Chapter 4
Care of the Patient with a
Musculoskeletal Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and
Physiology
• Functions of the skeletal system

Support
 Protection
 Movement
 Mineral storage
 Hemopoiesis
• Structure of bones

Four classifications based on form and shape
• Long, short, flat, and irregular
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Slide 2
Figure 4-2
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
Skeleton, anterior view.
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Slide 3
Figure 4-3
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
Skeleton, posterior view.
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Slide 4
Overview of Anatomy and
Physiology
• Articulations (joints)



Allow movement and flexibility
Hold bones together
Three types according to degree of movement
• Synarthrosis—no movement (skull)
• Amphiarthrosis—slight movement (pelvis)
• Diarthrosis—free movement (shoulder)
• Divisions of the skeleton


Axial skeleton
Appendicular skeleton
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Slide 5
Figure 4-1
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
Structure of a freely movable (diarthrotic) joint.
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Slide 6
Overview of Anatomy and
Physiology
• Under voluntary or involuntary control
• Functions of the muscular system

Motion
 Maintenance of posture
 Production of heat (85% of body heat)
• Skeletal muscle structure



Epimysium (connective tissue covering skeletal muscle)
Perimysium
Endomysium
• Both join with epimysium to create tendon
• Tendons anchor muscle to bone
• Tendon sheaths contain synovial fluid for easy movement
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Slide 7
Figure 4-5
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
Anterior view of the body.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 8
Figure 4-6
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
Posterior view of the body.
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Slide 9
Overview of Anatomy and
Physiology
• Nerve and blood supply

Blood vessels provide a constant supply of oxygen
and nutrition, and nerve cells/fibers supply a constant
source of information
• Muscle contraction



Muscle stimulus—when a muscle cell is adequately
stimulated, it will contract
Muscle tone—skeletal muscles are in a constant state
of readiness for action
Types of body movements—flexion, extension,
abduction, adduction, rotation, supination, pronation,
dorsiflexion, and plantar flexion
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Slide 10
Laboratory and Diagnostic
Examinations
• Radiographic studies







X-ray
Myelogram
Nuclear scanning
Magnetic resonance imaging (MRI)
Computed axial tomography (CT or CAT scan)
Bone scan
Aspiration/Synovial fluid aspiration
• Endoscopic examination


Arthroscopy
Endoscopic spinal microsurgery
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Slide 11
Laboratory and Diagnostic
Examinations
• Electrographic procedure

Electromyogram (EMG)
• Laboratory tests





Calcium
Erythrocyte sedimentation rate (ESR)
Lupus erythematosus (LE) preparation
Rheumatoid factor (RF)
Uric acid (blood)
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Slide 12
Inflammatory Disorders of the
Musculoskeletal System
• Arthritis

Several types; most common RA, rheumatoid
spondylitis, OA, DJD, gout
• Rheumatoid arthritis

Etiology/pathophysiology
•
•
•
•
Most serious form of arthritis
Chronic, systemic disease
Most common in women of childbearing age
Autoimmune disorder, but may also be genetic;
smoking greatly increases risk
• May affect lungs, heart, blood vessels, muscles, eyes,
and skin
• Chronic inflammation of the synovial membrane of the
diarthrodial joints (movable)
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Slide 13
Inflammatory Disorders of the
Musculoskeletal System
• Rheumatoid arthritis (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Characterized by periods of remission and exacerbation
Malaise
Muscle weakness
Loss of appetite
Generalized aching
Edema and tenderness of joints
Limited range of motion (morning stiffness)
Can lead to gross deformity and loss of function
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Slide 14
Figure 4-7
(From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.)
Rheumatoid arthritis of hands.
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Slide 15
Inflammatory Disorders of the
Musculoskeletal System
• Rheumatoid arthritis (continued)

Diagnostic tests
• Radiography studies show loss of articular cartilage and
change in bone structure
• Laboratory tests




Erythrocyte sedimentation rate (ESR)
Rheumatoid factor (RF)
Latex agglutination test
Synovial fluid aspiration
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Slide 16
Inflammatory Disorders of the
Musculoskeletal System
• Rheumatoid arthritis (continued)

