cellular abbe ration

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MR. ALETH M. TIBI, RN, MAN


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Overview of the Skeletal System

y Hambone as a cross-section of a typical

boney The center of the bone

is filled with marrow

y Surrounded by thehardened bone tissue


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y The extracellular matrix of the bone is composed ofcollagenwith Ca3(PO4)2 (superphosphate of lime)deposited in it.

y Bone tissue is composed of repeating, circular unitscalled Haversian Systems.

y In each Haversian system, there is a central canalwhere blood vessels and nerves can be found.


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Bones of the Skeletal Systemy cranium- bones of the skull surrounding the brain, not including the face

bonesy mandible- jaw bone, so the hinge of the jaw is joined by the temporal

bone by the temporo-mandibular joint

y vertebrae- bones which make up the spine, which include:a. cervical vertebrae - vertebrae in the neck regionb. thoracic vertebrae- vertebrae with ribs attachedc. lumbar vertebrae- vertebrae in the lower backd. sacrum- five fused as one vertebra which are joined to the pelvis

e. coccyx- four fused as one vertebra which comprise the tailbone


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y ribs- bones protecting the chest cavity (twelve pairs)y sternum- breastboney clavicle - collar boney scapula- shoulder bladey humerus- top of the army ulna- little finger side of the lower arm which also forms the

elbowy radius- thumb side of the lower army carpals- wrist bonesy metacarpals- palm of the handy phalanges- fingers


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y (os) coxa- hip bones

y ilium- big bone on top that we think of as the hip

y

ischium- bones on which we sity pubis- lower front hip bone


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y femur- thigh bone

y patella- kneecap

y

tibia- thick, inside (big-toe side) shinbonefibula- thin, outer (little-toe side) shinbone

y tarsals- heel bones

y metatarsals- arch of the foot, the sole

y

phalanges- toes


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The Muscular Systemy more than 650 individual muscles which are attached

to the skeleton, providing the pulling power for

movement.


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Function of the Musclesy Provide movement for the body


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Types of Muscle Tissuesy Voluntary muscles: muscles controlled by the will

y Involuntary muscles: muscles not controlled by the

will


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Types of Muscle Tissuesy Cardiac Muscles: found in the hearta. striatedb. contracts through the sliding filamentc. it forms branching fibersd. involuntaryy Skeletal Muscles: makes up about 40 % of an adult body

weight. e.g. biceps, triceps

a. it has stripe-like markings, or striationsb. composed of long muscle fibersc. muscle fiber has a cell which contains several nucleid. controlled by the nervous system during contractione. many of the skeletal muscle contractions are automatic


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y Smooth Muscles: the internal organs are made up ofsmooth muscles. e.g. bladder, bronchi

a. non-striatedb. controlled by the nervous system and hormones


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Joints, Ligaments and Tendonsy Joints: also known as articulations, it is where two

bones meet.

y

Tendons: fibrou

s connective tissu

es that connects tothe periosteum of the bones; it enables the bones tomove when skeletal muscles contract.

y Ligaments: dense bands of connective tissue thatconnect bones to bones.


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Functional Classification ofJoints

Type Description ExamplesSynarthroses Immovable joints Skull, first rib and

munubrium of thesternum

Amphiarthroses Slightly movable joints Vertebral joint, symphysispubis joint

Diarthroses Freely movable joints Shoulder, hip and limbjoints


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Structural Classification ofJoints

Type Description Example

Fibrous Permit little movement;

short connective tissue

Skull

Cartilaginous Immovable Intervertebral Discs

Synovial Freely movable; synovial

fluids and filtrate of bloodplasma

Limbs


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ssessmenty ChiefComplaint and History

y Physical Examination: focus on

a. Inspection: color, swelling, atrophy, deformity,symmetry, posture and gait, muscle strength,discharge , and movement (ADL)

b. Palpation: deviation/limitation in ROM, warmth,

tenderness, deformity of joints, muscle size andstrength, crepitation on joint movement, and presenceof subcutaneous nodules.

c. Palpation: turgor, tenderness, masses, and body

temperature


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Potts Disease

Osteomyelitis


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Potts Diseasey Other Names: TB of the spine; Potts Caries, David's

Disease, and Pott's Curvature; Tuberculous Spondylitis

y

It is named after Percivall Pott (1714-1788), a Londonsurgeon.

y Most common site of bone infection in TB.

y Most common site: lower thoracic and upper lumbar

vertebrae .


