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Prepared by:Edwin Jonathan A. Manlapas, DDM, R.N
“ Great Minds have purposes, others have wishes.”
Washington Irving
“ A winner has a plan, a loser has an excuse.”
Musculoskeletal system2nd largest body systemBones, joints & skeletal muscles
Anatomy & Physiology
Skeletal System206 bonesMultiple joints
Classification of bones by shape:
Long bones – cylindrical with rounded ends; often bear weight
Short bones – phalanges, small & bear little or no weight
Flat bones – scapulaProtect vital organs; often contain blood forming cells
Irregular bones – unique shapes; carpal bones of the wrist, bones in the inner ear
Classification of bone by structure:
Cortex – outer dense, compact bone tissue
Medulla – composed of spongy cancellous bone
Epiphyses – 2 knob-like ends
Diaphysis – bone shaftPlays a role in growth & development
Haversian system – structural unit of cortical, compact bone
Cancellous tissue – with trabecula; filled with red & yellow marrow
Hematopoiesis – production of blood cells; happen in the red bone marrow
Yellow marrow – contains fat cells
Osteoblasts – bone forming cellsOsteoclasts – bone destroying cells
Osteon – bone matrix; consists of collagen, mucopolysaccharides & lipids
Function of the skeletal system:
Provides a framework for the body.
Supports the surrounding tissues
Assists in movement (muscles, tendons)
Protect vital organs (heart, lungs)
Production of red blood cellsProvides storage for mineral salts (Ca & PO4)
Calcium & Phosphorus99% Calcium90% Phosphorus
Serum concentration of Ca & Phosphorus maintain an inverse relationship
Calcitonin Decreases the serum Ca concentration if increased above normal levels
Inhibits bone resorption
Increases renal excretion of Ca & Phosphorus
Vitamin D – promotes absorption of Ca & Phosphorus from the small intestine; enhance PTH activity
A decreased in Vitamin D can result in Osteomalacia among adults & Rickets in children
Parathyroid hormone (Parathormone, PTH) – stimulates bone’s osteoclastic activity & release calcium to the blood
Growth hormone – increase bone length; determines the amount of bone matrix formed before puberty
Glucocorticoids – regulate protein metabolism; regulate intestinal Ca & Phosphorus absorption
Estrogens & Androgens Estrogen stimulates osteoblastic activities & inhibit parathormone
Testosterone – increase bone mass by promoting anabolism
Thyroxine – increase the rate of protein synthesis
Insulin works with growth hormones to build & maintain healthy bone tissue
Joint – a space in which 2 or more bones come together
Provide movement & flexibility in the body
Types of joint:Synarthrodial – completely immovable joints (Ex. Joints in the cranium)
Ampiarthrodial – slightly movable joints (Ex. Pelvis)
Diarthrodial (Synovial) – freely movable joint (Ex.Elbow & knee)
Synovial joints are the only joints lined by synovium; a membrane that secretes synovial fluid for lubrication & shock absorption
consists of elongated cells called muscle fibers that utilizes ATP to generate force
produces heat, body movements & maintains posture
1. Skeletal muscle – attached to the bones of the skeleton; fibers with striations, voluntary controlled by CNS & PNS
2. Cardiac muscle – forms most of the wall of the heart; striated; involuntary, controlled by ANS
intercalated discs – unique structure of cardiac muscle
3. Smooth muscle – non-striated, involuntary, located in walls of hollow internal structures like blood vessels, airways of the lungs, stomach, intestine & gall bladder
Contraction helps constrict the lumen of blood vessels
CARTILAGECostal Cartilage – connects sternum to rib cage
