NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor:
Mrs. Lorna Paber
MUSKOLOSKELETAL
SYSTEM
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•
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TAUTO-AN, MARK CLARENCE PAUL
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Irregular bone – has a shape that does not
conform to the above three types. Examples
include the bones of the spine (vertebrae).
Example are vertebrae and mandible.
•
Flat bone – has a flattened, broad surface.
Examples include ribs, shoulder blades, breast
bone and skull bones
bones, muscles
joints, cartilages
tendons, ligaments
BONES
• Variously classified according to shape, location
and size
Functions:
• provide support
• assist in movement/ locomotion
• protect vital organs
• hematopoiesis
• calcium and phosphorus storage
MUSCLES
• A body tissue consisting of long cells that contract
when stimulated and produce motion
• Born with 230 muscles and adult has 630 / 650
muscles
How many bones in the body?
• Babies start with about 270 bones.
• Adults have 206 named bones.
o 80 in the axial skeleton and
o 126 in the appendicular skeleton.
Three types of muscles (exist in the body)
1. Skeletal Muscles - Voluntary and striated
2. Cardiac Muscles - Involuntary and striated
3. Smooth/Visceral Muscles - Involuntary & NON-striated
(vital organs, stomach, liver, uterus)
Functions:
• provide shape to the body
• protect the bones
• maintain posture
• cause movement
Types of bones:
• long: tibia, humerus, femur
• short: carpals and tarsals
• irregular: vertebrae, mandible
• flat: skull, ribs
•
Long bone – has a long, thin shape. Examples
include the bones of the arms and legs (excluding
the wrists, ankles and kneecaps). With the help of
muscles, long bones work as levers to permit
movement. Examples are tibia, humerus and
femur.
•
Short bone – has a squat, cubed shape. Examples
include the bones that make up the wrists and the
ankles. Examples are carpals and tarsals.
Muscles accomplish movement only by contraction:
• Flexion: bending at a joint
• Extension: straightening of a joint
• Abduction: action moving away from the body
• Adduction: action moving toward the body
• Hypertrophy: will occur if muscle is exercised
repeatedly
• Atrophy: will occur with muscle disuse
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
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Hinge joint – the two bones open and close in one
direction only (along one plane) like a door, such
as the knee and elbow joints.
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Condyloid joint – this permits movement without
rotation, such as in the jaw or finger joints.
•
Pivot joint – one bone swivels around the ring
formed by another bone, such as the joint
between the first and second vertebrae in the
neck.
•
Gliding joint – or plane joint. Smooth surfaces slip
over one another, allowing limited movement,
such as the wrist joints
JOINTS
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A joint is the part of the body where two or more
bones meet to allow movement.
• Permits bones to change position and facilitate
body movement.
• The part of the Skeleton where two or more bones
are connected
• The junction of two or more bones
How many joints?
• The estimated number is between 250 and 350.
Classification of joints:
• Synarthroses: immovable joints
• Amphiarthroses: slightly immovable
• Diarthroses (synovial): freely movable
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Immovable – the two or more bones are in close
contact, but no movement can occur – for
example, the bones of the skull. The joints of the
skull are called sutures.
•
Slightly movable – two or more bones are held
together so tightly that only limited movement is
permitted – for example, the vertebrae of the
spine.
•
Freely movable – most joints within the human
body are this type. Motion is the purpose of the
joint.
six types of freely movable joints
• Ball and socket joint – the rounded head of one
bone sits within the cup of another, such as the
hip joint or shoulder joint. Movement in all
directions is allowed.
•
Saddle joint – this permits movement back and
forth and from side to side, but does not allow
rotation, such as the joint at the base of the
thumb.
Inspection of joint
• Swellings
• Skin changes
o Color, scar, previous surgery, rashes
• Adjacent structures
o Muscles - wasting of muscles above and
below a joint often accompanies joint
disease
o Compare to opposite side
• Deformity
o Misalignment of bone mating up the joint
• Bursae
• Sac containing fluid that are located around
the joints to prevent friction
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
CARTILAGE
• A dense connective tissue that consists of fibers
embedded in a strong gel- like substance
• dense, rigid, avascular tissue
• covers end of bone
• cushion bony prominences
• lines the bony areas to protect cushion/rubbing of
two bones
• Rub, lack of cartilage
• Tissue that will line of the edge of the bone
TAUTO-AN, MARK CLARENCE PAUL
Past Health History
• Inquire whether the patient has ever had gout,
arthritis, tuberculosis (TB), or cancer, which may
have bony metastases. Has he been diagnosed
with osteoporosis?
• Info on injuries
• Ask whether he has had a recent blunt or
penetrating trauma.
• For example, did he suffer knee and hip injuries
after being hit by a car, or did he fall from a ladder
and land on his coccyx?
• Also ask the patient whether he uses an assistive
device, such as a cane, walker, or brace. If so,
watch him use the device to assess how he moves.
Medications
• Question the patient about the medications he
takes regularly.
• Many drugs can affect the musculoskeletal system.
• Corticosteroids, for example, can cause muscle
weakness, myopathy, osteoporosis, pathologic
fractures, and avascular necrosis of the heads of
the femur and humerus.