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Pathophysiologic Mechanismsresults from haematogenous spread of tuberculosis

from other sites particularly to the spine

infection then spreads from two adjacentvertebrae into the adjoining disc space

the intervertebral disc, which is avascular,cannot receive nutrients and collapses.

disc tissue dies and is brokendown by caseation

vertebrae collapses and

spinal damage occurs

a dry soft tissue mass often formsknown asGIBBUS


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Signs and Symptoms


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Signs and symptomsy back pain

y fever

y

night sweatingy anorexia

y weight loss

y Spinal mass, sometimes associated with numbness,

tingling, or muscle weakness of the legs


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Other Manifestationsy Localized back pain

y Para-vertebral swelling

y Neurological signs like paraplegia


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Diagnostic Testsy Needle biopsy of bone or synovial tissue: Numbers of

tubercle bacilli present are usually low but are

pathognomonicyAcid-fast stain and culture for Mycobacterium

Tuberculosis

y Elevated Erythrocyte Sedimentation Rate


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Imagingy Spinal x-ray will show vertebral destruction and

narrowed disc space.

y

Magnetic Resonance Imaging isu

sefu

l todemonstrate the extent of spinal compression andcan show changes at an earlier stage than plainradiographs. Bone elements visible within theswelling, or abscesses, are strongly indicative ofPotts disease as opposed to malignancy.

y CT scans and Nuclear Bone Scan


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T

RE

A

T

M

EN

T

Isoniazid (INH) Rifampin (Rifadin)

Ethambutol (EMB) Streptomycin (SM)

Pyrazinamide (PZA)

Anti-infective

agents


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Other Managementy Spinal Immobilization with a Brace:Jewette Brace

y Surgery is required if there is spinal deformity or

neurological signs of spinal cord compression:debridement and fusion with bone grafting


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Complicationsy Severe Kyphosis

y Sinus Formation

y Paraplegia: Pott's Paraplegia


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Nursing Responsibilities on Drug

Therapyy INH: taken before meals; causes peripheral

neuropathy (competes withVitamin B6 absorption).

y

Rifampicin: Best taken with empty stomach but causesgastric irritation hence should be taken with food;causes discoloration ofurine; should be kept in darkcontainers.


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more on responsibilitiesy PZA: Hepatotoxic; ototoxic; nephrotoxic; gastric

irritation; protect from light.

y

EMB: optic neuritis (causing red and green colorindiscrimination); skin rashes .


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Nursing Carey Isolation

y Skin Care: Braces


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Prevention


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y Osteomyelitis is an infection of bone or bonemarrow, usually caused by pyogenic bacteria ormycobacteria.

y Staphylococcus aureus is the organism most common.

y Bloodstream-sourced osteomyelitis is seen mostfrequently in children, and nearly 90% of cases arecaused byStaphylococcus aureus.


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Predispositionsy An open injury to the bone: open fracture with the bone ends

piercing the skin.y An infection from elsewhere in the body: urinary tract

infection that has spread to the bone throu

gh the blood.y A minor trauma, which can lead to a blood clot around the

bone and then a secondary infection from seeding of bacteria.y Bacteria in the bloodstream, which is deposited in a focal

(localized) area of the bone. This bacterial site in the bonethen grows, resulting in destruction of the bone. However,

new bone often forms around the site.y A chronic open wound or soft tissue infection can eventually

extend down to the bone surface, leading to a secondary boneinfection.


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On predispositionsy People with diabetes

y Patients receiving hemodialysis

y People with weakened immune systemsy People with sickle cell disease

y Intravenous drug abusers

y Elderly


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PathophysiologyPredisposition like:

Open wound, surgery,Soft tissue infection like boils, venous

stasis, DM

Bacteria enters, lodge and multiplyInfection reaches outer surface or

margin of the bone, raising theperiosteum

Phagocytes attempt to contain

infection by releasing enzymes thatdestroys eventually bone tissue

Pus forms, followed by edema andvascular congestion

Disruption of blood supply andNecrosis results

Bacteria adheres to damaged bonecoating underlying bone with

protective film


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ManifestationsBacteria can travel into the bone through the

bloodstream from other infected areas in the body

Bacteria enter the body's tissues througha wound and

travel to the bone (like after an injury or trauma)