Yellow Cartilage – external ear, epiglottis
Hyaline Cartilage – septum of nose, larynx, trachea
TENDONS – bands of tough, fibrous tissue that attach muscles to bones
LIGAMENTS – attach bones to other bones at joints
Decreased bone densityIncreased bone prominence
Kyphotic posture : widened gait, shift in the center of gravity
Cartilage degenerationDecreased ROMMuscle atrophy , decreased strength
Slowed movement
HistoryDemographic data:Young men – risk for trauma R/T motor vehicle crashes
Older adults – risk for falls fracture, soft tissue injury
Family history and genetic risk :
Osteoporosis – age related bone loss
Bone cancerOsteoarthritis
Personal History :Accidents, illnesses, lifestyle, medication
Level of physical activityTraumatic injuriesParticipation in sports/sports injuries
Diet History :Determine risk of inadequate nutrition
Lactose intolerance → affect Ca intake
Insufficient Vitamin C or D → inhibits healing of bone and tissue
Obesity→ places excess stress and strain on bones and joints
Socioeconomic Status:Computer related jobs→
carpal tunnel syndrome ( entrapment of median nerve in the wrist )
Construction worker, Health care workers → back injury
Athletes → joint dislocation, fractures
Current Health Problems:PAIN – most common complaint
- acute or chronic - best if client describes the pain in his/her own words
PQRST Model P rovoking incidentQ uality of painR egion, radiation and reliefS everity of painT ime
General InspectionPosture – body build and alignment when standing and walking
Gait – two phases of normal, automatic gait
1. Stance phaseAntalgic gait – abnormality in
the stance phase of gait Part of one leg is painful, the
person shortens the stance phase on the affected side
2. Swing phaseLurch – abnormality in the swing phase
Occur when muscles in the buttocks and/or legs are too weak to allow the person to change weight from one foot to the other
MobilityGoniometer – a tool use to provide an exact measurement of ROM
Assessment of the Head & Neck
- inspect, palpate the skull (shape, symmetry, tenderness and masses)
Common abnormal findings:1. tenderness and pain2. crepitus ( grating sound )
3. spongy swelling
Assessment of the spineBoth hands are placed over the lumbosacral area, apply pressure with thumb
Lordosis – in pregnancy , in abdominal obesity
Scoliosis – client flexes forward from the hip, inspect lateral curve
Assessment of the Upper Extremity
Assessment of the Lower Extremity
genu valgum ( “knock knee “)
genu varum ( “bow-legged )
Neurovascular Assessment
Lovett’s Scale for Grading Muscle Strength
5 Normal : ROM unimpaired against gravity with full resistance
4 Good : can complete ROM against gravity with some resistance
3 Fair : can complete ROM against gravity
2 Poor : can complete ROM with gravity eliminated
1 Trace : no joint motion and slight evidence of muscle contractility
0 Zero : no evidence of muscle contractility
LABORATORY PROFILESerum Calcium( 9-10.5 mg/dL )Hypercalcemia :• Metastatic cancers of the bone• Paget’s Disease• Bone fractures in healing stage
Hypocalcemia:• Osteoporosis• Osteomalacia
Serum Phosphorus ( 3–4.5 mg/dL )
Hyperphosphatemia:• Bone fracture in healing stage• Bone tumors• Acromegaly
Hypophosphatemia:• Osteomalacia
Alkaline Phosphatase, ALP (30-120 units/L)Elevations may indicate :• Metastatic cancers of the bone
• Paget’s Disease • Osteomalacia
Serum muscle enzymesCreatinine kinase ,CK Men : 55-170 units/L Women : 30-135 units/L
Elevations may indicate :Muscle trauma ; Effects of EMG
Progressive muscular dystrophy