ASSESSMENT
Physical Examination
• Inspect: body build, posture, gait
• Inspect, palpate and manipulate (joints)
o Swelling, masses, movement,
crepitations, tenderness
• Inspect, palpate and manipulate (muscles)
o Size, symmetry, tone, strength
• Flail Chest - check symmetry of chest for breathing
o Manipulate: ex. ask client to move the
arm or whatsoever then see it
• Neurogenic shock
Family History
• Ask the patient if a family member suffers from
joint disease.
• Disorders with a hereditary component include:
o Gout
o Osteoarthritis of the interphalangeal
joints
o Spondyloarthropathies (such as
ankylosing spondylitis, Reiter’s syndrome,
psoriatic arthritis, and enteropathy
arthritis)
o Rheumatoid arthritis
Patient Health History
• Ask the patient about
o Current illness/present
o Past illnesses
o Medications
o Family and social history
Social History
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Ask the patient about his job, hobbies, and
personal habits.
• Knitting, playing football or tennis, working at a
computer, or doing construction work can all
cause repetitive stress injuries or injure the
musculoskeletal system in other ways.
• Even carrying a heavy knapsack or purse can cause
injury or increase muscle size.
Current Illness
• Ask the patient about his chief complaint.
• Patients with joint injuries usually complain of
pain, swelling, or stiffness; those with bone
fractures have sharp pain when they move the
affected area.
• Muscular injury is commonly accompanied by
pain, swelling, and weakness.
• Ask the patient if his ability to carry out ADLs is
affected. Is pain more intense or has he noticed
grating sounds when he moves certain parts of his
body? Does he use ice, heat, or other remedies to
treat the problem? Is pain worse in the morning
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
PHYSICAL EXAM
Inspection
• Note the size and shape of joints, limbs, and body
regions; note body symmetry
• Inspect the skin and tissues around the joint, limb,
or body region for color, swelling, masses, and
deformities
• Observe how the patient stands and moves; watch
him walk, noting his gait, posture, arm
movements, and coordination
• Inspect the curvature of his spine
• To check range of motion (ROM), ask the patient
to abduct, adduct, and flex or extend affected
joints
• Inspect major muscle groups for tone, strength,
symmetry, and abnormalities; note contractures
and abnormal movements, such as spasms, tics,
tremors, and fasciculations
Palpation
• Palpate the patient’s bones, noting any
deformities, masses, or tenderness
• Evaluate the patient’s muscle tone, mass, and
strength
•
Palpate joints for tenderness, nodes, crepitus, and
temperature at rest and during passive ROM
• Palpate arterial pulses, and check capillary refill
time
• Check neurovascular status, including movement
and sensation
After palpation and inspection
Deviations from the normal include
• Pain, swelling, stiffness, deformities,
• Altered ROM,
• Crepitation (a grating sound or sensation
accompanying joint movement),
• Ankylosis (joint fusion or fixation), and
• Contracture (muscle shortening).
MEASURING YOUR MUSCLE STRENGTH
• To evaluate strength, the Medical Research
Council scale of muscle strength (MCR- scale) is
commonly used that grades the strength into 0 to
5:
o O - No contraction
o 1 - Flicker or trace of contraction
o 2 - Full of range of active movement, with
gravity eliminated
o 3 - Active movement against gravity
o 4 - Active movement against gravity and
resistance
o 5 - Normal Power
TAUTO-AN, MARK CLARENCE PAUL
Diagnostic Evaluation:
(all except imaging procedures are invasive)
Radiology assessment – radiographic
and imaging studies
1. X-ray Studies
2. Computed tomography (CT) scans,
3. Magnetic resonance imaging (MRI),
4. Bone scan
X-ray
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Anteroposterior (AP), posteroanterior (PA) &
lateral X-rays allow three-dimensional
visualization.
They help diagnose:
a. Traumatic disorders,
b. Fractures and dislocations bone disease
c. Solitary lesions, multiple focal lesions in
one bone,
d. Generalized lesions involving all bones
joint disease, such as arthritis, infection,
degenerative changes, synoviosarcoma,
osteochondromatosis, avascular necrosis,
slipped femoral epiphysis, and inflamed
tendons’ bursae around a joint masses
and calcifications.
e. Diagnose traumatic injuries, bone and
joint disease, and masses and
calcifications
CT Scan
• CT scan aids diagnosis of bone tumors and other
abnormalities
• Helps assess questionable cervical or spinal
fractures, fracture fragments, bone lesions, and
intra-articular loose bodies
• Multiple X-ray beams from a computerized body
scanner are directed at the body from different
angles. The beams pass through the body and
strike radiation detectors, producing electrical
impulses.
•
A computer then converts these impulses into
digital information, which is displayed as a threedimensional image on a video monitor
MRI
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MRI can show irregularities of the spinal cord and
is especially useful for diagnosing disk herniation.
Must be animal magnetism
The MRI scanner uses a powerful magnetic field
and radiofrequency energy to produce images
based on the hydrogen content of body tissues.
The computer processes signals and displays the
high-resolution image on a video monitor. The
patient can’t feel the magnetic fields.
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
Bone Scan
• Imaging study with the use of a contrast
radioactive material A bone scan helps detect
bony metastasis, benign disease, fractures,
avascular necrosis, and infection
• Pre-test: Painless procedure, IV radioisotope is
used, no special preparation, pregnancy is
contraindicated
• Intra-test: IV injection, Waiting period of 2 hours
before X-ray, Fluids allowed, Supine position for
scanning After I.V. introduction
•
Nursing care:
o Void before procedure
o Increase fluid intake to flush out
radioactive material/ encourage fluid
intake to increase excretion of dye
o Remain still during scan
OTHERS:
• Imaging procedures: CT, bone scan, MRI
• Nuclear studies: radioisotope bone density
o Invasive, written consent is needed.