Pain and/or tenderness in the infected areaSwelling and warmth in the infected areaFever

Nausea, secondarily from being ill with infectionGeneral discomfort, uneasiness, or ill feeling

Drainage of pus through the skinExcessive sweating

ChillsLower back pain

Swelling of the ankles, feet, and legsChanges in gait (walking pattern that is a painful, yielding a limp)

Blood supply to that area of the bone is disrupted.(older people with atherosclerosis)


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Typical Appearance of Osteomyelitis


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Diagnostic Testsy Blood tests: When testing the blood, measurements are

taken to confirm an infection:1. complete blood count (CBC), which will show if there is an

increased white blood cell count2. ESR (erythrocyte sedimentation rate) and/or CRP (C-reactive protein) in the bloodstream, which detects andmeasures inflammation in the body. (NV=0-15mm/hr)

yBlood culture:A blood culture is a test used to detectbacteria. A sample of blood is taken and then placed intoan environment that will support the growth of bacteria. Byallowing the bacteria to grow, the infectious agent can thenbe identified and tested against different antibiotics inhopes of finding the most effective treatment.


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y Needle aspiration: a needle is used to remove a sample of f luid andcells from the vertebral space, or bony area.

y Biopsy:A biopsy (tissue sample) of the infected bone may be takenand tested for signs of an invading organism.

y Bone scan: a small amount of Technetium-99 pyrophosphate, aradioactive material, is injected intravenously into the body. If the bonetissue is healthy, the material will spread in a uniform fashion. A tumoror infection in the bone will absorb the material and show an increased

concentration of the radioactive material, which can be seen with aspecial camera that produces the images on a computer screen.


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Treatmenty Drainage: needle aspiration of open wound. A needle

is inserted into the infected area and the fluid iswithdrawn.

y Medications:Antibiotics help the body get rid ofbacteria in the bloodstream that may otherwise re-infect the bone. Type of antibiotics is based on cultureresults; commonlyused is Methacillin.


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y Splinting or cast immobilization: to immobilize theaffected bone and nearby joints in order to avoidfurther trauma and to help the area heal adequately

and as quickly as possibley Surgery: destroyed bone is scraped out.

y Physiotherapy: to build up strength of the muscles


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Nursing Carey Risk for Infection related to compromised immune

system: Hand washing and maintain dietary kcal andCHON intake.

y Hyperthermia related to infection and inflammatoryprocess: maintain cool environment; light clothing;ensure daily fluid intake of 3L.


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y Impaired physical mobility related inflammation anduse of immobilizers: maintain functional position;maintain rest and avoid weight bearing activities;

ensure PROME.y Pain related to swelling: splint area; use of analgesics;use of distraction; minimal manipulation or handlingof affected area.


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Scoliosis


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Scoliosisy abnormal curvature of the spine

y "S" or a "C" curvature of the spine

ybones are rotated slightly, making the person's waist orshoulders appear uneven.


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Predispositionsy If someone in a family has scoliosis, the likelihood of

an incidence is much higher: approximately 20 percent

y

Children: It isu

su

ally develop in middle or latechildhood, before puberty, and is seen more often ingirls than boys

yAdult: Degeneration as in osteoporosis


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Etiologyy "idiopathic," meaning the cause is unknown.


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Manifestationsy Uneven shoulders

y One shoulder blade that appears more prominent than

the othery Uneven waist

y One hip higher than the other

y Leaning to one side


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y Ribs on one side of the body to stick out farther thanon the other side

y

Back pain and difficu

lty breathing


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Diagnostic Testsy Physical examination: examination of the spine as

well as the shoulders, hips, legs and the rib cage forsigns of scoliosis.

y X-rays: initial X-ray to confirm the diagnosis anddetermine the curve angle. Periodic X-rays are done tomonitor the curve and help make treatment decisions.