Medical management/nursing interventions
• Pharmacological management

•
•
•
•
•
Salicylates, NSAIDs, anti-inflammatory agents, diseasemodifying antirheumatoid drugs
Rest: 8 to 10 hours of sleep a night
Exercise: Range of motion two to three times per day
Heat: Hot packs, heat lamp, and/or hot paraffin
Rehabilitation
Joint replacement if needed
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Slide 17
Inflammatory Disorders of the
Musculoskeletal System
• Ankylosing spondylitis

Etiology/pathophysiology
• Chronic, progressive disorder of the sacroiliac and hip
joints, the synovial joints of the spine, and the adjacent
soft tissues
• Most common in young men
• Strong hereditary tendency

Clinical manifestations/assessment
• Pain and stiffness in back; decreased ROM
• Elevated temperature; tachycardia; hyperpnea
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Slide 18
Inflammatory Disorders of the
Musculoskeletal System
• Ankylosing spondylitis (continued)

Diagnostic tests
• Hemoglobin, hematocrit, ESR, alkaline phosphatase
• Radiographic

Medical management/nursing interventions
• Pharmacological management

•
•
•
•
Analgesics, NSAIDs
Exercise program: swimming and walking
Surgery: replace fused joints
Maintain spine alignment
Turn, position, and breathing exercises every 2 hours
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Slide 19
Inflammatory Disorders of the
Musculoskeletal System
• Osteoarthritis (degenerative joint disease)

Etiology/pathophysiology
• Nonsystemic, noninflammatory disorder that
progressively causes bones and joints to degenerate
• Primary

Cause is unknown
• Secondary

Caused by trauma, infections, previous fractures,
rheumatoid arthritis, stress on weight-bearing joints
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Slide 20
Inflammatory Disorders of the
Musculoskeletal System
• Osteoarthritis (degenerative joint disease)
(continued)

Clinical manifestations/assessment
• Joint edema, tenderness, instability, and deformity
• Heberden’s nodes
• Bouchard’s nodes

Diagnostic tests
•
•
•
•
Radiographic studies
Arthroscopy
Synovial fluid examination
Bone scans
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Slide 21
Figure 4-9
(From Kamal, A., Brocklehurst, J.C. [1991]. Color atlas of geriatric medicine. [2nd ed.]. St. Louis: Mosby.)
Heberden’s nodes.
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Slide 22
Inflammatory Disorders of the
Musculoskeletal System
• Osteoarthritis (degenerative joint disease)
(continued)

Medical management/nursing interventions
• Pharmacological management

•
•
•
•
Salicylates, NSAIDs, corticosteroids, glucosamine
supplements
Exercise balanced with rest
Heat applications
Gait enhancers (canes, walkers, etc.)
Surgery


Osteotomy
Joint replacement
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Slide 23
Inflammatory Disorders of the
Musculoskeletal System
• Gout (gouty arthritis)

Etiology/pathophysiology
• Metabolic disease resulting from an accumulation of
uric acid in the blood
• Caused by an ineffective metabolism of purines
• Primary: hereditary factors
• Secondary: use of certain drugs, complication of other
diseases, or idiopathic
• Affects men more frequently than women
• Does not occur before puberty in males or before
menopause in females
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Slide 24
Inflammatory Disorders of the
Musculoskeletal System
• Gout (gouty arthritis) (continued)

Clinical manifestations/assessment
•
•
•
•

Excruciating pain, often occurring at night
Edema
Inflammation (most common in the great toe)
Tophi (calculi containing Na urate deposits occurring in
periarticular fibrous tissue)
Diagnostic tests
• Serum and uric acid level, CBC, ESR
• Radiography studies
• Synovial fluid aspiration
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Slide 25
Inflammatory Disorders of the
Musculoskeletal System
• Gout (gouty arthritis) (continued)

Medical management/nursing interventions
• Pharmacological management

•
•
•
•
Colchicine, phenylbutazone (Butazolidin), indomethacin
(Indocin), corticosteroids, allopurinol (Zyloprim),
sulfinpyrazone (Anturane)
Encourage fluid intake
Monitor intake and output
Bed rest and joint immobilization
Dietary restrictions
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Slide 26
Other Disorders of the
Musculoskeletal System
• Osteoporosis