• Endoscopic studies: arthrocentesis(to aspirate
fluid), arthroscopy(to take a look what’s inside)
o Invasive, written consent is needed.
• Other studies: biopsy, synovial fluid,
arthrogram(make use of a dye), venogram
o Invasive, written consent is needed.
• Electromyography (use of needle to determine the
stimulation of the different muscles)
o Invasive, written consent is needed.
• Myelography (take fluid sample; for the spine)
o Invasive, written consent is needed.
• Laboratory studies
• Imaging tests:
o X-rays
o Bone scan: IV injection of radioisotope
Arthroscopy:
• Arthro- joint
• insertion of endoscope into a joint
• a surgical procedure that orthopedic surgeons use
to visualize and treat problems inside a joint.
• A direct visualization of the joint cavity
•
Usually used to evaluate the knee
o It helps the doctor assess joint problems,
plan surgical approaches, and document
pathology
• Pre-test: consent, explanation of procedure, NPO
Intra-test : Sedative, Anesthesia, incision will be
made
Nursing Care:
• Maintain/ Pressure dressing 24 hrs,
• monitor site,
• ambulation as soon as awake,
• mild soreness of joint for 2 days,
•
joint rest for a few days,
•
ice application to relieve discomfort
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
Arthrocentesis:
• insertion of needle (joint) to aspirate synovial
fluid.
• Arthrocentesis – a joint puncture that’s used to
collect fluid for analysis to identify the cause of
pain and swelling, to assess for infection, and to
distinguish forms of arthritis, such as pseudogout
and infectious arthritis.
•
Insertion of needle (joint ) to aspirate synovial
fluid.
• The doctor will probably choose the knee for this
procedure, but he may tap synovial fluid from the
wrist, ankle, elbow, or first metatarsophalangeal
joint.
Bone Marrow Aspiration
• Involves aspiration of the marrow to diagnose
diseases like leukemia, aplastic anemia
• Usual site is the sternum and iliac crest
• Pre-test: Consent
•
Intra-test: Needle puncture may be painful
• Post-test : maintain pressure dressing and watch
out for bleeding
TAUTO-AN, MARK CLARENCE PAUL
Myelography
• Mye- Spinal or vertebrae
• Is an imaging examination that involves
introduction of a spinal needle into the spinal
canal and the injection of contrast material in the
space around the spinal cord and nerve roots (the
subarachnoid space) using a real- time form of xray called fluoroscopy
• Purpose: identify spinal lesions Inserted into L3-L4
or L4 – L5
•
Pre-Procedure:
o check allergies to dye
o fetal position (chin towards the chest,
knees towards the abdomen, lateral
position)
•
Post Procedure:
o fetal position (chin towards the chest,
knees towards the abdomen, lateral/side
lying position)
o oil based: flat (12 hrs)
• Doesn't increase the volume of
csf fluid.
o water-based: elevate HOB 30-45 deg
QUESTION:
-As a nurse, where are you going to stay during
myelography: stay in front of the patient
-If you are the nurse assisting the doctor, back of the
patient, side of the doctor
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
Preventing complications of immobility:
•
Range of motion(ROM) exercises: movement of
joint through its full ROM
Types of ROM Exercises:
• Active - carried by the patient
• Passive - with nurse assistance
• Active assistive - client moves body part,
completed by the nurse
• Active resistive- contraction of muscles against an
opposing force
Electromyography:
• measures and records activity of contracting
muscles in response to electrical stimulation
• measures muscle response or electrical activity in
response to a nerve's stimulation of the muscle.
The test is used to help detect neuromuscular
abnormalities. During the test, one or more small
needles (also called electrodes) are inserted
through the skin into the muscle.
• Invasive, written consent is needed.
Nursing Care:
• explain procedure
• some discomfort: needle insertion
ASSESSMENT - DIANOSTIC TESTS
• Laboratory:
o Urine tests
o 24 hour creatinine- creatinine ratio
o Urine uric acid: 24 hr specimen
o Uric acid: Male: 4.5-6.5 mg/dl
• Female: 2.5-5.5 mg/dl
• If high, the patient would be
complaining for joint pain.
•
Laboratory:
o Blood tests
o Rheumatoid factor: NV is negative or
<1:20
o Erythrocyte Sedimentation Rate: <20
mm/hr
o Calcium, Phosphorous, Alkaline
phosphatase
• Detects osteoporosis
Isometric
• active exercise through contraction/relaxation of
muscle
• no joint movement (isometric)
• have flexion (isotonic)
• Muscle does not shorten but tension increases
Isotonic Exercises - muscle shortens and movement occurs
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
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ASSISTIVE DEVICES FOR WALKING:
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CANE
single, straight-legged, tripod cane, quad cane
Use uninjured foot place force on unaffected foot
Should advance together with injured leg
Place in a strong foot, distance with feet
4 to 6 inches gap between the cane and foot.
Height: hip or wrist
35 degrees of the hand holding the cane.
