musculoskeletal system. risk factors for m/s problems overweight family hx of arthritis systemic...

MUSCULOSKELETALMUSCULOSKELETALSYSTEMSYSTEM

Risk Factors For M/S ProblemsRisk Factors For M/S Problems

OverweightOverweight Family hx of arthritisFamily hx of arthritis Systemic problemsSystemic problems Occupational risksOccupational risks Plays contact sportsPlays contact sports Exercises less than twice per weekExercises less than twice per week Has poor eyesightHas poor eyesight Any problem that would impede ADLsAny problem that would impede ADLs

Key S&S That Suggest M/S ProblemsKey S&S That Suggest M/S Problems

Pain ContracturesPain Contractures Swelling Limited ROMSwelling Limited ROM Redness Joint StiffnessRedness Joint Stiffness Myalgia NodulesMyalgia Nodules Immobility WarmthImmobility Warmth Sensory DeficitsSensory Deficits FeverFever MalaiseMalaise

Functional AssessmentFunctional Assessment

Do your Do your joint/muscle/bone joint/muscle/bone problems create any problems create any limits on your usual limits on your usual activities of daily activities of daily living?living?

Screens for safety of Screens for safety of independent living, independent living, need for HHC, and need for HHC, and quality of life. quality of life.

BathingBathing DressingDressing ToiletingToileting GroomingGrooming EatingEating MobilityMobility CommunicationCommunication

Functional AssessmentFunctional Assessment

The functional assessment is important The functional assessment is important because it screens for the safety of because it screens for the safety of independent living, the need for home independent living, the need for home health care services, and quality of life.health care services, and quality of life.

Self Care BehaviorsSelf Care Behaviors

Any occupational hazards that could affect Any occupational hazards that could affect the muscles and joints?the muscles and joints?

Does your work involve any heavy lifting or Does your work involve any heavy lifting or any repetitive motion?any repetitive motion?

Do you engage in an exercise program?Do you engage in an exercise program? Have you had any recent weight gain?Have you had any recent weight gain? Are you taking any medications for Are you taking any medications for

musculoskeletal discomfort?musculoskeletal discomfort?

Orthopedic ScreeningsOrthopedic Screenings

Scoliosis- Scoliosis- done in Health Dept. and done in Health Dept. and

school setting at age 10-12. school setting at age 10-12.

Bone Mineral Density (BMD)- Bone Mineral Density (BMD)- measured bymeasured by

DEXA (dual energy x-ray absorptiometry)DEXA (dual energy x-ray absorptiometry)

*T Scores: -1 to -2.5 SD *T Scores: -1 to -2.5 SD osteopeniaosteopenia

>-2.5 >-2.5 osteoporosisosteoporosis

Diagnostic TestsDiagnostic Tests

Myelography Myelography ArthrocentesisArthrocentesis ArthrogramArthrogram ArthroscopyArthroscopy CT ScanCT Scan Bone ScanBone Scan Magnetic Resonance ImagingMagnetic Resonance Imaging EMGEMG

Diagnostic TestsDiagnostic Tests

Erythrocyte Sedimentation Rate(ESR)Erythrocyte Sedimentation Rate(ESR) ComplementComplement CalciumCalcium Phosphorus (Alk. Phosphotase)Phosphorus (Alk. Phosphotase)

PHARMACOLOGICALPHARMACOLOGICALTHERAPYTHERAPY

ANALGESIC/ANTIINFLAMMATORYANALGESIC/ANTIINFLAMMATORY

NSAIDSNSAIDS-5% of all prescriptions-5% of all prescriptions Nonsteroidal Anitinflammatory DrugsNonsteroidal Anitinflammatory Drugs INDICATIONS: Analgesic, Antiinflammatory, INDICATIONS: Analgesic, Antiinflammatory,

Anitrheumatic, AntipyreticAnitrheumatic, Antipyretic ACTION: Inhibition of the arachidonic acid ACTION: Inhibition of the arachidonic acid

pathway pathwayTx : Gout, Bursitis, Fever ,JRA, Osteoarthritis, Tx : Gout, Bursitis, Fever ,JRA, Osteoarthritis,

Rheumatoid Arthritis, Tendinitis, Mild to Mod. Rheumatoid Arthritis, Tendinitis, Mild to Mod. Pain, ankylosing spondylitis, dysmenorrhea, Pain, ankylosing spondylitis, dysmenorrhea, migrainesmigraines

