8.2 units/dL )
Elevations may indicate:
• Polymyositis and
dermatomyositis
• Muscular dystrophy
RADIOGRAPHIC
EXAMINATIONS
Standard Radiography ; CT Scan
Tomography – produces planes
or slices , for focus and blurs the
image of other structures
Xeroradiography – highlights the
contrast between structures
Myelography – involves
injection of contrast medium or
dye into the subarachnoid space
of the spine usually by spinal
puncture
Arthrography – x-ray study of
the joint after contrast medium
(air or solution ) has been
injected to enhance its
visualization
Other Diagnostic Tests:
Bone biopsy – the doctor extracts
a specimen of
bone for microscopic exam
Muscle biopsy – done for the
diagnosis of atrophy and
inflammation
Electromyography (EMG) –
accompanied by nerve conduction
studies for determining the
electrical potential generated in
individual muscle
-
Diagnosis of neuromuscular,
lower motor neuron and
peripheral nerve disorder
Client Prep: skeletal muscle
relaxant is d/c by the doctor
Procedure: at bedside or EMG
laboratory
Nerve conduction tested 1st –
flat electrodes placed along the
nerves
muscle potential – multiple
needle electrodes , ½ -3 inches
Follow up care:
• inspect needle site for hemato-

ma formation→ apply ice

• check complain of inc. pain and
anxiety
Arthroscopy – for diagnostic test
or surgical procedure
Arthroscope – a fiberoptic tube
inserted into a joint for direct
visualization
Client Prep: client must be able to
flex knee at least 40 degrees
- CI if client have joint infection
- ambulatory basis/same day
surgery
Procedure:
- local, light general or epidural
anesthesia
- knee flexed at 40 degrees,
irrigated
- less than ¼ inch incision, insert
arthroscope
Follow up care:
1. evaluate neurovascular status of
affected limb
2. monitor distal pulses, warmth,
color, capillary refill, movement,
pain, sensation of affected limb
3. Encourage client to perform
appropriate exercises
4. Ice – used for 24 hrs
5. Elevate extremity for 24-48 hrs
6. Monitor/ observe for:
Swelling, Hypothermia

Increase joint pain due to

mechanical injury
Thrombophlebitis, Infection
Bone scan – radionuclide test in
which radioactive material is
injected for visualization of the
entire skeleton
- detect tumors, osteomyelitis,
arthritis,vertebral compression
fracture, osteoporosis,
unexplained bone pain
Gallium/Thallium Scan – similar
to bone scan but more specific
and sensitive in detecting bone
problem
Radioisotopes used:
Gallium citrate - most common

Thallium - osteosarcoma
Client prep: Doctor/technician
administer isotope 1-2 days
before scanning
Procedure: 30-60 minutes, mild
sedation for older clients or in
severe pain, lie still
Follow up care:
encourage to push fluids
Magnetic Resonance Imaging –
image produced through the
interaction of magnetic fields,
radio waves and atomic nuclei
showing hydrogen density
- more accurate than CT scan and
Myelography
- Gadolinium-DTPA
(diethylenetriamine-pentacetid
acid ) – contrast agent
- remove all metal objects, check
clothing zippers and metal
fasteners, surgical clip
Ultrasonography – sound waves
produce an image of the tissue
Visualizes:
• Soft tissue disorder

• Traumatic joint injuries

• Osteomyelitis

• Surgical hardware placement

Common Health Problems of the
Neonate & Infant:
Congenital Hip Displacement
Head of the femur is
improperly seated in the
acetabulum, or hip
socket of the pelvis
Acetabulum of the pelvis is shallow.
Occurs most often among children of
Mediterranean ancestry
6 times more frequently among girls
than boys
Can be congenital or develop
after birth
I. Dysplasia of the Hip
Assessment
Neonates: laxity of the
ligaments around the hip
Infants beyond the newborn
period
Affected leg appears shorter than
the normal leg
Unequal number of skin folds on
the posterior thigh
Asymmetry of the
gluteal & thigh skin folds
Limited range of motion
(ROM) in the affected
hip
Asymmetric abduction of
the affected hip
Apparent short femur on
the affected side
(Galeazzi sign, Allis
sign)
Galeazzi sign – apparent
shortening of the femur; as
shown with the difference of
knee levels with the knees &
hips flexed at right angle when
patient is lying on a flat table
The walking child:
minimal to pronounced
variations in gait w/
lurching toward the
affected side; positive
Trendelenburg sign
Positive Barlow or
Ortolani’s maneuver
Barlow’s maneuver – performed
by adducting the hip (bringing
the thigh towards the midline)
while applying a light pressure
on the knees with the force
directed posteriorly
PositiveBarlow test – if the hip
can popped out from the socket
Ortolani’stest or maneuver –
physical exam for hip dysplasia
Performed by gently abducting
the infant’s leg with the
examiner’s thumb while placing
an anterior pressure on the
greater trochanter (index &
forefinger)
Positive sign is a distinctive
“clunk” which can be felt or
heard as the femoral head
relocates anteriorly into the
acetabulum
Diagnotic tests:
X-ray (shows shallow
acetabulum)
Sonogram

Magnetic Resonance Imaging

Implementation
In the neonatal period,
splinting of the hips w/
Pavlik harness to
maintain flexion &
abduction & external
rotation
Multiple diapers – effectively
separates the legs
Frejka splint – parents must keep
the splint at all times except when
bathing or changing diapers
Following the
neonatal period,
traction &/or surgery
to release muscles &
tendons
Bryant’s skin traction
Following surgery,
positioning &
immobilization in a
Spica cast
Osteotomy following
traction in profoundly
affected children
Pavlik Harness – an adjustable
chest halter that abducts the legs
Method of choice for long term
therapy; reduces therapy to 3-4
weeks, simplifies care
The defect may be
unilateral or bilateral
Long-term interval
follow-up is required
“Talus” – ankle
“Pes” – foot