Etiology/pathophysiology
• Reduction of bone mass
• Most common in women ages 55 to 65
• Contributing factors: immobilization; steroids; high
intake of caffeine; diet low in calcium, high in protein;
smoking; sedentary lifestyle

Clinical manifestations/assessment
• Backache
• Porous and brittle bones
• Dowager’s hump
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Slide 27
Other Disorders of the
Musculoskeletal System
• Osteoporosis (continued)

Diagnostic tests
• CBC, serum calcium, phosphorus, alkaline
phosphatase, blood urea nitrogen, creatinine level,
urinalysis, liver and thyroid function tests
• Radiography studies

Medical management/nursing interventions
• Pharmacological management


Calcium supplements, vitamin D
Estrogen, alendronate (Fosamax)
• Weight-bearing exercises
• Dietary recommendations
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Slide 28
Other Disorders of the
Musculoskeletal System
• Osteomyelitis

Etiology/pathophysiology
• Local or generalized infection of the bone and bone
marrow
• Staphylococci are the most common cause
• Introduced through trauma (injury or surgery) or via the
bloodstream from another site in the body to the bone
• Bacteria invade the bone and degeneration of bone
occurs
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Slide 29
Other Disorders of the
Musculoskeletal System
• Osteomyelitis (continued)

Clinical manifestations/assessment
• Persistent, severe, and increasing bone pain
• Wound draining purulent fluid
• Signs and symptoms of infection: temperature,
tachycardia, and tachypnea
• Edema of affected area

Diagnostic tests
• Radiography studies; bone scan
• CBC; ESR; cultures of blood and drainage
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Slide 30
Other Disorders of the
Musculoskeletal System
• Osteomyelitis (continued)

Medical management/nursing interventions
• Pharmacological management

Antibiotic therapy
• Surgery: removal of necrotic bone
• Absolute rest of affected extremity
• Wound care

Irrigate with hydrogen peroxide or antibiotic solution;
cover with sterile dressing
• Drainage and secretion precautions
• Dietary recommendations: high in calories, protein, and
vitamins
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Slide 31
Other Disorders of the
Musculoskeletal System
• Fibromyalgia syndrome (FMS)

Etiology/pathophysiology
• Musculoskeletal chronic pain syndrome
• Unknown etiology

Clinical manifestations/assessment
•
•
•
•
•
Generalized aching/stiffness
Irritable bowel syndrome
Tension headache
Paresthesia of upper extremities
Sensation of edematous hands
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Slide 32
Other Disorders of the
Musculoskeletal System
• Fibromyalgia syndrome (FMS) (continued)

Diagnostic tests
• No specific laboratory or radiographic tests diagnose
FMS

Medical management/nursing interventions
• Pharmacological management

Tricyclic antidepressants
• Patient education and reassurance
• Exercise
• Relaxation techniques
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Slide 33
Surgical Interventions for Total
Knee or Total Hip Replacement
• Knee arthroplasty (total knee replacement)


Replacement of the knee joint
Restore motion of the joint, relieve pain, or correct
deformity
• Hip arthroplasty (total hip replacement)

Replacement of the hip joint
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Slide 34
Figure 4-11
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)
A, Tibial and femoral components of total knee prosthesis. B, Total knee
prosthesis in place.
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Slide 35
Figure 4-14
Hip arthroplasty (total hip replacement).
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Slide 36
Surgical Interventions for Total
Knee or Total Hip Replacement
• Arthroplasty

Nursing interventions
• Intake and output



Drainage from operative drains
Oral and intravenous intake
Urinary output
• Promote respiratory function


•
•
•
•
Give oxygen 2 to 3 L/min
Incentive spirometer; cough and deep-breathe
Bed rest for 24 to 48 hours
Change dressing as ordered
Diet as ordered
Neurovascular checks and vital signs every 4 hours
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Slide 37
Surgical Interventions for Total
Knee or Total Hip Replacement
• Arthroplasty (continued)