Most common NSAIDS:Most common NSAIDS:

Aspirin/ASA(Salicylate) 3.2-6 g po daily divided q4-6hAspirin/ASA(Salicylate) 3.2-6 g po daily divided q4-6h Celebrex(Cox-2 inhibitor) 100-200 mg po once dailyCelebrex(Cox-2 inhibitor) 100-200 mg po once daily Vioxx (Cox-2 inhibitior) 12.5-50 mg po once dailyVioxx (Cox-2 inhibitior) 12.5-50 mg po once daily Ibuprofin(Propionic Acid) (motrin, advil) 1200-3200 mg Ibuprofin(Propionic Acid) (motrin, advil) 1200-3200 mg

po daily divided tid-qidpo daily divided tid-qid Indocin(Acetic Acid) 25-50 mg po bid-tid (max 200 mg) Indocin(Acetic Acid) 25-50 mg po bid-tid (max 200 mg)

Toradol(Pyrrolizine Carboxylic Acid)10 mg po q4-6hToradol(Pyrrolizine Carboxylic Acid)10 mg po q4-6h 15-60 IV/IM q6-12h15-60 IV/IM q6-12h Nursing implications/side effects andNursing implications/side effects and contraindications. Use of Cytotec????contraindications. Use of Cytotec????

BIPHOSPHONATESBIPHOSPHONATES

Inhibit osteoclast-mediated bone resorptionInhibit osteoclast-mediated bone resorption Increases BMD and total bone massIncreases BMD and total bone mass *Fosamax 5 mg daily or 35 mg/wk prevention*Fosamax 5 mg daily or 35 mg/wk prevention

10 mg daily or 75 mg/wk treatment10 mg daily or 75 mg/wk treatment *Instructions on administration: AM first thing, full *Instructions on administration: AM first thing, full

glass of water, do not eat or drink for 30 minutes, glass of water, do not eat or drink for 30 minutes, sitting upsitting up

These precautions aid in absorption and decrease These precautions aid in absorption and decrease GI side effects i.e. gastritis, weight loss, anorexia, GI side effects i.e. gastritis, weight loss, anorexia, esophageal irritation.esophageal irritation.

Osteoporosis Drug TherapyOsteoporosis Drug Therapy

SERM-selective estrogen receptor modulatorSERM-selective estrogen receptor modulator Postmenopausal use-increases BMD by mimicing effect Postmenopausal use-increases BMD by mimicing effect

of estrogen on bone by reducing bone resporption (may of estrogen on bone by reducing bone resporption (may cause leg cramps)cause leg cramps)

EVISTA (raloxifene) 60mg po qdEVISTA (raloxifene) 60mg po qd

CALCITONIN-hormonal substitute from salmon. CALCITONIN-hormonal substitute from salmon.

Calcimar IM/SC 100U qdCalcimar IM/SC 100U qd

Miacalcin Nasal Spray 200U qdMiacalcin Nasal Spray 200U qd

CORTICOSTEROIDSCORTICOSTEROIDS

Intra-articular Injections: Depo-MedrolIntra-articular Injections: Depo-Medrol Systemic: Decadron, Prednisone (PO)Systemic: Decadron, Prednisone (PO)

Solu-Cortef (parenteral)Solu-Cortef (parenteral)

Inhibit syntesis or release of mediators of Inhibit syntesis or release of mediators of

InflammationInflammation

Not recommended for long term useNot recommended for long term use

MUSCLE RELAXANTSMUSCLE RELAXANTS

DEPRESSANT EFFECT ON CNSDEPRESSANT EFFECT ON CNS

Relief of painful muscle spasm /in conjunction with PTRelief of painful muscle spasm /in conjunction with PT May also reduce rigidity and spasticity in chronic May also reduce rigidity and spasticity in chronic

disorders (cp, ms, parkinson’s, huntington’s chorea)disorders (cp, ms, parkinson’s, huntington’s chorea)

CNS side effects (dizziness, drowsiness, weakness)CNS side effects (dizziness, drowsiness, weakness)

Flexeril, Skelaxin, Lioresal/central actingFlexeril, Skelaxin, Lioresal/central acting Dantrium/ direct effect on striated muscleDantrium/ direct effect on striated muscle

OTCs and VitaminsOTCs and Vitamins

Calcium supplements- need 1000mg pre-Calcium supplements- need 1000mg pre-menopause and 1500mg post-menopausemenopause and 1500mg post-menopause

Vitamin D supplements-must have for Vitamin D supplements-must have for calcium absorption. 400-800IU.calcium absorption. 400-800IU.