Lactate dehydrogenase, LDH Total LDH: 100-190 units/LElevations may indicate:• Skeletal muscle necrosis• Extensive cancer• Progressive muscular dystrophy
Aspartate aminotransferase, AST
( 0-35 units/L )Elevations may indicate:• Skeletal muscle trauma• Progressive muscular dystrophy
Aldolase, ALD ( 3-8.2 units/dL )
Elevations may indicate:• Polymyositis and dermatomyositis
• Muscular dystrophy
RADIOGRAPHIC EXAMINATIONS
Standard Radiography ; CT Scan
Tomography – produces planes or slices , for focus and blurs the image of other structures
Xeroradiography – highlights the contrast between structures
Myelography – involves injection of contrast medium or dye into the subarachnoid space of the spine usually by spinal puncture
Arthrography – x-ray study of the joint after contrast medium (air or solution ) has been injected to enhance its visualization
Other Diagnostic Tests:Bone biopsy – the doctor extracts a specimen of
bone for microscopic exam
Muscle biopsy – done for the diagnosis of atrophy and inflammation
Electromyography (EMG) – accompanied by nerve conduction studies for determining the electrical potential generated in individual muscle
-
Diagnosis of neuromuscular, lower motor neuron and peripheral nerve disorder
Client Prep: skeletal muscle relaxant is d/c by the doctor
Procedure: at bedside or EMG laboratory
Nerve conduction tested 1st – flat electrodes placed along the nerves
muscle potential – multiple needle electrodes , ½ -3 inches
Follow up care:• inspect needle site for hemato- ma formation→ apply ice• check complain of inc. pain and
anxiety
Arthroscopy – for diagnostic test or surgical procedure
Arthroscope – a fiberoptic tube inserted into a joint for direct visualization
Client Prep: client must be able to flex knee at least 40 degrees
- CI if client have joint infection - ambulatory basis/same day surgery
Procedure: - local, light general or epidural anesthesia
- knee flexed at 40 degrees, irrigated
- less than ¼ inch incision, insert arthroscope
Follow up care:1. evaluate neurovascular status of affected limb
2. monitor distal pulses, warmth, color, capillary refill, movement, pain, sensation of affected limb
3. Encourage client to perform appropriate exercises
4. Ice – used for 24 hrs5. Elevate extremity for 24-48 hrs
6. Monitor/ observe for:Swelling, HypothermiaIncrease joint pain due to mechanical injury
Thrombophlebitis, Infection
Bone scan – radionuclide test in which radioactive material is injected for visualization of the entire skeleton
- detect tumors, osteomyelitis,
arthritis,vertebral compression fracture, osteoporosis, unexplained bone pain
Gallium/Thallium Scan – similar to bone scan but more specific and sensitive in detecting bone problem
Radioisotopes used:Gallium citrate - most common
Thallium - osteosarcoma
Client prep: Doctor/technician administer isotope 1-2 days before scanning
Procedure: 30-60 minutes, mild sedation for older clients or in severe pain, lie still
Follow up care: encourage to push fluids
Magnetic Resonance Imaging – image produced through the interaction of magnetic fields, radio waves and atomic nuclei showing hydrogen density
- more accurate than CT scan and Myelography
- Gadolinium-DTPA (diethylenetriamine-pentacetid acid ) – contrast agent
- remove all metal objects, check clothing zippers and metal fasteners, surgical clip
Ultrasonography – sound waves produce an image of the tissue
Visualizes:• Soft tissue disorder • Traumatic joint injuries• Osteomyelitis• Surgical hardware placement
Common Health Problems of the Neonate & Infant:
Congenital Hip Displacement
Head of the femur is improperly seated in the acetabulum, or hip socket of the pelvis
Acetabulum of the pelvis is shallow.