Nursing interventions (continued)
• Physical therapy will initiate ambulation and prescribe
routine
• Antiembolisim stockings
• Avoid dislocation of prosthesis


Avoid adduction and hyperflexion of hip
Use toilet riser to prevent hyperflexion of hip
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Slide 38
Fractures
• Fracture of the hip

Etiology/pathophysiology
• Most common type of fracture
• Women at higher risk due to osteoporosis
• Types: intracapsular and extracapsular

Clinical manifestations/assessment
• Severe pain at site
• Inability to move the leg voluntarily
• Shortening or external rotation of the leg
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Slide 39
Figure 4-16
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis:
Mosby.
Fractures of the hip.
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Slide 40
Fractures
• Fracture of the hip (continued)

Diagnostic tests
• Radiographic examination
• Hemoglobin

Medical management/nursing interventions
• Buck’s or Russell’s traction until surgery
• Surgical repair



Internal fixation
Neufeld nail and screws, Kuntscher nail
Prosthetic implants
o Austin Moore prosthesis, bipolar hip replacement
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Slide 41
Fractures
• Fracture of the hip (continued)

Medical management/nursing interventions
(continued)
• Postoperative interventions







Wound and drain assessment
Vital signs
Incentive spirometer and turning every 2 hours
Antiembolic stockings; anticoagulation therapy
Maintain leg abduction
Limit weight-bearing on affected side
Chairs and commode seats should be raised to prevent
flexion of hip beyond 60 degrees
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Slide 42
Fractures
• Fracture of the hip (continued)

Medical management/nursing interventions
(continued)
• Patient teaching for open reduction internal fixation
(ORIF)






Assess ability to understand
Assist to dangle at bedside
No weight on operative side
Turn every 2 hours, maintain abduction
Physical therapy will instruct as to ambulation and
weight-bearing
As patient progresses, encourage continuing ambulation
only with assistance
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Slide 43
Fractures
• Fracture of the hip (continued)

Medical management/nursing interventions
(continued)
• Patient teaching for hip prosthetic implant




Avoid hip flexion beyond 60 degrees for approximately 10
days; beyond 90 degrees for 2 to 3 months
Avoid adduction of the affected leg beyond midline for 2
to 3 months (maintain abduction)
Maintain partial weight-bearing for approximately 2 to 3
months
Avoid positioning on the operative side
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Slide 44
Fractures
• Other fractures

Etiology/pathophysiology
• A traumatic injury to a bone in which the continuity of
the tissue of the bone is broken
• Pathological or spontaneous fractures
• Types of fractures: open, closed, greenstick, displaced,
complete, comminuted, impacted, transverse, oblique,
spiral, Colle’s, and Pott’s
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Slide 45
Fractures
• Other fractures (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
•
Pain
Loss of normal function
Obvious deformity
Change in the curvature or length of bone
Crepitus (grating sound with movement)
Soft tissue edema
Warmth over injured area
Ecchymosis of skin surrounding injured area
Loss of sensation distal to injury
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Slide 46
Fractures
• Other fractures (continued)

Diagnostic tests
• Radiographic examination

Medical management/nursing interventions
•
•
•
•
•
•
•
Splinting to prevent edema
Body alignment
Elevation of body part
Application of cold packs, first 24 hours
Administration of analgesics
Assess for change in color, sensation, or temperature
Observe for signs of shock
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Slide 47
Fractures
• Other fractures (continued)

Medical management/nursing interventions
(continued)
• Closed (simple)


Closed reduction; immobilization; traction
Open reduction with internal fixation device
• Open (compound)





Surgical debridement and culture of wound
Administration of tetanus toxoid
Observation for signs of infection
Closure of wound
Reduction and immobilization of fracture
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Slide 48
Fractures
• Fracture of the vertebrae

Etiology/pathophysiology
•
•
•
•
•
•
Diving accidents
Blows to the head or body
Osteoporosis
Metastatic cancer
Motorcycle and car accidents
Displaced fracture may place pressure on or sever the
spinal cord nerves
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Slide 49
Fractures
• Fracture of the vertebrae (continued)

Clinical manifestations/assessment
• Pain at site of injury
• Partial or complete loss of mobility or sensation
• Evidence of fracture/fracture dislocation on x-ray