Glucosamine-role in synthesis of new Glucosamine-role in synthesis of new cartilage. Found in mucoproteins. cartilage. Found in mucoproteins.

Chondroitin-component of cartilageChondroitin-component of cartilage

NONPHARMACOLOGICALNONPHARMACOLOGICALTHERAPYTHERAPY

Heat & Cold TherapyHeat & Cold Therapy

Cold Therapy-After an injury, ice packs should be Cold Therapy-After an injury, ice packs should be applied for 20 minutes out of every hour for the first 24 applied for 20 minutes out of every hour for the first 24 hours. Reduces swelling. Trauma, surgery, arthritis.hours. Reduces swelling. Trauma, surgery, arthritis.

Heat therapy (such as heating pads, hot tub baths etc.) are Heat therapy (such as heating pads, hot tub baths etc.) are helpful in treating pain, stiffness and muscle spasms. helpful in treating pain, stiffness and muscle spasms. Whirlpool baths, ultrasound, paraffin wax (by PT)Whirlpool baths, ultrasound, paraffin wax (by PT)

DO NOT use in areas of radiation therapy, bleeding (with DO NOT use in areas of radiation therapy, bleeding (with heat), poor circulation, decreased sensation.heat), poor circulation, decreased sensation.

Cover heat or cold source with towel to prevent burns.Cover heat or cold source with towel to prevent burns.

Assistive DevicesAssistive Devices Crutches-two, three or four point gait. proper fit and Crutches-two, three or four point gait. proper fit and

safety. safety.

Walkers-extra support, independence, Pick up or rolling. Walkers-extra support, independence, Pick up or rolling. Weight bearing vs non-weight bearingWeight bearing vs non-weight bearing

Abduction Pillows-prevent internal rotation, adduction and Abduction Pillows-prevent internal rotation, adduction and dislocation of new hip joint. dislocation of new hip joint.

Prosthetic Limbs-immediate <edema, early ambProsthetic Limbs-immediate <edema, early amb

OTHER SUPPORTIVE THERAPYOTHER SUPPORTIVE THERAPY

Physical Therapy: ROM, Gait/strength, transfers, assisstive devices, Physical Therapy: ROM, Gait/strength, transfers, assisstive devices, treatmentstreatments

TENS-transcutaneous electrical nerve stimulation-delivers electric current to TENS-transcutaneous electrical nerve stimulation-delivers electric current to skin surface over painful region. (by PT)skin surface over painful region. (by PT)

Massage-pain therapyMassage-pain therapy

Cognitive Therapy-Relaxation, Distraction, Hypnosis, ImageryCognitive Therapy-Relaxation, Distraction, Hypnosis, Imagery

RICE –REST, ICE, COMPRESSION, ELEVATIONRICE –REST, ICE, COMPRESSION, ELEVATION

TraumaTrauma

Trauma accounts for a significant portion Trauma accounts for a significant portion of medical associated with the of medical associated with the musculoskeletal tissues. Injuries occur in musculoskeletal tissues. Injuries occur in all age groups.all age groups.

One in five emergency department visits is One in five emergency department visits is associated with musculoskeletal trauma.associated with musculoskeletal trauma.

TraumaTrauma

Contusion- A bruise without an external break in Contusion- A bruise without an external break in the skin.the skin.

Strain- A “pull” in a muscle, ligament, or tendon Strain- A “pull” in a muscle, ligament, or tendon caused by excessive stretch.caused by excessive stretch.

Sprain- A partial or full tearing off or away Sprain- A partial or full tearing off or away (avulsion) of one or more ligaments, tendon, or (avulsion) of one or more ligaments, tendon, or portions of bone in & around a joint.portions of bone in & around a joint.

Dislocation- Displacement of a part, usually a Dislocation- Displacement of a part, usually a bone from its normal anatomic position within a bone from its normal anatomic position within a joint.joint.