Occurs most often among children of Mediterranean ancestry
6 times more frequently among girls than boys
Can be congenital or develop after birth
I. Dysplasia of the Hip
AssessmentNeonates: laxity of the ligaments around the hip
Infants beyond the newborn period
Affected leg appears shorter than the normal leg
Unequal number of skin folds on the posterior thigh
Asymmetry of the gluteal & thigh skin folds
Limited range of motion (ROM) in the affected hip
Asymmetric abduction of the affected hip
Apparent short femur on the affected side (Galeazzi sign, Allis sign)
Galeazzi sign – apparent shortening of the femur; as shown with the difference of knee levels with the knees & hips flexed at right angle when patient is lying on a flat table
The walking child: minimal to pronounced variations in gait w/ lurching toward the affected side; positive Trendelenburg sign
Positive Barlow or Ortolani’s maneuver
Barlow’s maneuver – performed by adducting the hip (bringing the thigh towards the midline) while applying a light pressure on the knees with the force directed posteriorly
Positive Barlow test – if the hip can popped out from the socket
Ortolani’s test or maneuver – physical exam for hip dysplasia
Performed by gently abducting the infant’s leg with the examiner’s thumb while placing an anterior pressure on the greater trochanter (index & forefinger)
Positive sign is a distinctive “clunk” which can be felt or heard as the femoral head relocates anteriorly into the acetabulum
Diagnotic tests:X-ray (shows shallow acetabulum)
SonogramMagnetic Resonance Imaging
ImplementationIn the neonatal period, splinting of the hips w/ Pavlik harness to maintain flexion & abduction & external rotation
Multiple diapers – effectively separates the legs
Frejka splint – parents must keep the splint at all times except when bathing or changing diapers
Following the neonatal period, traction &/or surgery to release muscles & tendons
Bryant’s skin traction
Following surgery, positioning & immobilization in a Spica cast
Osteotomy following traction in profoundly affected children
Pavlik Harness – an adjustable chest halter that abducts the legs
Method of choice for long term therapy; reduces therapy to 3-4 weeks, simplifies care
The defect may be unilateral or bilateral
Long-term interval follow-up is required
“Talus” – ankle“Pes” – foot1 in every 1000 children born with the defect
Boys are affected than girls
Congenital Clubfoot
AssessmentThe foot is plantar flexed w/ an inverted heel & adducted forefoot
ImplementationTreatment begins as soon after birth as possible
Serial manipulation & casting are performed weekly, if correction is not achieved in 3 to 6 months, surgery is indicated
Monitor neurovascular status of the toes
Instruct parents in cast care & the signs of neurovascular impairment that requires physician
Dennis Browne SplintFor clubfoot/congenital Talipes Equinovarus
Tendon is short – complete soft tissue release
Torticollis (wry neck) – head is tilted/turned to 1 side; chin is elevated & turned to the opposite side
Head position should be corrected before adulthood
Affects 2% of newborn
Diagnosis:History taking – determine circumstances surrounding birth, trauma or associated symptoms
Physical examination – shows decreased rotation & bending to the side opposite the muscle affected
Neck muscles/areas between
the neck & shoulder are tense & tender
Management:Medications (muscle relaxants/NSAIDs)
Physical devices
Botulinum toxinSurgery
Radiographic examination – radiographs of the cervical spine
MRI – for structural problems
Common health Problem of Young Adolescent
Scoliosis
Scoliosis A lateral curvature
of the spine
AssessmentVisible curve fails to straighten when the child, bends forward & hangs down toward feet
Hips, ribs, & shoulders are asymmetrical
Apparent leg length discrepancy
Assessment
ImplementationPrepare the child & parents for the use of a brace if prescribed
Prepare the child & parents for surgery (spinal fusion; placement of internal instrumentation rods) if prescribed
BracesUsually worn from 16 to 23 hours a day
Keep the skin clean & dry, avoiding lotions & powders
Advise the child to wear soft nonirritating clothing under the brace
Common Health Problem of the Young Adult:
Osteogenic Osteosarcoma
Osteosarcoma/Osteogenic sarcoma
Most common type of primary malignant tumor
50% occur in distal femur
Primary – those that originate in bone
Secondary – those that originate in other tissues & metastasize to bone
Clinical Manifestations:PainSwellingLarge lesionSclerotic central massSunburst appearance
Inward bony expansionIncidence:Occurs more often in males than females (2:1); 10-20 y/o
Older clients with Pagets disease