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Descriptionsy Shape: Curves develop side-to-side as a C- or S-shaped

curve. The rotation of the spine causes the ribs andmuscles near the spine to move out of normal alignment.

y Location: The curve may occur in the upper back area(thoracic), the lower back area (lumbar) or in both areas(thoracolumbar)

y Direction: The curve can bend to the left or to the right.

y Angle:A normal spine, viewed from the back, is at 0degrees a straight line


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Treatmenty Braces: prevents further progression of the curve

a. Underarm or low-profile brace: made of modern plastic materialsand is contoured to conform to the body.

*Also called a thoracolumbosacral orthosis (TLSO), this closer-fitting brace is less visible under the clothes as it fits under the armsand around the rib cage, lower back and hips.

b.Milwaukee brace. This full-torso brace has a neck ring with rests forthe chin and for the back of the head. The brace has a flat bar in the

front and two flat bars in the back. A Milwaukee brace may be usedfor curves in the upper spine. This brace is not commonlyused.


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y Surgery: "Fusion" means joining two pieces together.

Fusion involves connecting two or more vertebrae withpieces of bone taken from the pelvis. Eventually, the

vertebrae and the pieces of bone fuse togetherpreventing further progression of the curve.


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Complications from Surgeryy bleeding, infection, pain, nerve damage, arthritis and

disk degeneration.


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y It involves the use of metal rods, hooks, screws or wires(instrumentation) to the spine to hold the vertebraetogether during the months after surgery while the

bones fuse.y The instrumentation is left in the body, even after the

bones have fused, to avoid another surgery.


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Complicationsy Lung and heart damage:

1. a curve greater than 70 degrees the rib cage maypress against the lungs and heart, making it moredifficult to breathe and harder for the heart topump. In very severe scoliosis

2. a curve greater than 100 degrees damage to the

lu

ngs and the heart can occu

r. Any time breathingis compromised, the risk of lung infections andpneumonia increases.


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y Back problems: chronic back and ifuntreated maydevelop arthritis of the spine.

y Body image: child might feel isolated and develop apoor body image from wearing a brace duringchildhood and teenage years.


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Conservative Treatmenty Electrical Stimulation

y Traction

y

Active and Passive ROMEy Weight reduction


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Nursing Carey Risk for injury related to bracing and other related

factors: Assess for skin irritation; use ofundergarments to reduce friction; frequent change of

undergarments during warm weather; teach to avoiduse of powders and lotion; loosen brace during mealsand for the first 30 minutes after meals.


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y Risk for peripheral neurovascular dysfunction relatedto brace and cast application: assess for movement,color and sensation.


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Osteoarthritis

Rheumatoid Arthritis


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OsteoarthritisyAlso known as degenerative joint disease or

osteoarthrosis

y characterized by the breakdown of joint cartilage

those in fingers, hips, knees, lower back and feet.y Initially it may strike only one joint. But if fingers are

affected, multiple hand joints may become arthritic.


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Causesy combination of factors: including being overweight,

the aging process, joint injury or stress, heredity, andmuscle weakness.


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Manifestationsy Often develops slowly, and some people may not

experience any signs or symptomsy Pain in a joint during or after use, or after a period of

inactivityy Discomfort in a joint before or during a change in the

weathery Swelling and stiffness in a joint, particularlyafter using ity Bony lumps on the middle or end joints of the fingers or

the base of the thumb known as Heberdens nodey Loss of joint flexibility


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Areasy Fingers: Bony knobs called Heberdens node can

enlarge in the finger joints, creating a gnarled

appearance

y Painful or stiff and numb joint.

y Nodes tend to run in families and affect morewomen than men.


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y Spine: Slow deterioration of disks between the bonesalong the spine can lead to back, neck pain andstiffness.


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In osteoarthritis, disks narrow and spurs form. Where bone surfaces rub

together (facets), cartilage becomes worn and may be painful.


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y Weight-bearing joints: The parts of the body thatbear the majority of the weight like hips, knees andfeet

y As cartilage slowly deteriorates over the years, chronicpain or varying amounts of discomfort when standingand walking


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The hip joint on the left is normal, but the hip joint on the right shows

deterioration of cartilage due to osteoarthritis.