DISLOCATION OF THE HIPDISLOCATION OF THE HIP

A. Normal. A. Normal. B. Subluxation B. Subluxation

(partial (partial dislocation). dislocation).

C. Dislocation. C. Dislocation.

TYPES OF HIP FRACTURE TYPES OF HIP FRACTURE INTERNAL FIXATION DEVICESINTERNAL FIXATION DEVICES

A. Femoral head A. Femoral head endoprosthesis. endoprosthesis.

B. Type of hip B. Type of hip compression screw compression screw with side plate. with side plate.

FracturesFractures

A fracture is a dicontinuity or a break in the A fracture is a dicontinuity or a break in the bone.bone.

A fractured bone can no longer maintain A fractured bone can no longer maintain its normal length unless the two fragment its normal length unless the two fragment impact into each other.impact into each other.

Usually there will be shortening of the Usually there will be shortening of the tissues around the fractured bone d/t tissues around the fractured bone d/t muscle contractions and spasms.muscle contractions and spasms.

Can you identify Can you identify

the different the different

types of types of

fractures and fractures and

what type of what type of

injury caused injury caused

them?them?

Explain the difference between Explain the difference between these fractures.these fractures.

Assessment: Areas of ConcernAssessment: Areas of Concern EdemaEdema Color ChangesColor Changes DeformityDeformity ParasthesiaParasthesia PainPain Limited MovementLimited Movement CrepitationCrepitation BruisingBruising BleedingBleeding Distal PulseDistal Pulse

PallorPallor ConfusionConfusion DyspneaDyspnea ShockShock Changes in BPChanges in BP DiaphoresisDiaphoresis Fear & AnxietyFear & Anxiety Concomitant Disease or Concomitant Disease or

Other InjuriesOther Injuries

Pain AssessmentPain Assessment

Pain Scale 0/10 to 10/10Pain Scale 0/10 to 10/10 LocationLocation QualityQuality IntensityIntensity DurationDuration Precipitating FactorsPrecipitating Factors Alleviating FactorsAlleviating Factors Exacerbating FactorsExacerbating Factors

REDUCTION AND IMBOLIZATIONREDUCTION AND IMBOLIZATION

OPEN-OPEN- surgical correction of bone fracturesurgical correction of bone fracture with use of internal fixation such as with use of internal fixation such as

wires, screws, pins, wires, screws, pins, plates.plates.

More risk for complications.More risk for complications.

CLOSED-CLOSED- nonsurgical, manual realignment.nonsurgical, manual realignment. anesthesia, immobilization by traction, anesthesia, immobilization by traction,

cast, external fixation, splint or brace.cast, external fixation, splint or brace.

EXTERNAL FIXATION-EXTERNAL FIXATION- metal pins inserted into bone and attached to metal pins inserted into bone and attached to

external rods.external rods. for traction, complex fractures, limb lengthening.for traction, complex fractures, limb lengthening. signs of infection: pain, redness, tenderness, signs of infection: pain, redness, tenderness,

exudate at pin site. Pin care ½ hydrogen exudate at pin site. Pin care ½ hydrogen peroxide with normal saline.peroxide with normal saline.

INTERNAL FIXATION- INTERNAL FIXATION- surgically inserted at time of realignment. surgically inserted at time of realignment.

Biologically inert metal devices.Biologically inert metal devices.

Casts and SplintsCasts and Splints Casts are primarily used after a closed reduction of Casts are primarily used after a closed reduction of

a fracture. Proper technique in handling cast and a fracture. Proper technique in handling cast and client is essential.client is essential.

Two basic types of casts: plaster and synthetic.Two basic types of casts: plaster and synthetic.

Splints are removable devices that are applied to an Splints are removable devices that are applied to an injured person prior to moving them.injured person prior to moving them.

Splints are also used in a more long-term manner to Splints are also used in a more long-term manner to prevent joint deformities and to maintain functional prevent joint deformities and to maintain functional and structural alignment.and structural alignment.

Common casts used in treatment of Common casts used in treatment of disorders of the musculoskeletal systemdisorders of the musculoskeletal system

TractionTraction

The exertion of a pulling force utilized to align The exertion of a pulling force utilized to align and immobilize bone fragments. and immobilize bone fragments.