¾ inches from foot
Types:
•
Single,
• straight-legged,
• tripod cane,
• quad cane
Nursing Care:
• hold cane opposite affected extremity
• advance cane at the same time the affected leg is
moved
Arm flex at 30 degree when holding crutches / walker In
teaching patient, nurse should be behind injured leg
NOTE:
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*the nurse should stand on the patient’s weak side
during ambulation; patient will hold the cane on
the strong side.
*advance the cane and the affected leg= weight is
in the good leg (unaffected)
*advance the cane and the unaffected leg= weight
is in the cane
*When going up, the cane and the unaffected leg
should be the first.
*When going down, affected leg and cane should
be the first=weight is in the cane.
*When the patient is getting out of a chair, the
weight will be in the cane.
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Getting into chair
o chair with armrest, against wall
o transfer crutches: affected side
o grasp arm of chair: hand unaffected side
o lean forward, flex knees and hips, lower
into chair
•
Getting out of chair
o place unaffected leg edge of the chair
o grasp crutches by horizontal hand bars
using hand on affected side
o grasp arm of chair using hand on
unaffected side
o push on crutches and chair armrest while
raising body
o assume tripod position
•
Going up stairs
o assume tripod position
o transfer weight to crutches, move
unaffected leg into step
o transfer weight to the unaffected leg on
the step and move crutches and the
affected leg up the step
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
2.
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CRUTCHES:
Ensure the proper crutches length:
o top of crutch: 1-1.5 inches (2-3 fingers)
below axilla;
• to check for phrenic nerve
response
• Phrenic nerve damage: pain,
swelling, loss of function
o tip is 4-6 inches front and to the side of
feet.
o elbows should be slightly flexed, weight
not on axilla
Patient in a Tripod position: triangle
Weight of the patient is not in the axillae (bc there
are nerves here), weight should be on the hand
grip of the crutches
Phrenic nerve damage- if you would weight
pressure on the axilla this would lead to phrenic.
Hand grip should be the weight
Crutch walking techniques:
• Two-point gait
o step forward: move both right crutch an
left leg simultaneously
o step forward: move both left crutch and
right leg simultaneously
o Partial injury
• Three-point gait
o tripod position
o advance both crutches and affected leg
o advance unaffected leg
o Suggested for Fracture/ injured
• Four-point gait
o advance right crutch
o step forward with left foot
o advance left crutch
o step forward with right foot
o Always last yung strong foot
•
Swing-through gait
o both crutches are placed forward
o client swings body through the crutches
•
Swing-to gait
o both crutches are placed forward
o client swings forward to the crutches
TAUTO-AN, MARK CLARENCE PAUL
3.
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WALKER
Must be level at the hips, wrist, head of the
trochanter
The last two stander of the walker must be at the
middle of the feet.
The hands must be the weight of the body.
At least 4 inches.
Nursing Care:
• teach client to hold upper bars of walker at each
side, then to move the walker forward and step
into it
• Provide security and safety by assisting the patient
be on its affected side.
• When the patient is able to ambulate, provide belt
to assist the patient so you can hold on the belt.
• Height: hip/wrist, femur
Getting into stair:
o Walker first and hold/stand with the strong leg
then follow with the weak leg
o Walker first and hold with the hand as the weight,
weak foot and followed by the strong foot.
Getting out of Chair:
o Place unaffected leg edge of the chair
o Grasp crutches by horizontal hand bars using hand
on affected side
o Grasp arm of chair using hand on unaffected side
o Push on crutches and chair armrest while raising
body
o Assume tripod position
Going Up Stairs:
o Assume tripod position
o Transfer weight to crutches, move unaffected leg
into step
o Transfer weight to the unaffected leg on the step
and move crutches and the affected leg up the
step
Going Down Stairs:
o Assume tripod position at top of stairs
o Shift weight to the unaffected leg
o Move crutches and the affected leg down onto the
next step Transfer weight to the crutches and
move unaffected leg to the step
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Nursing Care: Professor: Mrs. Lorna Paber
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TAUTO-AN, MARK CLARENCE PAUL
Teach client to hold upper bars of walker at each
side, then to move the walker forward and step
into it
Mechanical device with four legs for support: with
wheels
Hold client upper bars of walker at each side
Lift walker and place it 2 feet in front and step into
it
With wheels
------------------------------------------------------------------------------Care for the Client with a Cast
• Made of synthetic material or plaster of parts,
which encases the affected body part
• Immobilize or correct the affected part of the body
Application of Cast
• Types of Casts:
o Long arm, long leg
o Short arm, short leg
o Body cast
o Shoulder spica, hip spica
•
Plaster Cast
o Delayed drying (24-72 hours): Use palms
not fingers
o Soften when wet
o Dry: Shiny white, hard
o Heavy weight
o Durable, may crack
o May use fan
o Do not use heat lamp or hair dryer
•
Synthetic Cast
o Dries instantly
o May get weight
o Dull, matte appearance
o Light weight
o Higher durability
Nursing care:
o Neurovascular check: distal to cast
o Odor, bleeding
o Elevate:
o Do not insert foreign body:
o Itchiness: cool air blow dryer
o Cleaning
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Care of cast Professor: Mrs. Lorna Paber
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Carry with palms of the hand
Expose to air, should not be covered
Keep clean and dry
Observe for musty odor and bleeding
Elevate with pillow support once cast is dry