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Pathophysiologymechanical stress

cartilage wears downcompletely, leaving the bone

rubbing on the other bone.

imbalance of enzymes released

from the cartilage cells orfrom the lining of the joint

joint cartilage

breaks down faster

damaged end of the bones


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Risksy 45 years old or older and female

y hereditary conditions like defective cartilage and

malformed jointsyjoint injuries caused by physical activity or sports

y obesity

yweak thigh (quadriceps) muscles leading toosteoarthritis of the knees


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Diagnostic Testsy Fluid may be withdrawn from a joint for analysis

(joint aspiration)

y X-rays, bone scans, computerized tomography(CT) scans, magnetic resonance imaging (MRI)scans

yArthrography an image taken after dye has beeninjected into the joint. Imaging techniques can

reveal bone spurs, worn-down cartilage and loss ofjoint space


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Treatmenty Medications: to treat pain and mild inflammation and

therefore improving joints' functioning

1. Topical pain relievers: creams, gels, ointments and

sprays to temporarily relieve arthritic pain,

Examples: trolamine salicylate include Aspercreme andSportscreme; methyl salicylate, menthol and camphor likeIcy Hot and Ben-Gay.

Capsaicin: a cream made from the seeds ofhot chilipeppers, may relieve pain in joints close to the skinsurface, such as fingers, knees and elbows.


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y 2. Acetaminophen:Acetaminophen (Tylenol) canrelieve pain but doesn't reduce inflammation.

y

It has been shown to be effective to relieve mild tomoderate pain.

y Side Effect: liver damage, especially if taken with

alcoholic beverages


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y 3. NSAIDs: Nonsteroidal anti-inflammatory drugs(NSAIDs): It relieves pain and fight inflammation

y

Examples: aspirin, ibu

profen (Advil, Motrin IB) andnaproxen sodium (Aleve); ketoprofen (Orudis), diclofenac(Cataflam,Voltaren) and nabumetone (Relafen).

y Side Effects: ringing in the ears, gastric ulcers,cardiovascular problems, gastrointestinal bleeding, andliver and kidney damage.

y Consuming alcohol or taking corticosteroids while usingNSAIDs increases the risk of gastrointestinal bleeding.


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y 4. COX-2 inhibitors: Considered as effective formanaging pain and inflammation

y

Example: celecoxib (Celebrex)

y Side Effects: fluid retention and causing orexacerbating high blood pressure; has been linked

to an increased risk of heart attack and stroke.


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y 5. Tramadol: (Ultram) centrally acting analgesic;has no anti-inflammatory effect

y Used for short-term treatment of acute flare-ups;given in combination with acetaminophen toincrease pain relief

y

y Side Effect: nausea and constipation.


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Surgeryy Joint replacement: (Arthroplasty): damaged joint is

removed and replaces it with a plastic or metal device called aprosthesis; hip and knee joints common sites.

y Joint replacement is most successful in large joints, such aships and knees these replacement joints last at least 20

years in about 80 percent of those who had replacements.

y Joint replacement surgery can help resumes an active, pain-

free lifestyle. In smaller hand joints, it also can improveappearance and comfort and may improve joint's mobility.


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Knee replacement surgery can repair damage from osteoarthritis and other

inflammatory conditions. The artificial joint has metal alloy caps for thighbone

and shinbone and high-density plastic to replace eroded cartilage within the

joint and on the kneecap.


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Gradual deterioration of cartilage that occurs in osteoarthritis is the most

common reason for hip replacement surgery. Implanting an artificial joint

eliminates pain and restores near-normal movement


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y Arthroscopic lavage and debridement: Duringarthroscopy, lavage and debridement or both are done.

y Lavage involves using saline to flush out blood, fluid orloose debris inside the joint.

y Debridement removes loose fragments of bone or cartilageinside the joint.

y These procedures may provide short-term pain relief andimproved joint function


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y Repositioning bones: known as osteotomy

y Fusing bones: known as arthrodesis to increasestability and reduce pain.

The fused joint, such as an ankle, can then bear weightwithout pain, but has no flexibility.


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Nursing Carey Emphasize benefits ofExercise regularly:walking is a

good starter exercise; stationary bicycle or do hand or armexercises.

y Instruct patient as she moves, maintain a slow, steadyrhythm. No jerk or bouncing.

y Instruct not to hold your breath, as this can temporarilydeprive muscles of oxygen and tire them.

y Maintain good posture while doing exercise.y Avoid exercising tender, injured or severely inflamed joints.y If there is new joint pain, stop!