1 in every 1000 children born

with the defect
Boys are affected than girls
Congenital Clubfoot
Assessment
The foot is plantar
flexed w/ an inverted
heel & adducted
forefoot
Implementation
Treatment begins as
soon after birth as
possible
Serial manipulation &
casting are performed
weekly, if correction is
not achieved in 3 to 6
months, surgery is
indicated
Monitor
neurovascular status of
the toes
Instruct parents in cast
care & the signs of
neurovascular
impairment that
requires physician
 Dennis Browne Splint
For clubfoot/congenital Talipes
Equinovarus
Tendon is short – complete soft
tissue release
Torticollis (wry neck) – head is
tilted/turned to 1 side; chin is
elevated & turned to the opposite
side
Head position should be
corrected before adulthood
Affects 2% of newborn
Diagnosis:
History taking – determine
circumstances surrounding birth,
trauma or associated symptoms
Physical examination – shows
decreased rotation & bending to
the side opposite the muscle
affected
Neck muscles/areas between
the neck & shoulder are tense &
tender
Management:
Medications (muscle
relaxants/NSAIDs)
Physical devices
Botulinum toxin
Surgery
Radiographic examination –
radiographs of the cervical spine
MRI – for structural problems
Common health Problem of
Young Adolescent
Scoliosis
Scoliosis
A lateral curvature of
the spine
Assessment
Visible curve fails to
straighten when the
child, bends forward &
hangs down toward feet
Hips, ribs, & shoulders
are asymmetrical
Apparent leg length
discrepancy
Assessment
Implementation
Prepare the child &
parents for the use of a
brace if prescribed
Prepare the child &
parents for surgery (spinal
fusion; placement of
internal instrumentation
rods) if prescribed
Braces
Usually worn from 16
to 23 hours a day
Keep the skin clean &
dry, avoiding lotions &
powders
Advise the child to
wear soft nonirritating
clothing under the
brace
Common Health Problem of the
Young Adult:
Osteogenic Osteosarcoma
Osteosarcoma/Osteogenic
sarcoma
Most common type of primary
malignant tumor
50% occur in distal femur
Primary – those that originate in
bone
Secondary – those that originate
in other tissues & metastasize to
bone
Clinical Manifestations:
Pain

Swelling

Large lesion

Sclerotic central mass

Sunburst appearance
Inward bony expansion
Incidence:

Occurs more often in males than

females (2:1); 10-20 y/o
Older clients with Pagets disease
Primary tumors (breast, prostate,
kidneys, thyroid, lungs) bone
seeking tumor cells carried to
bone (blood stream) pathologic
fracture
Laboratory Assessment:
Elevated serum alkaline
phosphatase
Elevated serum Ca level

Elevated ESR
Radiographic Assessment:
Bone destruction

Irregular periosteal new bone

Cortical breakthrough

Increase/decrease bone density

MRI

Bone scan
Nursing diagnoses:
Acute/Chronic Pain r/t physical
injury
Anticipatory grieving r/t change
in body image
Disturbed body image r/t effects
of illness, treatment including
surgery
Interventions:
Treatment is aimed at reducing
the size/removing tumor
Drug therapy – analgesics,
chemotherapeutic agents
Radiation therapy – reduce
tumor size & pain
Surgery
Common Health Problems of the
Adult:
Adult Rheumatoid Arthritis
Rheumatology – study of
rheumatic disease
Rheumatic disease –
disease/condition affecting the
musculoskeletal system
Arthritis– inflammation of one
or more joints
Rheumatoid Arthritis (RA)
Most common connective tissue
disease
Most destructive to the joints
Chronic, progressive, systemic
inflammatory autoimmune
disease affecting the synovial
joints
characterized by remissions &
exacerbations
Autoantibodies (rheumatoid factors
RF’s) are formed attack healthy
tissues (synovium) inflammation of
synovial membrane synovium
thickens fluid accumulates in joint
space pannus formation erosion of
cartillage bone erosion
Pannus – vascular granulation
tissue composed of inflammatory
cells; erodes the cartillage &
eventually destroys bone
Etiology of RA is unclear;
research suggests a combination
of genetic & environmental
factors
Some researchers suspect female
reproductive hormones
Epstein Barr virus

Physical/emotional stress
Clinical Manifestations:
Joint stiffness

Swelling

Pain

fatigue
Generalized weakness
Morning stiffness

Upper extremity joints affected

(proximal
interphalangeal/metacarpophalange
al joints)
Bilateral/symmetric joint
affectation; number of joints
affected increases
Gel phenomenon – morning
stiffness that lasts 45 minutes to
several hours upon awakening
Swan neck
Ulnar deviation
Laboratory Assessment:
No single test that confirms the
disease
Rheumatoid factor – measures the
presence of unusual antibodies
IgM, IgG types
Antinuclear Antibody Titer
Erythrocyte Sedimentation Rate
(ESR) – diagnosis of
inflammatory CT disease
C Reactive Protein test
Standard X-ray – visualize joint
changes & deformities
CT Scan – determines cervical
spine involvement
Arthrocentesis – synovial fluid is
analyzed for inflammatory cells
& immune complexes; RF
included
Nursing responsibility:
Monitor insertion site for
bleeding/leakage of synovial fluid
Teach the client to use ice & rest
affected joint for 24 hrs.
Management:
NSAID’s

Disease-Modifying Anti-
Rheumatic Drugs –
hydroxychloroquine (Plaquenil)
Sulfasalazine(Azulfidine)
Minocycline (Minocin)

Methotrexate (Rheumatrex) –
immuno suppressive medication
Gold therapy
Gold sodium thiomalate
(Myochrysine)
Nonpharmacologic modalities:
Adequate rest

Proper positioning

Ice & heat applications

Gouty Arthritis (Gout) – systemic
disease in which urate crystals
deposit in joints causing
inflammation.
2 types of gout:
1. Primary gout – most common
type; results from 1 of several
inborn errors of purine
metabolism
Production of uric acid exceeds
the excretion capability of the
kidneys
Sodium urate is deposited in
synovium causing inflammation
2. Secondary gout – involves
hyperuricemia (excessive UA in
blood) caused by another
disease
Renal insufficiency, diuretic
therapy, chemotherapeutic
agents; multiple myeloma
4 phases of the primary disease:
1. Asymptomatic hyperuricemic
phase – serum level elevated; no
overt signs of disease
2. Acute phase – 1st attack of
gouty arthritis; excruciating
pain in 1 or more small joints
(metatarsophalangeal joint of
the great toe)
Podagra – 75% experience
inflammation of this joint as the
initial manifestation
Elevated ESR & WBC
3. Intercritical/Intercurrent state of
the disease – attack occurs after
months or years; asymptomatic;
no abnormalities found in joints
4. Chronic tophaceous gout –
deposits of urate crystals
develop under the skin & major
organs
Gout affects more men than women
Clinical Manifestations:
Acute gout – Painful inflamed
joints
Chronic gout – inspect for tophi
Tophi – deposits of Na urate
crystals; commonly appear on
the outer ear
Arms & fingers near the joints

Renal calculi
Diagnostic tests:
Serum uric acid – more than 8
mg./100 ml.
Urinary uric acid levels – more
than 600 mg./24 hr after a 5 day
restriction of purine intake
Synovial fluid aspiration
(arthrocentesis) – detect the
presence of needle-like crystals
Drug therapy:
Colchicine (Colsalide) – works
within 12 hrs.
Repeated acute gout/chronic gout
– Allopurinol (Zyloprim) –
promotes uric acid excretion
Nurse monitors serum uric acid
levels to check the effectiveness
of medications
Diet therapy:
 Strict low-purine diet; avoid
foods such as organ meats,
shellfish, oily fish with bones
(sardines)
Avoid aspirin & diuretics
Avoid excessive
physical/emotional stress
Force fluids
Intake of Alkaline ash foods –
citrus foods & juices, milk
Carpal Tunnel Syndrome
Carpal tunnel – rigid canal
between the carpal bones and
flexor retinaculum
Compressed median nerve in the
wrist
Pain and numbness