Primary tumors (breast, prostate, kidneys, thyroid, lungs) bone seeking tumor cells carried to bone (blood stream) pathologic fracture
Laboratory Assessment:Elevated serum alkaline phosphatase
Elevated serum Ca levelElevated ESR
Radiographic Assessment:Bone destructionIrregular periosteal new boneCortical breakthroughIncrease/decrease bone density
MRIBone scan
Nursing diagnoses:Acute/Chronic Pain r/t physical injury
Anticipatory grieving r/t change in body image
Disturbed body image r/t effects of illness, treatment including surgery
Interventions:Treatment is aimed at reducing the size/removing tumor
Drug therapy – analgesics, chemotherapeutic agents
Radiation therapy – reduce tumor size & pain
Surgery
Common Health Problems of the Adult:
Adult Rheumatoid Arthritis
Rheumatology – study of rheumatic disease
Rheumatic disease – disease/condition affecting the musculoskeletal system
Arthritis – inflammation of one or more joints
Rheumatoid Arthritis (RA)Most common connective tissue disease
Most destructive to the joints
Chronic, progressive, systemic inflammatory autoimmune disease affecting the synovial joints
characterized by remissions & exacerbations
Autoantibodies (rheumatoid factors RF’s) are formed attack healthy tissues (synovium) inflammation of synovial membrane synovium thickens fluid accumulates in joint space pannus formation erosion of cartillage bone erosion
Pannus – vascular granulation tissue composed of inflammatory cells; erodes the cartillage & eventually destroys bone
Etiology of RA is unclear; research suggests a combination of genetic & environmental factors
Some researchers suspect female reproductive hormones
Epstein Barr virusPhysical/emotional stress
Clinical Manifestations:Joint stiffnessSwelling Painfatigue
Generalized weaknessMorning stiffnessUpper extremity joints affected (proximal interphalangeal/metacarpophalangeal joints)
Bilateral/symmetric joint affectation; number of joints affected increases
Gel phenomenon – morning stiffness that lasts 45 minutes to several hours upon awakening
Swan neckUlnar deviation
Laboratory Assessment:No single test that confirms the disease
Rheumatoid factor – measures the presence of unusual antibodies IgM, IgG types
Antinuclear Antibody TiterErythrocyte Sedimentation Rate (ESR) – diagnosis of inflammatory CT disease
C Reactive Protein test
Standard X-ray – visualize joint changes & deformities
CT Scan – determines cervical spine involvement
Arthrocentesis – synovial fluid is analyzed for inflammatory cells & immune complexes; RF included
Nursing responsibility:Monitor insertion site for bleeding/leakage of synovial fluid
Teach the client to use ice & rest affected joint for 24 hrs.
Management:NSAID’sDisease-Modifying Anti-Rheumatic Drugs – hydroxychloroquine (Plaquenil)
Sulfasalazine (Azulfidine)Minocycline (Minocin)Methotrexate (Rheumatrex) – immuno suppressive medication
Gold therapyGold sodium thiomalate (Myochrysine)
Nonpharmacologic modalities:
Adequate restProper positioningIce & heat applications
Gouty Arthritis (Gout) – systemic disease in which urate crystals deposit in joints causing inflammation.
2 types of gout:1.Primary gout – most common type; results from 1 of several inborn errors of purine metabolism
Production of uric acid exceeds the excretion capability of the kidneys
Sodium urate is deposited in synovium causing inflammation
2. Secondary gout – involves hyperuricemia (excessive UA in blood) caused by another disease
Renal insufficiency, diuretic therapy, chemotherapeutic agents; multiple myeloma
4 phases of the primary disease:
1.Asymptomatic hyperuricemic phase – serum level elevated; no overt signs of disease
2. Acute phase – 1st attack of gouty arthritis; excruciating pain in 1 or more small joints (metatarsophalangeal joint of the great toe)
Podagra – 75% experience inflammation of this joint as the initial manifestation
Elevated ESR & WBC
3. Intercritical/Intercurrent state of the disease – attack occurs after months or years; asymptomatic; no abnormalities found in joints
4. Chronic tophaceous gout – deposits of urate crystals develop under the skin & major organs
Gout affects more men than women
Clinical Manifestations:Acute gout – Painful inflamed joints
Chronic gout – inspect for tophi
Tophi – deposits of Na urate crystals; commonly appear on the outer ear
Arms & fingers near the joints
Renal calculi
Diagnostic tests:Serum uric acid – more than 8 mg./100 ml.
Urinary uric acid levels – more than 600 mg./24 hr after a 5 day restriction of purine intake
Synovial fluid aspiration (arthrocentesis) – detect the presence of needle-like crystals
Drug therapy:Colchicine (Colsalide) – works within 12 hrs.