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y Control weight: Excess weight puts added stress onjoints of the back, hips, knees and feet.

y Eat a healthy diet:A healthy diet emphasizing fruit,vegetables and whole grains can help control theweight and maintain overall health.


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y Applyheat: Heat will ease pain, relax tense, painfulmuscles and increase the regional f low of blood.

y

Instru

ct patient to apply heat before exercising.

y One of the easiest and most effective ways to apply heat: a15-minute hot shower or bath.

y Other options: hot pack, an electric heating pad on its

lowest setting or a radiant heat lamp with a 250-wattreflector heat bulb.

y Precautions: If the skin has poor sensation or have poorcirculation, don't use heat treatment.


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y Choose appropriate footwear: Wearing comfortablecushioned shoes that properly support the weight

y Applycold for occasional flare-ups: Cold may dull thesensation of pain during the first day or two.

Cold also has a numbing effect and decreases musclespasms.

Precaution: Don't use cold treatments if there is poorcirculation or numbness


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y Practice relaxation techniques: Hypnosis,guided imagery, deep breathing and musclerelaxation can all be used to control pain.

y Take your medications as recommended: Bytaking medications regularly instead of waiting forpain to build, will lessen the overall intensity of

you

r discomfort.


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y Teach to use assistive devices: painful knee mayneed a brace for support.

y a. Teaching to use a cane to take weight off thejoint when walking.

y How: The cane should be used in the handopposite the affected joint.

y

y b. If the hands are affected, various helpful toolsand gadgets are available to help maintain anactive lifestyle.


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y 2. Know limitations. Rest when tired. Arthritis canmake one prone to fatigue and muscle weakness

A rest or short nap that doesn't interfere with nighttime sleep may help.


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3. Avoid grasping actions that strains finger joints: Forexample, instead of a clutch-style purse, select one with ashoulder strap.

Use hot water to loosen a jar lid and avoid pressure fromthe palm to open it, or use a jar opener.

Don't twist or use your joints forcefully.

4. Spread the weight ofan object over several joints: Useboth hands, for example, to lift a heavy pan. Tryusing awalking stick or cane.

5. Take a break. Periodically relax and stretch.


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6. Use the strongest muscles and favor large joints.Don't push open a heavy glass door. Lean into it.

To pick up an object, bend the knees and squat whilekeeping the back straight.


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Use of Coping Skillsy Osteoarthritis can affect everyday activities and

overall quality of life. As a result, it's important toadopt coping strategies for dealing with the disease

1. Keep a positive attitude. Make a plan formanaging arthritis. Studies show that people whotake control of their treatment and activelymanage their arthritis experience less pain and

function better.


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Complementary and Alternative

Therapyy Common forms of complementary and alternative

medicine for treatment of osteoarthritis include:

a. Acupuncture

b. Copper jewelry

c. Homeopathy

d. Magnets


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Rheumatoid Arthritisy an inflammatory condition causing joints to ache and

throb and eventually become deformed.


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Causey unknown, but it's believed to be the body's immune

system attacking the tissue that lines the joints(synovium)


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Prevalencey two to three times more common in women than in

men

y generally strikes between the ages of 20 and 50


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Risk Factorsy Getting older: incidence of rheumatoid arthritis

increases with age

y

Being femaley Being exposed to an infection, possibly a virus or

bacterium, that may trigger rheumatoid arthritisin those with an inherited susceptibility

y Inheriting specific genesy Smoking cigarettes over a long period of time.


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Pathophysiology

white blood cells whose usual jobis to attack unwanted invaders,such as bacteria and virusesmove from the bloodstream

into the synovium

proteins damagescartilage, bone,

tendons and ligaments.Predisposition like Infection

Inflammation of the synovial joints

release of proteins that

cause thickening of the synovium

joint loses its shape and

alignment

Pain and swelling in the joints,especially in the smaller joints of hands and feet

Generalized aching or stiffness of the joints and muscles,especially after sleep or after periods of rest

Loss of motion of the affected jointsLoss of strength in muscles attached to the affected joints

Fatigue, which can be severe during a flare-upLow-grade fever

Deformity of joints over time

General sense of not feeling well (malaise)


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Manifestationsy Pain and swelling in the joints, especially in the smaller

joints of the hands and feety Generalized aching or stiffness of the joints and muscles,

especially after sleep or after periods of resty Loss of motion of the affected jointsy Loss of strength in muscles attached to the affected jointsy Fatiguey Low-grade fevery

Deformity of the joints over timey General sense of not feeling well (malaise)


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Rheumatoid arthritis typically strikes joints, causing pain, swelling and

deformity. As the synovial membranes become inflamed and thickened, fluid

builds up and joints erode and degrade.