Paresthesia ( painful tingling )

Etiology and Genetic risk:
Excessive hand exercise

Edema or hemorrhage into CT

Thrombosis of the median artery

CTS – most common repetitive
strain injury (RSI)
- fastest growing type of
occupational injury : factory
worker, computer operators etc;
sports activities ( golf, tennis )
Incidence and prevalence :
Adults – bet 30-60 yrs old

Women

Dominant hand

Children and adolescent –

computer use
Clinical Manifestation:
 Phalen’s maneuver/test

Relax the wrist into flexion

Place back of hands together and
flex both wrist
(+) – paresthesia palmar side of
thumb, index and middle finger,
radial half of ring finger
Tinel’s sign
Lightly tapping area of median
nerve in the wrist
(+) – paresthesia
BP cuff placed on the upper
arm , inflated to the client’s
systolic pressure
(+) – pain and tingling
Diagnostic Assessment :
Xray – bone changes, lesions,
synovitis
EMG- nerve dysfunction
MRI ,UTZ
Finding : Enlarged median nerve
within the carpal tunnel
Interventions:
 Nonsurgical

Drug – NSAIDS

Immobilization - splint
Surgical
Open carpal tunnel release
(OCTR)
Endoscopic carpal tunnel release
( ECTR )
Synovectomy – for rheumatoid
arthritis , complication of CTS
Post Operative Care:
Elevate hand and arm above
heart level
Check neurovascular status
Move fingers of affected hand
Restrict hand movements, lifting
heavy objects – 4 to 6 wks after
surgery
Musculoskeletal disorders:
Metabolic bone diseases
(osteoporosis, Paget’s disease)
Bone tumors

Bone deformities
Osteoporosis
Metabolic disease

bone demineralization

Decreased bone density

Fractures
“silentdisease”
Mostly affected are wrists, hip &
vertebral column
Osteoclastic (bone resorption) activity
exceeds osteoblastic (bone building)
activity decreased bone mineral
density (BMD) loss of spongy
bone/cortical bone
fragile bone tissue Fracture
Diagnosis is based on BMD values
using T-scores
T-score – the number of standard
deviations above or below the
average BMD for young, healthy
white women
Osteopenia – T-score between 1 &
2.5
Osteoporosis among
postmenopausal women BMD T-
score more than 2.5 standard
deviations below normal
2 theories in osteoporosis:
May result from decreased
osteoblastic activity
Increased osteoclastic (bone
resorption) activity
Classification of osteoporosis:
1. Generalized osteoporosis:
Involves many structures in the
skeleton
Primary osteoporosis – occurs
among postmenopausal
women/men in 6th or 7th decade
of life
Decrease estrogen/testosterone
Secondary osteoporosis – results
from associated medical
conditions (hyperparathyroidism,
long term corticosteroid use,
prolonged immobility)
2. Regional osteoporosis –
occurs when limb is
immobilized r/t fracture,
injury, paralysis or joint
inflammation
Immobilization greater than 8-12
weeks
Exact cause of osteoporosis is
unknown
About 98% of peak bone mass
achieved by 20 years of age
Building strong bone as a young
person – best defense against
osteoporosis in later adulthood
(National Osteoporosis
Foundation 2003)
Most health care providers focus
on the risk of osteoporosis in
women older than 50 years old
& do not assess risk as often in
women 49 years of age &
younger (Berarducci et.al 2000)
Risk factors:
Postmenopausal women

Breast Ca survivors

Genetics – Hx of fracture among

a 1st degree relative
Thin, lean built White, Asian
women
Protein deficiency

Alcohol consumption/Cigarette
smoking
Incidence
Women are affected than men
80%
1.5 million fractures/year

300,000 are hip fractures

Clinical Manifestations:
“dowager’s hump” or kyphosis of
the dorsal spine
Client verbalized that height has
been shortened (2-3 inches)
Backpain occurs after lifting,
bending or stooping
Pain is worsened by activity &
relieved by rest
Laboratory Assessment:
No definite laboratory test that
confirm a diagnosis of primary
osteoporosis
uPYR Crosslinks assay – measures
urinary concentrations of
pyridinium; a collagen substance
found in bone & cartilage
Increased urinary levels indicate
bone resorption
Radiographic Assessment
X-rays of the spine & long bones
show loss of bone density &
fractures
Bone density changes are evident
if 25-40% of bone loss has
occurred
Dual-energy x-ray absorptiometry
(DEXA) – painless scan that
measures
bone mineral density (BMD)
Physicians recommend that
women in their 40’s have a
baseline DEXA
Nursing diagnoses:Impaired
physical mobility r/t decreased
muscle strength, pain
Acute/Chronic pain r/t effects of
acute physical illness
Interventions:
Medications

Nutritional therapy

Exercise
Drug therapy:
HRT

Ca supplements

Vitamin D
Biphosphonates

Selectiveestrogen receptor
moduloators (SERM’s)
Calcitonin
Hormone Replacement Therapy
(HRT)
Used as primary prevention
strategy for reducing bone loss
among post menopausal woman
Long term effects of HRT include
breast’s CA, CV disease & stroke
Parathyroid hormone –
teriparatide (Forteo), SQ injection
Calcium – not a treatment for
osteoporosis; it is an important
part of the prevention program in
promoting bone health
Ca carbonate (Tums, OsCal)
Teach clients to take Ca with food
& 6-8 ounces of H20
Instruct clients to take foods rich
in Ca (Milk & dairy products,
green leafy vegetables)
Vitamin D for optimal Ca
absorption in the small intestines
Bisphosphonates – inhibit bone
resorption by binding with
crystal elements in bone
 alendronate (Fosamax),
ibandronate (Boniva), risedronate
(Actonel)
Nursing Alert:
Instruct clients to take the drug early
in the morning with 8 oz.
of H2O & wait 30 minutes
before eating. Must remain
upright during the 30 minutes
before eating
Selective Estrogen Receptor
Modulators (SERM’s)
Designed to mimic estrogen in some
parts of the body & blocking its
effect elsewhere
Raloxifene (Evista)
Calcitonin – inhibits osteoclastic
activity
Diet therapy – Ca & Vitamin D
intake must be increased; alcohol
& caffeine consumption must be
discouraged
Fallprevention – a hazard free
environment is necessary
“Falling star protocol”

Exercise – PT’s prescribed

exercises that strengthen the
Abdominal & back muscles;
active ROM exercises
Walking 30 minutes 3X a week,
swimming & bicycling are
recommended
Bowling & horseback riding are
avoided – may cause vertebral
compression
Orthotic devices or dorsolumbar
orthoses – immobilize the spine
during acute pain phase &
provide spinal column support
Osteomalacia – softening of the
bone tissue; characterized by
inadequate mineralization of
osteoid
Etiology
Primary Vitamin D deficiency –
lack of sunlight exposure, poor
dietary intake, malabsorption of
Vitamin D
Hypophosphatemia