Also helps to relieve muscle spasms and correct Also helps to relieve muscle spasms and correct flexion contractures, deformities, and flexion contractures, deformities, and dislocations.dislocations.

There are 2 types of traction: Skin (Buck’s There are 2 types of traction: Skin (Buck’s traction & Russell’s traction) and Skeletal traction & Russell’s traction) and Skeletal traction. traction.

Care of the Traction ClientCare of the Traction Client

SKIN-temporary immobilization, spasms, SKIN-temporary immobilization, spasms, stabilization. No movement. Body is stabilization. No movement. Body is counterforce. Skin breakdown prevention. counterforce. Skin breakdown prevention.

SKELETAL-free falling weights, ropes taught, SKELETAL-free falling weights, ropes taught, pin assess and care, free movement. Need pin assess and care, free movement. Need trapeze, rope and weight assess. essential.trapeze, rope and weight assess. essential.

AmputationAmputation

The removal of all or part of a specific The removal of all or part of a specific tissue or organ. Musculoskeletal tissues tissue or organ. Musculoskeletal tissues are frequently amputated because of are frequently amputated because of crush injuries, severe sepsis, malignant crush injuries, severe sepsis, malignant tumors, or gangrene.tumors, or gangrene.

Assessment/Areas of Concern-Assessment/Areas of Concern-

Nsg Considerations-Nsg Considerations-

ComplicationsComplications

For Casts-For Casts- Compartment Syndrome Compartment Syndrome

InfectionInfection

Skin BreakdownSkin Breakdown

For Traction-For Traction- Skin Breakdown Skin Breakdown

Orthostatic Hypotension Orthostatic Hypotension Boredom/Cabin Boredom/Cabin FeverFever

Complications …….Complications …….

For Surgery – For Surgery – Venous thrombosis r/t Venous thrombosis r/t decreased activity which may lead to clot decreased activity which may lead to clot formation.formation.

Phantom Pain Phantom Pain AspirationAspiration Fat EmbolusFat Embolus PneumoniaPneumonia

Complications…….Complications…….

For Fractures –For Fractures – Fat embolism- This is a serious Fat embolism- This is a serious circulatory condition characterized by the circulatory condition characterized by the blocking of an artery by an embolus of fat that blocking of an artery by an embolus of fat that entered the circulatory system after the fracture entered the circulatory system after the fracture of a long bone or, less commonly, after a of a long bone or, less commonly, after a traumatic injury to adipose tissue or to a fatty traumatic injury to adipose tissue or to a fatty liver.liver.

Conditions/Diseases/DisordersConditions/Diseases/Disorders

Bursitis- Inflammation of the bursa (small Bursitis- Inflammation of the bursa (small sac or cavity surrounding or near a joint). sac or cavity surrounding or near a joint). Typically involves the shoulder, elbow, Typically involves the shoulder, elbow, knee, and hip.knee, and hip.

Treatment-Treatment-

Nursing InterventionsNursing Interventions

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

A, Wrist structures A, Wrist structures involved in carpal involved in carpal tunnel syndrome. tunnel syndrome.

B, Decompression of B, Decompression of median nerve. median nerve.


Paget’s Diseases- A metabolic bone disorder of Paget’s Diseases- A metabolic bone disorder of unknown etiology and which normally affects unknown etiology and which normally affects older people. This process causes an increased older people. This process causes an increased and irregular formation of the bone due to and irregular formation of the bone due to irregular osteoclast and osteoblast activity. irregular osteoclast and osteoblast activity. Deformities & bony enlargement often occur.Deformities & bony enlargement often occur.

TreatmentTreatment

Nsg ConsiderationsNsg Considerations

OSTEOMYELITISOSTEOMYELITIS Severe infection of the bone (Staph aureus)Severe infection of the bone (Staph aureus)

Occurrence reduced by prophylactic use of antibioticsOccurrence reduced by prophylactic use of antibiotics

Blount trauma in males less than 12 yrs oldBlount trauma in males less than 12 yrs old

Diagnosed by bone biopsy, MRI, CT, CBCDiagnosed by bone biopsy, MRI, CT, CBC

Intensive IV antibiotic therapy from 4 weeks to 6 monthsIntensive IV antibiotic therapy from 4 weeks to 6 months

Surgical removal of dead bone (Amputation) in advanced Surgical removal of dead bone (Amputation) in advanced casescases