Neurovascular check: distal to cast
(6 P’s)
1. Pain
2. Poikilothermia
3. Paralysis
4. Paresthesia
5. Pulselessness
6. Pallor
Petaling (check the sharp edges)
Itchiness: cool air-blow dryer
Do not insert foreign object
Check for circulation
TAUTO-AN, MARK CLARENCE PAUL
Preparation of equipment:
- Hospital traction bed with a bar at the end of the bed
- Traction kit OR adult size (foam stirrup with rope and
bandage)
- Overhead traction frame
- Pulley
- Traction weight bag
- Water
Traction: General principles
1. ALWAYS ensure that the weights hang freely and
do not touch the floor
2. NEVER remove the weight
3. Maintain proper body alignment
4. Ensure that the pulleys and ropes are properly
functioning and fastened by tying square knot
5. Observe and prevent foot drop (Provide foot plate
)
6. Observe for DVT, skin irritation and breakdown
7. Provide pin care for clients in skeletal tractionuse of hydrogen peroxide
Types of Traction
SKIN TRACTION: adhesive and elastic bandage
• Dunlop’s
• Buck’s
• Bryant’s
• Russell’s
Materials:
• Extension strapping with hypoallergenic adhesive:
titanium dioxide
• Spreader plate: hard plastic
• Cord: braided synthetic
• Foam: soft synthetic
• Elastic bandage low-stretch: 100% cotton
• Counter weight: body weight
• Position: Trendelenburg's
• Staiman’s pin
Skin traction:
Traction:
• A pulling force exerted on bones with countertraction
• Purposes:
o Immobilization of fractures
o Decrease, Prevent or Correct deformities
o Decrease muscle spasms
•
Types:
o Skin: tape, boots, splints
o Dunlops, Buck’s, Russelle
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
Skin traction:
Materials:
o Extension strapping with hypoallergenic adhesive:
titanium dioxide
o Spreader plate: hard plastic
o Cord: braided synthetic
o Foam: soft synthetic
o Elastic bandage low-stretch: 100% cotton
Skeletal traction:
TAUTO-AN, MARK CLARENCE PAUL
Skeletal: pins or wires inserted into bones
● Balanced traction with Thomas ring
● splint and Pearson Attachment
● Kirschner bow
● Steinman’s pin
● Balanced Skeletal traction with Thomas Ring
Splint and Pearson Attachment
● Performed when more pulling is needed than
can be withstood by skin traction. Uses weights
25- 40 lbs. Requires placement of tongs, pins,
screws into the bone so that weight is directly
applied to the bone
●This is the case when the force exerted is more
than skin traction
can bear, or when skin traction is not appropriate
for the body part needing treatment
Buck’s Extension
● Straight pull (leg)
● Shocks blocks (foot bed)
● Indicated: fx in the Lower Extremity
● Purpose: To reduce femoral fracture in children
Russell Traction
● Knee suspended in sling attached to
● a rope and pulley on a Balkan frame
● Weights: food of bed
Bryant’s Traction
● Fracture: femur
● Both limbs suspended at 90 degrees
● 2 pullers
Skeletal Traction
● Traction directly applied to the bones: pins,
wires, tongs that are surgically inserted
Cervical Traction
● Cervical head halter attached to weights that
hang over head of bed
Pelvic Traction
● Pelvic girdle with extension straps attached to
ropes and weights
Complications of traction
Related to IMMOBILITY
•
Constipation, atelectasis, pressure ulcers
To prevent:
•
Foods high in fiber
• Passive rom exercises
•
Reposition every 2 hours
• Assess areas vulnerable for skin integrity changes
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
Fixation Devices
Surgical implanted devices
• External fixation:
•
Open reduction internal fixation (ORIF)
o Pins, wires, screws, and plate, rods are
inserted into the bone
Nursing Care:
•
Meticulous skin care: half strength hydrogen
peroxide and Normal Saline
• Assess for infection, pin loosening, proper
alignment
TAUTO-AN, MARK CLARENCE PAUL
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
Boutonniere deformity - is the result of an injury to the
tendons that straightens the middle joint of your finger.
Swan-neck deformity - the finger bends at the joint, forcing
the fingertip to point downward.
Diagnostic Tests:
• Rheumatoid factor (RF)
• Inc C-reactive protein
• Arthrocentesis: Inc, wbc, rf present
• Anti-cyclic citrullinated peptide (anti-CCP)
antibodies
Rheumatoid Arthritis (RA)
•
Chronic, systemic, bilateral (Symmetrical)
inflammatory changes in joints
o Remissions, exacerbations
• Cause: autoimmune
• Remissions, exacerbations
• No manifestations
Assessment: Symmetrical
• Joints are painful, warm, swollen, limited motion,
morning stiffness
• Characteristic hand deformities
o Subcutaneous nodules (painless)
o Boutonniere, swan neck
• Fatigue, weight loss, slight fever
Medical Management:
• NSAIDs: Aspirin, Ibuprofen (Motrin), Indomethacin
(Indocin)
• Corticosteroids: Intra-articular injection, IV
• Methotrexate: Cytoxan
• Gold compounds: Chrysotherapy
o Aurothioglucose (Solganol), Auranofin
(Ridaura)
• Physical therapy, heat and/or cold applications
Nursing Interventions:
•
Assess joints
• Relieve pain:
• Warm compress (chronic pain), cold (acute
episodes)
• Immobilize (splints), bed rest (acute), firm
mattress, prone BID (½ hour)
• Maintain joint mobility
• Maintain in extension (not flexion)
• Joints extension, ROM exercise
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
Osteoarthritis (Degenerative Joint Disease)
•
Chronic, non-systemic, non-inflammatory,
progressive loss of joint cartilage
• Cause: unknown
o Aging (wear and tear), Obesity
Assessment:
• Pain and joint stiffness
• Nodes: Bouchard’s, Heberdens
• Decreased ROM, Crepitation (cracking or grinding
accompanies flexing a joint)
• Heat : circulation, cold : pain relief
Diagnostic tests:
• Symptoms and history
• X-ray
Nursing Interventions:
• Exercise program, ideal body weight
• Warm compress:
• Cold compress: to reduce swelling and pain
• Medication:
o Acetaminophen, NSAIDs, corticosteroids,
glucosamine
• Assist surgery: Joint replacement
TAUTO-AN, MARK CLARENCE PAUL
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
GOUT
•
•
•
Risk:
•
Disorder of PURINE metabolism that leads to HIGH
level of URIC ACID in the blood.