Intake of barbiturates,
anticonvulsants & fluoride
Incidence:
Common among non
industrialized nations
Strict vegetarians without adequate
supplement of Vitamin D
Muscle weakness
Joint pain

Waddling & unsteady gait (due

to muscle weakness)
Diagnostic Assessment:
X-ray – reveal a decrease in the
trabeculae of cancellous bone &
lack of osteoid sharpness
Classic diagnostic finding –
presence of radiolucent bands
(Looser’s lines/zones)
Looser’s zones – stress fractures
that have not mineralized.
Bone biopsy will confirm the
diagnosis
Interventions:

Major treatment is Vitamin D

RDA – 400 IU
Meeting the RDA for Vitamin D
Advise clients to get sun exposure
for at least 5 minutes weekly
Eat food high in Ca to promote
Vitamin D absorption
Eat foods high in Vitamin D
including milk & dairy products,
ice cream, yogurt & cheese
Egg, swordfish, chicken, liver &
cereals
 Characteristic Osteoporosis Osteomalacia
Definition Decreased bone Demineralized
mass bone
Pathophysiology Lack of Ca Lack of Vitamin D
Radiographic Osteopenia/fractur Pseudofractures,
Findings es Looser’s zone,
fractures
Calcium level Normal Low or Normal
Phosphate level Normal Low or Normal
Parathyroid Normal High or Normal
hormone
Alkaline Normal High
Osteoarthritis (Degenerative Joint
Disease DGD)
 most common arthritis

2nd most common cause of disability

among adults in U.S.
Common cause of disability worldwide
Progressive deterioration & loss
of cartilage in 1 or more joints
Affects weight bearing joints
(hips, knees, vertebral column)
Cartilage becomes soft fissures/pitting
develop cartilage thins joint space
narrows bone spurs formed
inflammatory enzymes enhance
tissue deterioration
repair process fails
Causative mechanism of primary
Osteoarthritis at the cellular level
has not yet identified
Predisposing factors:
Developmental

Genetic

Metabolic

Trauma
Age – strongest risk factor
About ¾ of people older than 55
y/o has joint changes seen in X-
rays
Health promotion/ Illness
prevention:
Keep weight within normal
limits
Avoid/limit activities that
promote stress on joints (jogging)
Limit participation in recreational
sports, risk seeking activities to
prevent trauma
Assessment:
 Ask questions about the course of
the disease
Collect information specific for
OA (nature/location of joint pain)
Ask clients about their
occupation, nature of work, Hx
of trauma, weight history &
exercise
Physical Assessment:
Middle-aged/older women who
complains of chronic joint pain
or stiffness
Pain during palpation/ROM
Crepitus

Enlarged joints
Heberden’s nodes – (distal
interphalangeal joint)
Bouchard’s nodes – (proximal
interphalangeal joint)
Atrophy of skeletal muscles

Hip/knee pain cause the client to

limp
Laboratory assessment:
Elevated erythrocyte
sedimentation rate (ESR)
High-sensitivity C-Reactive
Protein
Radiographic assessment:
Structural joint changes

CT scan

 MRI
Nursing Diagnoses:
Chronic pain r/t muscle spasm,
cartilage degeneration & joint
inflammation
Impaired physical mobility r/t pain
& muscle atrophy
Major concern is pain control
Non-surgical management:
Analgesics

Rest

Positioning

Thermal modalities
Acetaminophen (Tylenol) – drug
of choice
NSAID’s

Direct injection with cortisone

Rest
Local rest – immobilizing a joint
with a splint or brace
Systemic rest – immobilizing the
whole body – nap
Psychological rest – relief from
daily stress
Positioning – joint in functional
position; small pillow under the
neck or head
Elevate the legs (8-12 inches)
Thermal modalities:

Heat application (hot showers,

baths, hot packs, compresses &
moist heating pads)
Weight control
Transcutaneous Electrical Nerve
Stimulation (TENS)
Stem cell therapy
Surgical Management:
Total joint arthroplasty – surgical
creation of a joint
Arthroscopy- less invasive
procedure to remove damage
cartilage
Total hip arthroplasty –
performed among clients greater
than 60 y/o
Common complication -
subluxation
Position client in supine position
with the head slightly elevated
with abduction pillow in
between the legs to prevent
adduction
Lifethreatening complication –
Deep Venous thrombosis (DVT)
& pulmonary embolism
Use thigh high stockings &
sequential compression devices
Anticoagulant:
Low molecular weight heparin

Aspirin
Client getting out of bed – stand
on the side of affected leg; client
assumes sitting position, client
stands on the unaffected leg &
pivot to the chair with assistance
Client must not flex the hips
more than 90 degrees
Partial weight bearing allowed
for the 1st few weeks/x-ray
evidence of bony growth
 Characteristic Rheumatoid Osteoarthritis
Arthritis (RA) (OA)
Age of onset 35-45 y/o > 60 y/o
Gender Affected Female (3:1) Female (2:1)
Risk factors/cause Autoimmune Aging, genetic
(Genetic) factor, obesity,
trauma,
occupation
Disease process Inflammatory Degenerative
Disease pattern Bilateral, Unilateral, single
symmetric, joint, affects
multiple joints, weight bearing
usually affects joints &
upper extremities hands,spine
first Metacarpophalang
Distal eal joint spared
interphalangeal Non-systemic
joints of hands
spared
Systemic
Lab findings Elevated Normal or slightly
rheumatoid factor, elevated ESR
antinuclear
antibody, ESR

Dug therapy NSAID’s, NSAID’s,

Corticosteroids, Acetaminophen
Methotrexate,
Leflunomide
(Arava
Osteomyelitis –
inflammation/Infection of bone
tissue
Exogenous osteomyelitis –
infectious organisms enter from
outside of the body (from open
fracture)
Endogenous osteomyelitis
(hematogenous osteomyelitis)–
organisms are carried by the
blood stream from other areas of
infection
Contiguous bone infection
results from skin infection of
adjacent tissues
2 Major types of Osteomyelitis:
Acute hematogenous infection –
results from bacteremia,
underlying disease or non-
penetrating trauma
Subchronic/chronic
osteomyelitis – due to
inadequate treatment.
About 50% of cases due to gram
negative bacteria
Incidence
Hematogenous osteomyelitis is
the most common type
More common among children;
increasingly common in adults
Men experience osteomyelitis
more frequently than women
Bone tissue in vertebrae & long
bones are common sites of
infection
Assessment
Bone pain – common complaint of
client’s with bone infection
Constant, localized, pulsating
sensation that intensifies with
movement
Fever (> 38° C)
Area of infected bone swells;
tender to palpation
Erythema