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Osteoarthritis, the most common form of arthritis, involves the wearing awayof the cartilage that caps the bones in the joints. With rheumatoid arthritis, the

synovial membrane that protects and lubricates joints becomes inflamed,

causing pain and swelling. Joint erosion may follow.


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Diagnostic Testsy Blood tests: (ESR or sedimentation rate) can indicate

the presence of an inflammatory process

y People with rheumatoid arthritis tend to haveelevated ESRs.

y The ESRs in those with osteoarthritis tend to benormal.


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y Blood test for antibody called rheumatoid factor


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Differential Characteristicsy Rheumatoid Arthritis

1. Systemic Disease: fever,malaise and fatigue

2. Inflammation sites:fingers and proximalinterphalangeal joint

3. Nodules: subcutaneousextraarticular nodules

around the joints

y Osteoarthritis

1. Local Joint Disease: nosystemic symptoms

2. Inflammation sites:distal interphlangealjoints

3. Nodules: no periarticularof subcutaneous

nodules; Heberdensnodes are present


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4. ESR: Elevated; elevatedserum rheumatoid factor

5. Who are predispose:

young adults to olderadults

4. ESR: normal

5. Who are predispose:adults in later years


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Treatmenty Corticosteroids: prednisone and methylprednisolone

(Medrol), reduce inflammation and pain, and slowjoint damage.

y Side Effects: easy bruising, thinning of bones,cataracts, weight gain, a round face and diabetes


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y Immunosuppressants: It tames the immunesystem, which is out of control in rheumatoidarthritis.

y It attacks and eliminate cells that are associatedwith the disease.

y Examples: leflunomide (Arava), azathioprine

(Imu

ran), cyclosporine (Neoral,S

andimmu

ne) andcyclophosphamide (Cytoxan).

y Side Effect: increased susceptibility to infection.


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y Abatacept (Orencia).Abatacept, a type of co-stimulation modulator, it reduces theinflammation and joint damage caused by

rheumatoid arthritis by inactivating T cells atype of white blood cell.

y Side Effects: headache, nausea and mild

infections, such as upper respiratory tractinfections. Serious infections, such as pneumonia


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y Rituximab (Rituxan): Rituximab reduces thenumber of B cells in the body. B cells are involvedin inflammation. Rituximab is administered as an

infusion into a vein in arm.

y Side effects: flu-like signs and symptoms, such asfever, chills and nausea; extreme reactions to the

infusion: difficulty breathing and heart problems.


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Nursing Carey Pain related to joint inflammation and stiffness:

apply heat or cold prior to exercise and at bedtime;change position frequently; provide rest periods;use of resting splints during acute pain

y Impaired physical mobility related to jointdestruction: encourage regular active exercise of

joints; assist and su

pport du

ring exercise; avoidexercise during acute pain


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y Potential for injury related to weakness and impairedmovement: avoid positions of f lexion, encourage activeROME; encourage ambulation with assistance; use

ambu

latory devices like cane;u

se shoes than slipperswhen ambulating; teach use safety devices such as grabbars on tubs and showers


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y SelfCare Deficits related to pain and limitation ofmovement: provide time for ADL; use comfortmeasures as needed before required activities; use

assistive device in dressing, feeding and ADLy Body Image Disturbances related to deformed

joints: provide opportunities to discuss feelings;identify personal strengths; allow maximum

independence; identify and anticipate needs


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y Knowledge Deficit related to control andmanagement of arthritis: teach the following:

a. natu

re of the disorderb. medication

c. exercise program

d. activity

e. nutrition


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Club Foot

Congenital Hip Dysplasia


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Clubfooty Feet point down and inward

y It does not cause pain in the newborn child

y It can cause long-term abnormalities in gait

y It may lead to complications such as chronic skinulcers


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Mechanismsy The tendons on the inside and the back of the foot are

too short.

y The foot is pulled then toes point down and in, and it

is held in this position by the shortened tendons.