o Great toe or knee, deposition urate
crystals (tophi)
Most often in men
Familial tendency
Obesity, alcohol, chemotherapy
Assessment:
• Asymmetric joint pain (tophi - uric acid deposit in
feet, hands and outer ear), redness, heat, swelling
• Fever
Diagnostic Test:
• Uric acid is elevated
Medications:
• Colchicine is used to prevent or treat gout attacks
(flares)
• NSAIDs: with food
• Prevention of attack:
o Uricosuric agent (Benemid), Allopurinol
(Zyloprim): with food
• Warm or cold therapy, bed cradle
TAUTO-AN, MARK CLARENCE PAUL
Nursing Management:
•
Supportive care of inflamed joints
• Pain management with NSAIDs
• Avoiding weight bearing exercises
• Limiting exercises during acute stages
• Dietary management to limit uric acid in blood
• Prevention of infection during steroid therapy
• Local heat application to the joint
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
Osteoporosis
• Metabolic bone disease
o Imbalance between new bone formation
and bone resorption
❖ Loss of bone mass
❖ Increase bone fragility
❖ Increase risk of fractures
Medical Management:
• Diet: High protein, calcium, Vitamin D
• Pain: Narcotic, NSAID, firm mattress
• Calcium: OS-Cal, Caltrate-600, Citracal
• Bisphosphonates (Fosamax, Didronel, Actonel);
Calcitonin
• Moderate exercise
Cardinal signs:
• Loss of height
• Dowager’s Hump (or hyperkyphosis is an excessive
curvature of the spine)
• Low back pain
• Hip fracture is more common in older people.
• A femoral neck fracture happens 1 to 2 inches
from the hip joint.
• Bones become thinner and weaker from calcium
loss as a person ages.
Nursing Diagnosis:
• Acute pain related to fracture and muscle spasm
• Ineffective coping related to fear of the unknown,
perception of the disease process
• Deficient knowledge about the disease process
and treatment regimen
•
Impaired physical mobility related to fractured
ribs
Nursing Care:
• Pain relief and symptom management
• Education:
o Diet: Increase Calcium, Vitamin D
o Exercise and medication
• Fall prevention
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
o
•
•
•
OSTEOSARCOMA
OSTEO
• Bone
SARCOMA
• Tumor
BONE CANCER
• Femur, Tibia, Humerus
ASSESSMENT:
• Pain (tumor site) is the most common
manifestation
• Client may limp (to walk with an uneven and
usually slow movement or gait)
DIAGNOSIS:
• CT scan
• X-Ray
NURSING MANAGEMENT:
• Preoperative preparation is crucial
• Support during adjustment to concept of
amputation, surgical resection
• Body image concerns- issues of adolescents
• Straightforward & honesty
• Lack of alternatives
• Answer only questions
o Allow the patient to verbalize
o Use of therapeutic technique
• Allow grieving
• Chemotherapy & SE's: hair loss
•
Prosthetics
o After surgery
o Wounds are healed
o More or less 3-4 weeks
o The younger you are , the higher chance
of fast healing from surgery
• Stump care
o Amputate the localized area
(gently wash your stump at least once a
day (more frequently in hot weather)
with mild unscented soap and warm
water, and dry it)
Physical Therapy, activities
Assess environmental barriers:
o Crutches
o Walker
Phantom limb pain
o Give pain medication
o is a condition in which patients
experience sensations, whether painful or
otherwise, in a limb that does not exist
MEDICAL INTERVENTION:
• Chemotherapy
• Amputation
• Radiation
TREATMENT OF OSTEOSARCOMA:
• Surgery
• The main goal of surgery is to safely and
completely remove the tumor
• Historically- amputation
• Over the past few years - limb sparing procedures
have become the standard , mainly due to
advances in chemotherapy and sophisticated
imaging techniques.
• Limb salvage procedures now can provide rates of
local control and local-term survival equal to
amputation.
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
OSTEOMALACIA (Bone Softening)
• Metabolic bone disease- a weakening of the
bones caused by abnormal levels of the bone's
“building blocks,” such as calcium, phosphorus or
of vitamin D.