Draining ulcers
Elevated WBC count
Elevated ESR value

Bone scan using technetium or

gallium is helpful in the
diagnosis
Definitive diagnosis – bone
biopsy
Nursing Diagnoses:
Acute/Chronic Pain r/t
inflammation
Hyperthermia r/t pathogenic
invasion of the bone
Ineffective tissue perfusion
(peripheral) r/t tissue swelling
Interventions:
IV antibiotics

Hyperbaric Oxygen Therapy –

affected area is exposed to a
high concentration of O2 that
diffuses in the tissues to promote
healing
Sequestrectomy – to debride the
infected bone; allow
revascularization of tissues
Common Health Problems Across
the Life Span:
Fractures

Traction
Fracture – break or disruption in
the continuity of bone
Caused by direct blow, crushing
force, sudden twisting motion or
extreme muscle contraction
Classification of fractures:
According to the extent of the break:
Complete fracture – break is across
the entire width; bone is divided
into 2 distinct sections
Incomplete fracture – partial
break in the bone; break is
confined through only part of the
bone
According to the extent of
associated soft tissue damage:
Open (Compound) – skin over
broken bone is disrupted; soft
tissue injury & infection are
common
These are graded to define the
extent of tissue damage:
Grade 1 – least severe injury;
skin damage is minimal
Grade 2 – accompanied by skin
& muscle contusions
Grade 3 – damage to the skin,
muscle, nerve tissue & blood
vessels
Wound is more than 6-8 cms.
Closed (simple) fracture – skin
over the fractured area remains
intact
Pathologic ( spontaneous) –
occurs after minimal trauma to a
bone that has been weakened by
a disease
Greenstick fracture – one side of
bone is broken, the other is bent,
most commonly seen in children
Classification According to
pattern:
Transverse fracture – bone is
broken straight across
Oblique fracture – the break
extends in an oblique direction;
slanting direction
Spiral fracture – the break
partially encircles the bone
Classification as to appearance:
Comminuted – bone is splintered
or crushed with 3 or more
fragments
Impacted – when fractured end
of bones are pushed into each
other
Compression fracture – produced
by a loading force applied to the
long axis of cancellous bone
Depressed – usually occurs in
the skull; broken bone driven
inward
Longitudinal – break runs
parallel with bone
 Fracture dislocation – fracture is
accompanied by a bone out of
joint
 Fatigue or stress fracture results
from excessive strain or stress
on the bone
Fractures
Classification in relation to the
joint:
Intracapsular within the joint
Extracapsular – outside the capsule
Intra-articular – within the joint
Classification as to Location:
Proximal

Distal

Mid-shaft
Clinical Manifestations:
Pain or tenderness over the
involved area
Swelling

Loss of function
Obvious deformity
Crepitus – grating sensation
either heard or felt
Erythema, Edema
Muscle spasm/impaired
sensation
Bleeding from an open wound
with protrusion of fractured bone
Principles of fracture treatment:
Reduction of bone fragments to
normal position &
immobilization
Maintenance of reduction until
healing is sufficient to prevent
displacement
Preservation & restoration of
musculoskeletal function
Stages of bone healing:
1. Hematoma formation – blood
accumulates into the area between
& around the fragments. The clot
begins 24 hrs after the fracture
occurs
2. Cellular proliferation – (within
5 days) hematoma undergoes
organization. Fibrin strand form
with the clot creating a network
for revascularization & invasion
of fibroblast & osteoblast.
 Beginning of external
cartilaginous callus formation.
(osteoid tissue)
3. Callus formation – (2-3
weeks) minerals are being
deposited in the osteoids forming
a large
mass of differentiated tissue
bridging the fractured bone.
4. Ossification – mineral
deposition continues & produces
a firmly reunited bone. Final
ossification takes
3-4 months.
5. Consolidation & remodeling –
final stage of fracture repair
consists of removal of any
remaining devitalized tissue &
reorganization of new bone
Interventions for Fracture:
Reduction

Fixation

Traction

Casts
Reduction – restoring the bone to
proper alignment
Closed Reduction – performed by
manual manipulation
Maybe performed under
local/general anesthesia
Open Reduction – involves surgical
intervention
Treated with internal fixation
devices
Client may be placed in traction or
cast following the procedure
Fixation
Internal fixation – follows open
reduction
Involves the application of screws,
plates, pins, nails to hold the bone
fragments in alignment
May involved the removal of
damaged bone & replacement
with a prosthesis
Provides immediate bone
strength
Risk of infection is associated
with this procedure
 External fixation – an external
frame is utilized with multiple
pins applied through the bone
Provides more freedom of
movement than with traction
Roger Anderson External Fixator
(RAEF)
For fracture of the tibia, radius,
ulna done under anesthesia
Ilizarov fixator – for severe
comminuted fracture, bone
lengthening
 Plaster cast – a temporary
immobilization device which is
made up of gypsum sulfate
Undergoes unhydrous calcinations
when mixed with water, swells &
forms into a hard cement
Made of rolls of plaster bandage,
wet in cool water & applied to the
body
Cools after 15 minutes

Requires 24-72 hrs to dry

completely
 Non-plaster cast –(fiberglass
cast)
Lighter in weight, stronger,
water resistant & durable
Impregnated with cool water-
activated hardeners & reach full
rigidity in minutes
Diminish skin problems
Functions:
To immobilize

To prevent or correct deformity

To support, maintain & protect

realigned bone
Topromote healing & early
weight bearing
Materials for casting:
Stockinette

Wadding sheet

Plaster of Paris
Complications of cast:
1. Neurovascular compromise
Watch out for 6 P’s:
Pain

Pulselessness

Pallor
Paresthesia

Paralysis

Poikilothermia
2. Incorrect alignment
3. Cast syndrome – (Superior
mesenteric artery syndrome)
occurs with body casts; any
cast that involves the abdomen
Decreases the blood supply to
the bowel
Signs/Symptoms:

Abdominal pain, nausea &

vomiting
4. Compartment syndrome –
increased pressure within a
limited space, compromises
the function & circulation in
the area
Long arm posterior mold
Fracture of radius/ulna with open
wound, swelling or infection
Mechanical Aids for Walking:
Canes:

Standard straight-legged cane

Tripod or crab cane

Quad cane – provides the best support

Standard cane – 36 inches in
length
The length should permit the
elbow to be slightly flexed
Health Teachings:
Hold the cane with the hand on the
stronger side of the body
Position the standard cane 6 inches
to the side & 6 inches in front of
the near foot.
When Maximum Support is
Required:
Move the cane forward 1 foot
while the body weight is borne
by both legs
Move the weak leg forward to
the cane while weight is borne
by the cane & stronger leg
Move the stronger leg forward
ahead of the cane & weak leg
while the weight is borne by the
cane & weak leg.
Walkers – for ambulatory clients
needing more support than a
cane provides.
Client needs to bear at least
partial weight on both legs