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Pathophysiologyfailure to keep pace with the development of the foot

posterior and medial tendons and ligaments(in the back and inside)

tendons and ligaments tether

posterior and medial parts of the footpoint downwards and the twist inwards

Bones are mis-shapened


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EtiologyyAssociated with other congenital malformations such

as spina bifida

y No known cause of the deformity has been established


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Prevalencey It tends to be more common in boys, although girls are

not exempted.

yA positive family history is a predisposition


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Manifestationsy It does not cause pain in the infant

y Ifuncorrected in the older child, it is veryunsightlyand very crippling

y Patient walks on the outside of his foot which is notmeant for weight-bearing

y Skin breaks down, and the development of chroniculceration and infection.


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Treatmenty Manipulating the foot to get it to the best position

possible, and then holding the correction in a cast.(Ponseti Method)

y The cast is changed on a weekly basis, withmanipulation before each casting, to obtainfurther correction.

yAfter the first 6 weeks surgery can be planned, the

foot is manipulated and cast applied every 2 weeks.


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Surgeryy Releasing all the tight tendons and ligaments in the

posterior and medial aspects of the foot, and repairingthem in the lengthened position.

y The lateral ligaments are released to allow a completerelease.

y Objective: Plantigrade and Flexible foot

a. "Plantigrade" means the child stands with the sole of thefoot on the ground, not on heels or the outside of foot.

b. "Flexible" means one can move the foot around freelywithout pain.


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yAfter surgery, the foot needs to be casted at biweeklyintervals for 6 weeks, followed by the use of athermoplastic brace known as Wheaton Brace

Purpose: to hold the correction. The brace is used full-time for about 6 weeks, followed by night use only tillthe child starts to walk at one year of age


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Wheaton Brace


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Nursing Care1. Check for NEUROVASCULAR IntegrityHow: observe for color and sensation

2. Regularly inspect the cast for irritation

3. Provide diversional activities


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Congenital Hip Dysplasiay It is a disorder in children that is either present at

birth or shortly thereafter.

y During gestation, the infant's hip should bedeveloping with the head of the thigh bone(femur) sitting perfectly centered in its shallowsocket (acetabulum).

y

The acetabu

lu

m shou

ld cover the head of thefemur as if it were a ball sitting inside of a cup.


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y In congenital hip dysplasia, the development of theacetabulum in an infant allows the femoral head toride upward out of the joint socket, especially when

weight bearing begins.


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Congenital Hip Dysplasia


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Prevalence

y more females affected than males.

y related to common practice of swaddling and usingcradleboards for restraining the infants. It places the

infant's hips into extreme adduction (broughttogether)

y higher in infants born by caesarian and breechposition births.


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y greater chance in the first born compared to thesecond or third child.


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y For unilateral dislocation symptoms include:

a. The skin creases of the buttocks dont match.

b. One knee joint looks higher than the other.


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DiagnosticTest

y Ortolani Test: begins with each of the examiner'shands around the infant's knees, with the secondand third fingers pointing down the child's thigh.

With the legs abducted (moved apart), theexaminer may be able to discern a distinctclicking soundwith motion.

y If symptoms are present with a noted increase in

abdu

ction, the test is considered positive for hipjoint instability.


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Ortolani Test

Barlow Test


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y Barlow Test : with the infant's hip brought togetherwith knees in full bent position

y The examiner's middle finger is placed over outside of

the hipbone while the thumb is placed on the innerside of the knee. The hip is abducted to where it can befelt if the hip is sliding out and then back in the joint.


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yX-ray films can be helpful in detecting abnormalfindings of the hip joint.

yX rays may also be helpful in finding the proper

positioning of the hip joint for treatment of casting.


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Treatment

y Objective: is to replace the head of the femur into theacetabulum and, by applying constant pressure, toenlarge and deepen the socket.

y

In the past, stabilization was achieved by placingrolled cotton diapers or a pillow between the thighs,thereby keeping the knees in a frog like position.


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Pavlic Harness


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Nursing Care1. Check for NEUROVASCULAR IntegrityHow: observe for color and sensation

2. Regularly inspect the cast for irritation

3. Provide diversional activities

cellular abbe ration

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