• Resulting in soft bones (adult) from
decalcification
• Termed as "Rickets" in children
CAUSES:
• Lack of Vitamin D from sunlight,
• malabsorption
ASSESSMENT:
• Skeletal pain, progressive muscle weakness
• Progressive deformities of spine and extremities
• Blood studies:
o Serum calcium, Vitamin D: decreased
• X-ray: demineralization
INTERVENTIONS:
• Administer vitamin D, calcium salts
• Diet: eggs, milk, fish, vegetables
• Exercise
TAUTO-AN, MARK CLARENCE PAUL
SYSTEMIC LUPUS ERYTHEMATOUS (SLE)
• It also affects the joints of the patients
• Chronic inflammatory autoimmune disease
o Involves major organs systems
o Exacerbations- present yung s/sx
o Remission- no s/sx but the disorder is still
there
• During winter and spring mostly
• Butterfly rash seen on the patient
• Exposure of the sun would complicate or risk for
infection of the skin
• Inflammatory process that would affect the joints
RISK FACTORS:
• Familial tendencies
• May be drug induces
• STRESS, infection, injuries, pregnancy
• More common in young women: 13-14 years
ASSESSMENT:
• Erythematous rash: face, neck, external, butterfly
alopecia
o Oral, nasopharyngeal lesions
• Joint pain, morning stiffness (finger, hands, wrists,
knees)
• Complications:
o pericarditis,
o pleurisy,
o renal failure
• Swollen lymph nodes, Low grade fever,
unexplained weight loss
DIAGNOSTIC TEST:
• ANA (Anti nuclear antibody)+
o to detect a positive SLE
o used to help diagnose autoimmune
disorders
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
INTERVENTIONS:
•
•
•
•
•
MEDICATIONS:
o NSAIDS: fever, arthritis
IMMUNOSUPRESSIVE:
o Azathioprine (Imuran)
o Cytoxan,
o Corticosteroids
• Possibility of reverse isolation
• to impose reverse isolation
because the patient is prone of
infection
Supportive therapy, plasma exchange
Prevent exacerbations:
o Maintain good nutrition
o Avoid exposure:
• infections,
• sunlight (heavy sun screen),
• stress,
• infection,
• fatigue
o Contact physician before immunization
o Monitor the patient due to possibility of
infections
Don’t introduce antigen to the patient - consult for
immunization
SPRAIN/ STRAIN:
• STRAIN: Excessive stretching of a muscle or tendon
• SPRAIN: Excessive stretching of a ligament
ASSESSMENT:
• Pain
• Redness
• Swelling
• Bruising
• Reduced mobility
MANAGEMENT:
• First 48 hours: RICE
o Rest
o Ice- pain and swelling
o Compress- Compression is like
mobilization
o Elevate- Circulation, too much fluid on
the affected area, make plasma go back
to its intravascular
• Analgesic (topical)- for pain
• Splint or brace
• After 48 hours:
o heat compress for circulation,
o gentle massage
SUBLUXATION, DISLOCATION
•
•
DISLOCATION: Complete displacement of the joint
SUBLUXATION: Incomplete/Partial dislocation of a
joint
TAUTO-AN, MARK CLARENCE PAUL
ASSESSMENT:
• Asymmetrical
• Pain
• Edema
• Functional loss
INTERVENTION:
• Assist realignment in mobilization
• Give analgesic
• Gentle ROM exercise
FRACTURES
• Classification:
o Incomplete: greenstick
o Complete
• Transverse,
• Oblique
• Spiral
• Impacted
o Comminuted
•
•
CLOSED OR SIMPLE- bone is broken, but the skin is
intact
OPEN OR COMPOUND- bone pokes through the
skin and can be seen or a deep wound exposes the
bone through the skin
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
HIP FRACTURE
• Femoral fracture: neck area
• Predisposing factors:
o Osteoporosis,
o Degenerative changes
ASSESSMENT:
• Severe pain
• External rotation
• Shortening of affected exit
•
According to location:
o Colle's- break in the radius part close to
the wrist
o Pelvis: turn on specific orders only
o Hip:
o Femur, Tibia
o Vertebral fx
o Maxillofacial
ASSESSMENT:
• Pain:
• Edema: around injured site
• Loss of function, false movement
• Crepitation- crackling sound in the bone
• Erythema, discoloration
• Sensation may be impaired …………………………………
DIAGNOSTIC:
• History
• XRAY
EMERGENCY CARE:
• Maintain immobilization (splinting- realignment)
• Cover open fracture
• Neurovascular check- motor movements, sensory
• Fracture reduction
NURSING INTERVENTION:
• Diet: High protein, Fiber
• Calcium, Vitamin C, D
• Increase fluid intake, stool softeners (Colace)
• Trapeze bar
• Surgery: Realignment
o Open Reduction and Internal Fixation
(ORIF) - used to repair broken bones that
need to be put back together. During the
surgery, some form of hardware is used
to hold the bone together so it can heal.