Hand bar below the client’s
waist & client’s elbow slightly
flexed
Crutches
Axillary crutch with hand bars

Loftstrand bar – extends only to

the forearm; substitute to cane
Canadian or Elbow Extensor
Crutch – made of single tube of
aluminum with lateral
attachments, a hand bar, cuff for
the forearm & has a cuff for the
upper arm
Nursing Alert:
The weight of the body must be
borne by the arms rather than the
axillae (can injure the radial
nerve, eventually can cause crutch
palsy)
CrutchPalsy – weakness of the
muscles of the forearm, wrist &
hand
Measuring Clients for Crutches:
To obtain the correct length for
the crutches & the correct
placement of the handpieces
2 ways to measure the crutch
length:
Client in supine position, the
nurse measures from the anterior
axillary fold to the heel of the foot
& add 1 inch.
The client stands erect. The
shoulder rest of the crutch is at
least 3 finger widths, that is 1-2
inches below the axilla.
The angle of the elbow flexion
must be 30 degrees.
Tip of the crutch is 6 inches from
the side & 4 inches from the
front of the foot.
Crutch stance (Tripod Position) –
proper standing position with
crutches.
Crutches are placed 6 inches in
front of the feet & 6 inches
laterally.
Crutch gait – gait a person
assumes on crutches by
alternating body weight on one
or both legs & the crutches.
5 Standard Crutch Gaits:
Four Point Gait

Three Point Gait

2 Point Gait

Swing to

Swing through
Four Point- Alternate Gait –
most elementary, safest gait;
client needs to bear weight on
both legs
The nurse ask the client to:
Move the right crutch ahead 4-6
inches.
Move the left front foot forward,
to the level of the left crutch
Move the left crutch forward
Move the right foot forward
3 Point Gait
Client bears entire body weight
on the unaffected leg
Both crutches & affected leg
advances
Unaffected leg advances
Two-Point Alternate Gait
Partial weight bearing on each
foot
Faster than 4 point gait
Move the left crutch & the right
foot together
Move the right crutch & the left
foot ahead together
Swing – To Gait – paralysis of the
legs & hips
Move both crutches ahead together

Lift body weight by the arms &

swing to the crutches
Swing –Through Gait
Move both crutches forward
together
Lift body weight by the arms &
swing through beyond the crutches
Going up the Stairs
Nurse stands behind the client

Placing weight on crutches while

moving the unaffected leg onto
the step
Going down the Stairs
The nurse stands 1 step below

Moving the crutches & affected

leg to the next step
Traction – is the act of pulling and
drawing which is usually
associated with counter traction
Providesproper bone alignment
& reduces muscle spasm
For support, reduce bone fracture
Nursing responsibility:
Maintain proper body alignment

Ensure that the weights are

hanging freely
Ensure that pulleys are not
obstructed; pulleys move freely
Place knots in the ropes to
prevent slipping
Types of traction:
Manual traction – done with the
use of the hands of the operator
Skeletal traction – pin is driven
across the bone to provide an
excellent hold while a weight is
attached
Use of pins, tongs & wires
 Crutchfield tongs
For fracture of cervical spine

C1-C5 cervical spine tension

Use for 4 weeks

 Vinke’s skull caliper
C1-C5 cervical spine tension

Use for 4 weeks

Nursing responsibility:
Monitor color, motion &
sensation of affected extremity
Monitor the insertion site for
redness, swelling or infection
Provide insertion site care as
prescribed
Skin traction – applied by the
use of elastic bandages or
adhesive straps to the skin while
a pull is applied by a weight
2 Types:
Non-adhesive type – uses laces,
buckles, leather & canvas
Ex. Head halter strap
Adhesive type – uses adhesive
tape or elastic bandages
Ex. Dunlop skin traction
 Cervical skin traction – relieved
muscle spasm & compression in
the upper extremities & neck
Uses a head halter & chin pad
For cervical spine affectation
For Pott’s disease
Principles of traction:
1.Patient must be in dorsal recumbent
position
2.Line of pull should be in line with the
deformity. Consider the position of
diagonal bar & positioning of pulley.
 1stpulley in line with the thigh, 2nd
pulley in line with the knee or
screw, 3rd pulley in line with the 2nd
& 3rd pulleys
 Weight bag must be at the level of
the bed frame
3.Traction must be continuous.
Emphasized the importance of
manual traction.
4. Avoid friction – rope should be
running along the groove of the
pulley, knots away from the pulley.
Weights should be hanging freely.
Observe for wear & tear of ropes.
5. Provide counter traction. For
every traction there must be a
counter traction (Patient’s body
weight)
Nursing Care of Patients with
Traction:
1. Assessment
 Assess patient as to level of
understanding/consciousness
2. Provision of general comfort
 Skin care – head to toe; focus on the
sponging of affected extremity
3. Potential Complications:
 Upper respiratory – Pneumonia –
back tapping & deep breathing
 Bed sore – good perineal care;
proper skin care, turning, lift
buttocks once in a while
 Urinary & kidney problem – good
perineal care, increase fluid intake
 Bowel complication – fear of
apparatus, no privacy, lack of
fluids/perineal care
 Pinsite infection – observe for
signs & symptoms of infection;
loosening pin tract, pus coming out
from insertion site, foul smelling
odor, fever
 Deformity – contracted knees,
atrophy of muscles, foot drop, joint
contractures
4. Provision of Exercises:
 ROM exercises with the use of
trapeze
 Deep breathing exercises
 Static quadriceps exercise –
alternate contraction & relaxation
of quadriceps muscles
 Toe pedal exercises
5. Nutritional status
6. Psychological aspect
 Fear of the unknown, fear of death,
fear of apparatus, fear of losing a
job, financial fear
 7. Provision of supportive therapy
 Offer books to read, listen to radio
or TV, discover interest
 8. Spiritual aspect
 Know patient’s religion, encourage
relatives to give spiritual
communication, visiting chaplain
 Divertional activities – divert
attention for any pain
Knee Injuries
Medial/lateral meniscus – act as
shock absorbers; can tear.
Tearing – result of twisting the leg
when the knee is flexed & foot is
placed firmly on the ground.
Medial meniscus tear – due to
internal rotation
Lateral meniscus tear – due to
external rotation
“Bucket handle injury” – causes
the knee to lock; torn cartilage
jams between the femur & tibia
thus preventing the extension of
knees.
Diagnostic tests:
McMurray test – examiner flexes
& rotates the knee & then
presses on the medial aspect
while slowly extending the leg.
Positive test – if clicking is
palpated or heard
Clinical manifestations:

Pain

Swelling
Tenderness in the knee
Clicking/snapping sound
Management:
Locked knee – manipulation;
casting for 3-6 weeks
Meniscectomy – Partial/total
Open meniscectomy – requires a
surgical incision
for the removal of all or the part
of the meniscus
Closed meniscectomy –
accomplished through an
arthroscope
Client begins leg exercises
immediately after the procedure
to strengthen the leg, prevent
thrombophlebitis & reduce
swelling.
Elevate the affected leg to 1 or 2
pillows
Apply ice to reduce swelling

Full weight bearing restricted for

several weeks
Dislocations/Subluxations
Occurs when articulating surfaces
are no longer in proximity
Common in shoulder, hip, knee &
fingers
Etiology:
Trauma

Congenital/pathologic - arthritis
Clinical manifestations:
Pain

Immobility

Alteration in contour of joint

Deviation in length of extremity

Rotation of extremity
Management:
Closed manipulation/reduction

Cast – immobilized the joint

until healing
Traction/splint
Strain (muscle pull) – excessive
stretching of a muscle or tendon
when weak or unstable
Etiology:
Falls

Lifting of heavy items

Exercise
Classification according to
severity:
1. 1st degree (mild) strain – mild
inflammation, little bleeding,
swelling, ecchymosis &
tenderness
2. 2nd degree (moderate) strain –
tearing of muscle or tendon
fibers without complete
disruption; muscle function
might be impaired
3. 3rd degree (severe) strain –
ruptured muscle or tendon,
involving separation of muscle
to muscle, muscle to tendon or
tendon from bone
Management
Cold & heat applications

Exercise

Activity limitations

NSAIDs
Muscle relaxant
Surgical repair
Sprains – excessive stretching of
a ligament
Etiology : twisting motion from
falls; sports activity
Classification according to
severity:
1. 1st degree (mild) sprain – involves
tearing of a few fibers of a
ligament; joint function not
affected
2. 2nd degree (moderate) sprain –
more fibers are torn; stability
of joint remains intact
3. 3rd degree (severe) sprain –
marked instability of joint
Clinical manifestations:
 Pain

 Swelling
Management:
1st degree sprain:

Rest

Ice (24-48 hrs.)

Application of compression
bandage (reduce swelling;
provide support)
Elevation
2. 2nd degree sprain –
immobilization (elastic
bandage, splint or cast), partial
weight bearing until ligament
heals
3. 3rd degree (severe) sprain –
immobilization (4-6 weeks);
surgery
Amputation – removal of the part
of the body
Note: The nurse recognizes that
the psychosocial effect of the
procedure is more devastating
than the physical impairment
Loss experienced is complete &
permanent causing a change in
body image & self esteem
Amputation – ranges from removal
of part of a digit to removal of
nearly half of the entire body.
1. Open (guillotine) method – for
clients with infection, for those who
most likely to develop infection
 Wound remains open, drains allow
exudates to escape until infection
clears
Surgeon suture the skin flaps
over the wound at a later time
2. Closed (flap) method – surgeon
pulls the skin flaps over the
bone end & sutures them in
place. 1 or more drains are
inserted.
Traumatic amputation – occurs
when body a part is severed
unexpectedly; attempt of
replantation is possible
Levels of amputation:
Lower extremity amputation
performed frequently
Syme amputation – most of the foot
removed; ankle preserved
for peripheral vascular disease
Advantage – weight bearing can
be achieved without the use of
prosthesis & without pain
Below knee amputation (BKA) –
preserve the knee joints
Above knee amputations – cause
of amputation extends beyond the
knee
The higher the level of
amputation more energy is
required for ambulation
Complications of amputations:
Hemorrhage

Infection
Phantom limb pain
Neuroma – sensitive tumor
found in severed nerve endings
Flexion contractures
Phantom limb pain – frequent
complication of amputation
More often after AKA

Felt during the early post op

period
Common among clients who
experienced chronic limb pain before
the surgery
Client complains of pain (intense
crushing/burning) in the removed body
part most often shortly after surgery
Incidence/Prevalence:

More than 100,000 amputations

yearly in US
Half of these among clients with
DM
Middleaged or older man with
DM & a lengthy history of
smoking
2ndlargest group affected young
men involved in vehicular
accidents (Motorcycle)
Injury at work (industrial
equipment)
Diagnostic assessment:
Measurement of segmental limb
BP – Ankle-brachial index – Ankle
systolic pressure/Brachial systolic
pressure
Normal ABI=1 or greater
Doppler ultrasonography
Laser Doppler flowmetry

Transcutaneous Oxygen Pressure

Angiography
Ultrasonography – measures the
velocity of blood flow in the
limbs
TcPO2 – measures the oxygen
pressure to indicate blood flow in
the limb
Nurse’s Primary Focus:
Monitor for signs that there is
sufficient tissue perfusion but no
hemorrhage
Pain Management:
Phantom limb pain – recognize
that pain is real; It is not
therapeutic that the limb can’t
hurt because it is missing.
Drug therapy:
IV Infusion of Calcitonin
(Calcimar) – during the week of
amputation
Alternative treatment:
Transcutaneous Electrical Nerve
Stimulation (TENS)
Massage

Distraction therapy
Prevention of Infection:

Initial pressure dressings/drains

usually removed in 48-72 hrs after
surgery.
Promotion of ambulation:
Start muscle-strengthening
exercises before the surgery
Arrange for a client to see a
certified prosthetist-orthotist (CPO)
Older clients with PVD – fitted
after the residual limb has healed
Wrapping with elastic bandages –
to reduce the edema, shrink the
limb & hold the wound dressing
in place
Reapply the bandages every 4-6
hrs when loose
Figure 8 wrapping prevents
restriction of blood flow
Common Health Problems of the
Young Adult
Multiple Sclerosis

Myasthenia Gravis
Chronic, progressive
neurologic disease of the CNS
Unknown etiology
Progressivedemyelinization of
the white matter of the CNS
Occurs between ages 20-40
Affects women twice as often
as men
Whites are affected compared
to Hispanics, Blacks or Asians
Etiology: Unknown
Immunogenetic viral disease

Inmmune mediated
demyelination triggered by
viral infection
15-20 times more common in
primary relatives of affected
patients
Infection

Physicalinjury
Emotional stress

Pregnancy

Fatigue
Formation of plaque along myelin sheath

Inflammatory reaction; Edema

Scarring/destruction of myelin sheath

Primary demyelination
 Death of oligodndrocyte

Incomplete remyelination of nerves

Optic nerves
Cerebrum

Cervical SC
Weakness

Paresthesia of 1 or more
extremities
Vision loss (optic neuritis)

Incoordination
Bowel/bladder dysfunction
(SC involvement)
Fatigue common symptom that
worsens as the day progresses
History/ Clinical findings
2 episodes of neurologic
dysfunction in different
locations in the CNS
Spinalfluid evaluation
MRI- brain, SC – presence of
MS plaques
Relieve symptoms
Help the patient to function