Medical management/nursing interventions
• Stable injuries


Pain medication, muscle relaxants
Back support, brace, or cast
• Unstable fractures

Traction, open reduction
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Slide 50
Fractures
• Fracture of the pelvis

Etiology/pathophysiology
• Falls, automobile accidents, crushing accidents

Clinical manifestations/assessment
• Unable to bear weight without discomfort
• Pelvic tenderness and edema
• Signs of shock

Medical management/nursing interventions
• Bed rest—More severe fractures may require surgery
and/or spica or body cast
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Slide 51
Complications of Fractures
• Compartment syndrome

Cause
• Progressive development of arterial vessel compression
and reduced blood supply to an extremity

Clinical manifestations/assessment
• Sharp pain with movement, numbness or tingling in the
affected extremity, cool and pale or cyanotic, slow
capillary refill

Medical management/nursing interventions
• Fasciotomy (incision into the fascia)
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Slide 52
Figure 4-26
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
Compartment syndrome.
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Slide 53
Complications of Fractures
• Shock

Cause
• Blood loss, pain, fear

Clinical manifestations/assessment
• Altered level of consciousness, restlessness
• Hypotension, tachycardia, and tachypnea
• Pale, cool, moist skin

Medical management/nursing interventions
• Restore blood volume; shock trousers
• IV (blood and/or isotonic solutions)
• Oxygen
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Slide 54
Complications of Fractures
• Fat embolism

Cause
• Embolization of fat tissue with platelets

Clinical manifestations/assessment
• Irritability, restlessness,disorientation, stupor, coma,
chest pain, and dyspnea

Medical management/nursing interventions
• IV fluids
• Steroids, digoxin
• Oxygen
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Slide 55
Complications of Fractures
• Gas gangrene

Cause
• Severe infection of skeletal muscle by Clostridium

Clinical manifestations/assessment
• Pain at site of injury
• Signs of infection; gas bubbles under the skin
• Necrotic skin at site; foul odor from wound

Medical management/nursing interventions
• Excision of gangrenous tissue
• Antibiotics; strict aseptic technique
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Slide 56
Complications of Fractures
• Thromboembolus

Cause
• Blood vessel is occluded by an embolus

Clinical manifestations/assessment
• Area tingles and is cold, numb, and cyanotic
• Pulmonary embolus causes a sharp thoracic pain

Medical management/nursing interventions
• Anticoagulants
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Slide 57
Complications of Fractures
• Delayed fracture healing

Healing is delayed but will eventually occur
• Nonunion

The ends of the fracture fail to stabilize and heal after
6 to 9 months
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Slide 58
Skeletal Fixation Devices
• External fixation devices

Skeletal pin external fixation
• Immobilizes fractures by the use of pins inserted
through the bone and attached to a rigid external metal
frame
• Casts/cast brace

Made of layers of plaster of Paris, fiberglass, or plastic
roller bandages
 Stockinette applied, then a sheet of wadding, and
casting material
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Slide 59
Nonsurgical Interventions for
Musculoskeletal Disorders
• Traction

The process of putting an extremity, bone, or group of
muscles under tension by means of weights and
pulleys to:
•
•
•
•
•

Align and stabilize a fracture site
Relieve pressure on nerves
Maintain correct positioning
Prevent deformities
Relieve muscle spasms
Skeletal or skin
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Slide 60
Traumatic Injuries
• Contusion: A blow or blunt force that causes local
bleeding under the skin
• Sprains: Wrenching or hyperextension of a joint
• Whiplash: Injury at cervical spine caused by
hyperextension
• Strains: Microscopic muscle tears as a result of
overstretching muscles and tendons
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Slide 61
Traumatic Injuries
• Contusions, sprains, whiplash, strains

Medical management/nursing interventions
• Elevate injured area
• Cold compresses for 15 to 20 minutes intermittently for
12 to 36 hours
• Warm compresses for 15 to 30 minutes four times a
day after 24 hours
• Compressive dressings and/or splint
• Surgery
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Slide 62
Traumatic Injuries
• Dislocations