MEDICAL MANAGEMENT:
• Traction: Buck's, Russell
• Open Reduction and Internal Fixation ORIF
• Hemiarthroplasty: Prosthesis
o (replacing the femoral head with a
prosthesis whilst retaining the natural
acetabulum and acetabular cartilage)
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
Joint replacement, Total Hip Replacement (THR)
Interventions:
•
Dislocation prevention: at least 4-6 weeks
• Avoid 90 degree flexion of affected hip
• Prevent adduction
o Use abduction pillow, avoid crossing legs,
twisting to reach objects behind, driving
car, taking tu baths
• Neurovascular check
• Monitor:
o Infection: redness, swelling, foul odor,
increased temperature
o DVT: pain, swelling, warmth, skin
discoloration
• Diet: high protein, Vitamins
•
Encourage fluids
• Cast care, crutch walking
Nonunion - not siya form of osteocytes (Neurotic)
Malunion - Mali yung healing
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
FRACTURE COMPLICATIONS:
TAUTO-AN, MARK CLARENCE PAUL
Direct complications
• Delayed union, Non-union
Infection (osteomyelitis)
• fever, pain, erythema
• tachycardia, leukocytosis, ↑ESR
Decreased circulation
• decreased pulse, sensory, motor function
• edema, pain, pallor
COMPARTMENT SYNDROME
• Generalized swelling and increased pressure
within a compartment
o blood cannot circulate to the muscles and
nerves
Assessment
• Paresthesia
• Pain unrelieved by analgesia
• Pulselessness (late sign)
Interventions
• Elevation, ice packs
• Release of tension: Cast: bivalved
• Fasciotomy:
o incision and cut open
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
FAT EMBOLISM
•
Associated with function of long bones
Assessment:
• Dyspnea
• Confusion
• Petechiae
TAUTO-AN, MARK CLARENCE PAUL
Stump care after wound has healed:
• Continually assess for skin breakdown
• Monitor stump for redness, abrasions, blistering
• Do not apply: alcohol, lotions
• Wear prosthesis all day
• Inspect daily, bacteriostatic soap, rinse and dry
https://www.youtube.com/watch?v=RKScXgsYXwk
AMPUTATION
• Removal of part of an extremity at various
anatomic locations
HERNIATED LUMBAR DISC
Risk Factors:
• Degenerative disk disease
• Obesity
• Injury or stress lower back
• Muscle-strengthening exercises
Interventions:
• Wash daily: warm water, bacteriostatic soap
• Rinse, pat dry
• Expose air at least 20 min after washing
• Avoid lotions, alcohol, powder, oils unless
prescribed
• ROM daily
POST- OP Interventions:
• Compression dressing
• Phantom pain: analgesic
LAMINECTOMY
• Surgical incision of lamina
Interventions:
• Pain management
• Neurovascular assess:
• CSF leak: severe headache, amt, character
drainage
• Flat position, logroll technique
• Pillows between legs: when on side
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
CLUB FOOT
CLUB FOOT
Foot is twisted and fixed in an abnormal position
1. Calcaneous: Upward rotation
2. Varus: inside rotation
3. Valgus: outward rotation
4. Talipes Equinovarus: inward and downward
Interventions:
• Cast care, Orthopedic shoes (bar shoe)
• Skin care, neurovascular check
• Pain management, change diaper frequently,
sponge bath
• Surgery
SPINAL DEFORMARTIONS
• Curvature of the spine with vertebral body
malalignment
o Kyphosis
o Lordosis
o Scoliosis
TAUTO-AN, MARK CLARENCE PAUL
SCOLIOSIS
• Lateral curvature of the spine
Assessment:
• Uneven hips and shoulders
• Visible curvature
• Waist line uneven
Dx tests:
• Clinical manifestations
• X-ray
Interventions:
• Milwaukee brace, Boston brace
o Light T-shirt
o Worn 20 –23 hrs
• Surgery: spinal fusion and rod placement
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
TAUTO-AN, MARK CLARENCE PAUL
LEGG-CALVE-PERTHES DISEASE
• Aseptic necrosis of femoral head
Cause:
• unknown,
• familial predisposition
DEVELOPMENT DYSPLACIA OF HIP (DDH), CONGENITAL HIP
DYSPLASIA
• Displacement of head of femur from acetabulum
Assessment:
• Limp, limitation of movement
• Pain
• X-ray
Interventions:
• Cast care
Cause:
Unknown, may be fetal position
Assessment:
• May be unilateral, bilateral
• Limitation of abduction
• Ortolani’s click, Barlow’s, Trendelenburg test
• Additional skin folds with knees bent
• Lying on abdomen, affected buttocks will be flatter
Interventions:
• Keep legs abducted:
o Pavlik harness,
o Fredjka pillow splint,
o place infant abdomen with legs in frog
position,
o splints,
o casts,
o braces
Interventions:
• Bed rest, abduction traction
• Immobility: brace, harness, traction, cast, surgery
• Neurovascular checks
• Pain management
NCM 116j- MUSKOLOSKELTERAL MEDSURG
MODULE 1: MUSKOLOSKELETAL
2nd Semester | SY: 2022-2023
D.
Professor: Mrs. Lorna Paber
OSTEOGENESIS IMPERFECTA (OI)
• Inherited disease
• Fragile bones that break easily caused by poor
collagen formation
• Fractures may result from trauma or normal daily
activities
• Other manifestations may include deafness, dental
deformities, blue sclera, short stature
Types:
• OI congenital: autosomal recessive: poor
prognosis
• OI retarda: autosomal dominant
Assessment:
1. OI congenital
o multiple fractures at birth: soft skull,
possible intracranial hemorrhage
2. OI retarda
o delayed walking, fractures, scoliosis and
dental carries
Interventions:
• Splints, braces, casts, surgery (insertion of rods
into bones to prevent fx)
• Diet: high vit and minerals
• Injury prevention
TAUTO-AN, MARK CLARENCE PAUL