Bone CancerBone Cancer

Multiple MyelomaMultiple Myeloma Osteogenic SarcomaOsteogenic Sarcoma OsteoclastomaOsteoclastoma Ewing’s SarcomaEwing’s Sarcoma Metastatic Bone DiseaseMetastatic Bone Disease

GERIATRICGERIATRICconsiderationsconsiderations


Osteoporosis- A condition of overall Osteoporosis- A condition of overall reduction in the bone mass or density in reduction in the bone mass or density in which bone reabsorption has outstripped which bone reabsorption has outstripped bone formation, thereby upsetting the bone formation, thereby upsetting the normal balance.normal balance.

TreatmentTreatment

Nursing InterventionsNursing Interventions


Osteoarthritis- AKA osteoarthrosis- a Osteoarthritis- AKA osteoarthrosis- a degenerative condition of the articular degenerative condition of the articular cartilage primarily within the major weight cartilage primarily within the major weight bearing joints although other joints can bearing joints although other joints can also be affected.also be affected.

Treatment-Treatment-Nsg Interventions-Nsg Interventions-

Joints most frequently Joints most frequently involved in involved in osteoarthritis.osteoarthritis.

PEDIATRICPEDIATRICconsiderationsconsiderations

Pediatric ProblemsPediatric Problems

Scoliosis- Lateral curvature of the spine. A Scoliosis- Lateral curvature of the spine. A common abnormality of childhood. Causes common abnormality of childhood. Causes include congenital malformations, spastic include congenital malformations, spastic paralysis, and unequal leg length.paralysis, and unequal leg length.

Kyphosis- An abnormal condition of the vertebral Kyphosis- An abnormal condition of the vertebral column that is characterized by increased column that is characterized by increased convexity in the curvature of the thoracic spine. convexity in the curvature of the thoracic spine. It may be caused by rickets or tuberculosis of It may be caused by rickets or tuberculosis of the spine. Adolescent kyphosis is usually self-the spine. Adolescent kyphosis is usually self-limiting and often undiagnosed.limiting and often undiagnosed.

Pediatric ProblemsPediatric Problems

Muscular Dystrophy- A group of Muscular Dystrophy- A group of genetically transmitted diseases genetically transmitted diseases characterized by progressive atrophy of characterized by progressive atrophy of symmetric groups of skeletal muscles symmetric groups of skeletal muscles without the involvement of neural tissue. without the involvement of neural tissue. There is a loss of strength with increasing There is a loss of strength with increasing disability and deformity.disability and deformity.

Congenital Hip DysplasiaCongenital Hip Dysplasia

The abnormal placement and The abnormal placement and development of the head of the femur and development of the head of the femur and acetabulum resulting in the dysfunction of acetabulum resulting in the dysfunction of the hip.the hip.

It is more common in female babies (6:1).It is more common in female babies (6:1).

The left hip is more commonly affected The left hip is more commonly affected than the right hip.than the right hip.

Legg-Perthes DiseaseLegg-Perthes Disease

A disease of the femoral head in which A disease of the femoral head in which either the cartilage or the femoral head either the cartilage or the femoral head itself develops avascular necrosis.itself develops avascular necrosis.

TreatmentTreatment

Nsg ImplicationsNsg Implications

CLUB FOOT-complex deformity of the CLUB FOOT-complex deformity of the ankle and foot including inversion, ankle and foot including inversion, eversion, .plantar or dorsiflexion. 1-2 births eversion, .plantar or dorsiflexion. 1-2 births in 1000. boys 2x girls.in 1000. boys 2x girls.

50% bilateral. Goal: correction of 50% bilateral. Goal: correction of deformity:deformity:

manual manipulation/Serial Casting q1-manual manipulation/Serial Casting q1-2wks.2wks.

Surgical: pinning and tendon release.Surgical: pinning and tendon release.

PSYCHOSOCIAL INTEGRITYPSYCHOSOCIAL INTEGRITY

Assess for :Assess for : Self esteem disturbanceSelf esteem disturbance Loss of independenceLoss of independence Body image disturbanceBody image disturbance Role performance disturbanceRole performance disturbance Social isolationSocial isolation Impaired physical mobilityImpaired physical mobility

musculoskeletal system. risk factors for m/s problems overweight family hx of arthritis systemic...

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