Etiology/pathophysiology
• Temporary displacement of bones from their normal
position

Clinical manifestations/assessment
•
•
•
•
•
Erythema; discoloration
Edema
Pain
Limitation of movement
Deformity or shortening of the extremity
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Slide 63
Traumatic Injuries
• Dislocations (continued)

Medical management/nursing interventions
• Closed reduction
• Open reduction
• Cold compresses first 24 hours and warm compresses
after 24 hours
• Elevate injured extremity
• Elastic bandage
• Immobilize
• Analgesics
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Slide 64
Traumatic Injuries
• Carpal tunnel syndrome

Etiology/pathophysiology
• Compression of the median nerve between the carpal
ligament and other structures
• Predisposing factors


Obese, middle-aged women
Employment in occupations involving repetitious motions
of the fingers and hands
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Slide 65
Figure 4-38
(From Thompson, J.M., et al. [2002]. Mosby’s clinical nursing. [5th ed.]. St. Louis: Mosby.)
A, Wrist structures involved in carpal tunnel syndrome. B,
Decompression of median nerve.
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Slide 66
Traumatic Injuries
• Carpal tunnel syndrome (continued)

Clinical manifestations/assessment
• Paresthesia (any subjective sensation; pricks of pins)
• Hypoesthesia (decrease in sensation in response to
stimulation of sensory nerves)
• Burning pain or tingling in the hands
• Inability to grasp or hold small objects
• Edema of the hand, wrist, or fingers
• Muscle atrophy
• Depressed appearance at the base of the thumb on the
palmar side
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Slide 67
Traumatic Injuries
• Carpal tunnel syndrome (continued)

Diagnostic tests
• Physical exam—Tinel’s sign
• Electromyogram
• MRI

Medical management/nursing interventions
•
•
•
•
•
Immobilizer
Elevate extremity
ROM exercises
Hydrocortisone injections
Surgery
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Slide 68
Traumatic Injuries
• Herniation of intervertebral disk

Etiology/pathophysiology
• Rupture of the fibrocartilage surrounding an
intervertebral disk, releasing the nucleus pulposus that
cushions the vertebrae above and below
• Lumbar and cervical herniations are most common
• May occur from lifting, twisting, trauma, or degenerative
changes
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Slide 69
Figure 4-39
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
Sagittal section of vertebrae showing both normal and herniated
disks.
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Slide 70
Traumatic Injuries
• Herniation of intervertebral disk (continued)

Clinical manifestations/assessment
• Lumbar

Low back pain that radiates over the buttock and
numbness and tingling in affected leg
• Cervical
Neck pain, headache, and neck rigidity
Diagnostic tests


• CAT scan, myelography, and electromyelography
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Slide 71
Traumatic Injuries
• Herniation of intervertebral disk (continued)

Medical management/nursing interventions
• Pharmacological management


•
•
•
•
Analgesics
Muscle relaxants
Bed rest
Physical therapy
Traction
Surgery

Laminectomy, spinal fusion, diskectomy,
chemonucleolysis
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Slide 72
Tumors
• Tumors of the bone

Etiology/pathophysiology
•
•
•
•

May be primary or secondary
Benign or malignant
Osteogenic sarcoma
Osteochondroma
Clinical manifestations/assessment
•
•
•
•
Spontaneous fractures
Anemia
Pain especially with weight-bearing
Edema and discoloration of skin at site
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Slide 73
Tumors
• Tumors of the bone (continued)

Diagnostic tests
•
•
•
•

Radiography studies
Bone scan; bone biopsy
CBC; platelet count; serum protein levels
Serum alkaline phosphatase level
Medical management/nursing interventions
• Surgery
• Chemotherapy and radiation
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Slide 74
Amputation
• Amputation of a portion of or an entire extremity

Malignant tumors, injuries, impaired circulation,
congenital deformities, infections
• Postoperative nursing interventions







Raise foot of bed to elevate extremity
Encourage movement
Place in prone position at least two times a day
Teach strengthening exercises
Elastic wraps to shape residual extremity
Assess for respiratory complications
Phantom-limb pain is normal
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Slide 75
Figure 4-40
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
Correct method of bandaging amputation stump.
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Slide 76
Nursing Process
• Assessment