Corticosteroids
Chronic autoimmune disorder
affecting the neuromuscular
transmission of impulses in the
voluntary muscles of the body.
Antibody mediated attack
against the acetylcholine
receptors in the neuromuscular
junction
Cardinal features:
Muscle weakness/ fatigue

Worsens with exercise;

improves with rest
Etiology: unknown
Onset: early onset 20-30 yrs old

Predilection to women

Late onset: after age 50 men are

more susceptible
Increasing weakness with
sustained muscle contraction –
primary feature
 Depletion of Acetylcholine receptors
(NMJ)

Elevated antibody titers

Muscle weakness
Clinical presentation – testing
the response of anticholinergic
drugs
Endrophonium – Tensilon test
Neostigmine methylsulfate
(Prostigmin) longer duration of
effect (1-2 hrs)
EMG – confirm the diagnosis
Muscle weakness
Ptosis

Diplopia

Expressionless face
Drooping eyelids
Open mouth

Severe cases respiratory

muscle arrest
No treatment available
Short acting anticholinesterase
compounds – achieved
maximum muscle strength &
endurance
Corticosteroids – prednisone –
decrease levels of serum Ach
receptor antibodies
Complications:
Myasthenic crisis experience
worsening condition
Increase dose on
anticholinergic drugs
Cholinergiccrisis –
overmedication
Abdominal cramps, diarrhea,
excessive pulmonary
secretions
Plasmaphereis

Thymectomy – alter
immunologic control mechanism
that affect production of antibody
to ACH receptor
Common Health Problems of the
Older Adult:
Parkinson’s Disease

Alzheimer’s disease
Parkinson’s disease
- is a progressive neurological
disorders that results from
degeneration of neurons in a
region of the brain that
controls movement
Parkinson Disease (Paralysis
agitans)
3rd most common neurologic
disorder of older adult
Debilitating disease affecting
motor ability
4 Cardinal Symptoms:
Tremor

Rigidity

Akinesia (slow movement)

Postural instability
Pathophysiology:
Degeneration of Substantia Nigra

Decrease dopamine production

Decrease ability to refine voluntary movement

 Organ/ System affected
- Brain

( substantia nigra & basal

ganglia)
- Neuromuscular system
 Neuromuscular system
- combination of the
nervous system & muscles.
- work together to permit
movement.
Basal ganglia
 integrates feeling and movement

 shifts and smoothens fine motor

behavior
 suppression of unwanted motor
behaviors
 sets the body's idle or anxiety level

 enhances motivation
 Caudate
Putamen
Globus pallidus
Substantia nigra
Substantia nigra
- controls voluntary
movement, regulates
mood, and produces the
neurotransmitter
dopamine
Causative:
Toxins

Head trauma

Cerebral anoxia

Drug-induced
 Predisposing factor:
- Age
- Heredity
- Sex
- Exposure to toxins
 Tremor

]Rapid shaking of the

hands, arms or legs
Arms and legs
become stiff and
hard to move
Difficultystarting
or completing
movements
Lack of balance or
difficulty adjusting to
sudden changes in
position
 isa nuclear medicine
imaging technique
which produces a
three-dimensional
image or map of
functional processes in
the body.
 is a noninvasive
transthoracic graphic
produced by an
electrocardiograph,
which records the
electrical activity of
the heart over time.
High risk for injury related
to postural, instability &
muscular rigidity
Impaired verbal
communication related
slowness of movement
Alterednutrition: less than
body req. related to poor or
pharyngeal muscle control
& coordination
Knowledge deficit related to the
complexity of & fluctuations in
the treatment regimen.
Levodopa
Dopamine agonists
Amantadine
COMT inhibitor
Anticholinergic
Bromocriptine
Levodopa
- a dopamine precursor,
increases the dopamine supply
in neurons making more
availabale to stimulate
dopaminergic receptors.
Dopamine agonists
- directly stimulate nerves in
the brain that are not naturally
being stimulated by dopamine.
Amantadine
- blocks acetylcholine
receptors and promotes release
of dopamine
Anticholinergic
- block acetylcholine
receptors that help control the
muscles of the arms, legs, and
body.
Ablative surgery
this procedure locates, targets
and then ablates or destroys a
targeted area of the brain
affected by Parkinson's.
Deep brain stimulation
- treats the tremors and slowness
associated with Parkinson's
disease. This therapy has been
shown to provide greater relief of
symptoms with fewer side effects
than other treatments.
 Pallidotomy

 In this procedure, a surgeon

selectively destroys a portion of
the brain called the globus
pallidus. 
 can improve gait and balance.
 Thalamotomy

 a related procedure that

involves surgically
destroying part of the
brain's thalamus.
 is useful primarily to
reduce tremor. 
Transplantation
 called restorative surgery

 dopamine-producing
cells are implanted into a
certain part of the brain.
Most common form of dementia
Progressive impairment in
memory, cognitive function,
language, judgment & ADL
Incidence:
10-15% people older than age
65
19% older than 75

47% older than 85

Etiology- unknown
Risk factors:

Genetics

Increasing age
Female gender
Viruses, toxins & previous
head injury
 Changes in CHON of the nerve cells of
cerebral cortex

Accumulation of neurofibrillary tangles &

neuritic plaques

Degenerating nerve terminals

 Changes in CHON of the nerve cells of
cerebral cortex

Neurotransmitter changes

Decrease in cholinergic neurons in basal nucleus

Loss of choline acetyltransferase

 Cognitive decline
(Learning, reasoning, memory , recall, language
recall)
Onset is subtle/insidious
Gradual decline of cognitive
functioning
Shortterm memory
impairment
Impairment in decision making

Decrease cognition
Apraxia

Hyperorality – desire to take

everything in the mouth
Loss of self care abilities
• Patient history
• EEG

• CT Scan (Non contrast)

• MRI

• Neuropsychological evaluation
Maximize functional abilities
Improve quality of life

Cholinesterase inhibitors
Tacrine(Cognex)
Donepezil (Aricept)
Reminiscence therapy

Art/recreational therapy
Common Health Problems Across
the Life Span
Guillain-Barre Syndrome
Polyradiculoneuritis

Inflammatory disease of
unknown cause/involves
degeneration of myelin sheath
of peripheral nerves
Affects people of all ages &
races
Most common cause of acute
general paralysis
.75 – 2 cases/ 100000 population
Predisposing factors:
Respiratory/GI infections

Viral infections

Immune reactions

vaccination
 Viral infection

Autoimmune reactions

Damage to myelin sheath (Peripheral Nerves)

Paresthesia

Symmetric progressive muscle

weakness
Loss of DTR
Autonomic dysfunction (Increase
HR/postural hypotension)
Deep aching muscle pain in
shoulder girdle
Respiratory muscle weakness –
cause of death
85-90 % recover completely
History/Physical Exam
CSF analysis
Electrophysiologic studies
Plasmapheresis

Supportive care