Scoliosis
• Lateral curvature of the spine

Kyphosis
• A rounding of the thoracic spine
• Hump-backed appearance

Lordosis
• An increase in the curve at the lumbar region

Blanching test
• Capillary nail refill
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 77
Nursing Process
• Nursing diagnoses

Mobility, impaired physical
 Mobility, impaired bed
 Coping, ineffective
 Anxiety
 Pain
 Knowledge, deficient
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Slide 78
Chapter 18
Antiinflammatory, Musculoskeletal, and
Antiarthritis Medications
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Chapter 18
Lesson 18.1
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Learning Objectives



List medications commonly used for the
treatment of minor musculoskeletal pain and
inflammation
Compare the actions of various
antiinflammatory and muscle relaxant agents
Identify the appropriate use for
musculoskeletal relaxants
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Muscular and Skeletal Systems





Bones, joints, muscles, and ligaments
Antiinflammatory and analgesic drugs
Skeletal muscle relaxants
Drugs used to treat arthritis
Drugs used to treat gout
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The Skeletal System
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83
The Muscular System
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The Muscular System
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The Inflammatory Response




Triggers to inflammation
Phases of the inflammatory response
Symptoms of inflammation
Cellular response
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Antiinflammatory and
Analgesic Agents



Aspirin: acetylsalicylic acid (ASA)
Acetaminophen
NSAIDs
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Salicylates
Action



Analgesic, antipyretic, and antiinflammatory effects
Stop the production of prostaglandins
Table 18-1
Uses



Treatment of mild to moderate pain; reduces the risk of
myocardial infarctions and stroke, as well as transient
ischemic attacks (TIAs) in men
First-line therapy for various forms of arthritis, fever,
myalgia, neuralgia, arthralgia, headache, and
dysmenorrhea
Systemic lupus erythematosus, acute rheumatic fever
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Salicylates (cont.)
Adverse Reactions
 Tinnitus, visual disturbances, edema, urticaria,
anorexia, epigastric discomfort, and nausea
Drug Interactions
 Alcohol use increases the chance for GI
bleeding; NSAIDs; sulfonamides, sulfonylureas;
phenytoin
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Salicylates (cont.)
Nursing Implications
 Assessment, diagnosis, planning,
implementation, and evaluation
Patient Teaching
 Administration time, adverse effects; time for
drug effectiveness; implications for drug
interactions and when to contact the
healthcare provider; storage and safety; other
routes of administration if PO is not tolerated
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Acetaminophen





Over-the-counter drug used to treat fever and
pain; no antiinflammatory effect
Action: antipyretic – direct action of the
hypothalamic heat-regulating center; blocks
pyogenic cytokines through vasodilation and
sweating
Use: chronic, nonmalignant pain; osteoarthritis
Adverse reactions: rare blood response; liver
toxicity; overdosage can be fatal
Drug interactions and hepatotoxicity
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Nonsteroidal Antiinflammatory
Drugs





Action: unknown; may block prostaglandins;
analgesic, antiinflammatory, and antipyretic
effects
Uses: rheumatic disease, degenerative joint
disease, osteoarthritis, and acute
musculoskeletal problems
Adverse reactions: GI most common
Drug interactions
Nursing implications and patient teaching
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Skeletal Muscle Relaxants

Action: reduce muscle tone and involuntary
movement without loss of voluntary motor
function



Centrally acting or direct myotropic blocking
Uses: relief of pain in musculoskeletal and
neurologic disorders involving peripheral injury
and inflammation; relief of spasticity in chronic
conditions
Table 18-2
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Skeletal Muscle Relaxants (cont.)


Adverse reactions: symptoms
Drug interactions: sedatives, narcotic
analgesics, antianxiety agents, hypnotics,
alcohol, general anesthetics, MAOIs, and
tricyclics

Cyclobenzaprine and orphenadrine:
anticholinergic effects that interfere with
antihypertensive activity of alpha-adrenergic
blockers
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Skeletal Muscle Relaxants (cont.)


Nursing implications: assessment,
diagnosis, planning, implementation, and
evaluation
Patient and family teaching: administration
considerations; avoiding activities requiring
alertness; drug interactions; missed
dosages; when to contact the health care
provider; HS administration; storage and
safety
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Question 1
Which of the following is NOT a phase of the
inflammatory response?
1.
2.
3.
4.
Acute, brief, local vasodilation (opening up of
the blood vessels) and increased capillary
permeability
An immediate vasoconstriction to decrease
blood flow to the area
A delayed, subacute infiltration (movement) of
leukocytes and phagocytic cells into the tissue
Chronic, proliferative tissue degeneration
(breakdown) and fibrosis
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Chapter 18
Lesson 18.2
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Learning Objectives



Explain the mechanisms of action for different
antiarthritis medications
Describe adverse reactions often found in the
use of antiarthritis medications
Describe the clinical situations in which
uricosuric therapy may be indicated
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Antiarthritis Medications





Inflammation of the joints
Rheumatoid arthritis: autoimmune response
Osteoarthritis: local joint destruction of
weight-bearing joints
Symptoms
Complementary and Alternative Therapies
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Slow-Acting
Antirheumatic Drugs
SAARDs
 Gold Compounds
 Hydroxychloroquine sulfate
 Penicillamine
 Methotrexate
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100
Gold Compounds





Chrysotherapy
Action: unknown; interference with biochemical
reactions at the cellular level; inhibit lysosomal
enzyme activity; effect on antigen response in
rheumatoid arthritis; stops synovitis
Adverse reactions and toxicities
Dosage and administration
Forms of medication
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Hydroxychloroquine Sulfate





Action: unknown; antimalarial drug; acts to
stop antigen formation in the body
Uses
Adverse reactions
Drug effectiveness
Drug interactions
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Infliximab


Action/Use: in combination with methotrexate
to reduce signs and symptoms of rheumatoid
arthritis, Crohn disease, other orthopedic
inflammatory or destructive processes
Adverse reactions: FDA warning; symptoms
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Leflunomide


Action: pyrimidine synthesis inhibitor that has
an antiinflammatory effect
Use: adults with rheumatoid arthritis


Therapy: initial and maintenance
Adverse reactions: FDA warning label
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Methotrexate



Action: unknown, may affect immune function
to reduce inflammation
Uses: treatment of cancer and rheumatoid
arthritis
Toxicities
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105
Penicillamine




Action: chelating agent
Use: rheumatoid arthritis
Nursing implications: assessment, diagnosis,
planning, implementation, evaluation
Patient and family teaching: treatment
length/drug effectiveness; toxic effects; when to
contact healthcare provider; monitoring; brief
pain increase following injection; adverse
reactions
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Antigout Medications







Uric acid
Uric acid levels; crystal formation
Symptoms
Gouty arthritis
Relief of pain and inflammation – acute
period
Uricosuric agents
Table 18-4
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107
Uricosuric Agents


Action: increase excretion of urate salts in the
urine by blocking tubular reabsorption of
these salts in the kidney; decrease amounts
of circulating urate and deposition of urate;
promote reabsorption of urate deposits
Uses: reduce uric acid levels in patients who
do not excrete enough uric acid
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108
Uricosuric Agents (cont.)


Adverse reactions: drug-specific symptoms
Drug interactions





Salicylates
Increased drug effects
Acidifying and alkalinizing agents
Anticoagulants
Hypersensitivity reactions
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109
Uricosuric Agents (cont.)


Nursing implications: assessment, diagnosis,
planning, implementation, evaluation
Patient and family teaching: preventing attacks;
drug administration; diet and fluid intake; selfmonitoring of urine and stools; when to contact
the health care provider; colchicine
administration; drug interactions
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110
Question 2
Cyclooxygenase-1 (COX-1) is NOT found in
the:
1.
2.
3.
4.
Blood vessels.
Stomach.
Lungs.
Kidneys.
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111
Question 3
Which of the following medications is the
strongest or most potent salicylate in
stopping prostaglandin synthesis and the
antiinflammatory response?
1.
2.
3.
4.
Acetaminophen
Aspirin
Ibuprofen
Cyclobenzaprine
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112