Repeated acute gout/chronic gout – Allopurinol (Zyloprim) – promotes uric acid excretion
Nurse monitors serum uric acid levels to check the effectiveness of medications
Diet therapy: Strict low-purine diet; avoid foods such as organ meats, shellfish, oily fish with bones (sardines)
Avoid aspirin & diureticsAvoid excessive physical/emotional stress
Force fluidsIntake of Alkaline ash foods – citrus foods & juices, milk
Carpal Tunnel SyndromeCarpal tunnel – rigid canal between the carpal bones and flexor retinaculum
Compressed median nerve in the wrist
Pain and numbnessParesthesia ( painful tingling )
Etiology and Genetic risk:Excessive hand exerciseEdema or hemorrhage into CT
Thrombosis of the median artery
CTS – most common repetitive strain injury (RSI)
- fastest growing type of occupational injury : factory worker, computer operators etc; sports activities ( golf, tennis )
Incidence and prevalence :Adults – bet 30-60 yrs oldWomenDominant handChildren and adolescent – computer use
Clinical Manifestation: Phalen’s maneuver/testRelax the wrist into flexion Place back of hands together and flex both wrist
(+) – paresthesia palmar side of thumb, index and middle finger, radial half of ring finger
Tinel’s signLightly tapping area of median nerve in the wrist
(+) – paresthesia
BP cuff placed on the upper arm , inflated to the client’s systolic pressure
(+) – pain and tingling
Diagnostic Assessment :Xray – bone changes, lesions, synovitis
EMG- nerve dysfunctionMRI ,UTZFinding : Enlarged median nerve within the carpal tunnel
Interventions: NonsurgicalDrug – NSAIDS Immobilization - splint
SurgicalOpen carpal tunnel release (OCTR)
Endoscopic carpal tunnel release ( ECTR )
Synovectomy – for rheumatoid arthritis , complication of CTS
Post Operative Care:Elevate hand and arm above heart level
Check neurovascular status
Move fingers of affected hand
Restrict hand movements, lifting heavy objects – 4 to 6 wks after surgery
Musculoskeletal disorders:Metabolic bone diseases (osteoporosis, Paget’s disease)
Bone tumors Bone deformities
Osteoporosis Metabolic diseasebone demineralizationDecreased bone densityFractures
“silent disease”Mostly affected are wrists, hip & vertebral column
Osteoclastic (bone resorption) activity exceeds osteoblastic (bone building) activity decreased bone mineral density (BMD) loss of spongy bone/cortical bone
fragile bone tissue Fracture
Diagnosis is based on BMD values using T-scores
T-score – the number of standard deviations above or below the average BMD for young, healthy white women
Osteopenia – T-score between 1 & 2.5
Osteoporosis among postmenopausal women BMD T-score more than 2.5 standard deviations below normal
2 theories in osteoporosis:May result from decreased osteoblastic activity
Increased osteoclastic (bone resorption) activity
Classification of osteoporosis:
1.Generalized osteoporosis:Involves many structures in the skeleton
Primary osteoporosis – occurs among postmenopausal women/men in 6th or 7th decade of life
Decrease estrogen/testosterone
Secondary osteoporosis – results from associated medical conditions (hyperparathyroidism, long term corticosteroid use, prolonged immobility)
2. Regional osteoporosis – occurs when limb is immobilized r/t fracture, injury, paralysis or joint inflammation
Immobilization greater than 8-12 weeks
Exact cause of osteoporosis is unknown
About 98% of peak bone mass achieved by 20 years of age
Building strong bone as a young person – best defense against osteoporosis in later adulthood
(National Osteoporosis Foundation 2003)
Most health care providers focus on the risk of osteoporosis in women older than 50 years old & do not assess risk as often in women 49 years of age & younger (Berarducci et.al 2000)
Risk factors:Postmenopausal womenBreast Ca survivorsGenetics – Hx of fracture among a 1st degree relative
Thin, lean built White, Asian women
Protein deficiencyAlcohol consumption/Cigarette smoking
IncidenceWomen are affected than men 80%
1.5 million fractures/year300,000 are hip fractures
Clinical Manifestations:“dowager’s hump” or kyphosis of the dorsal spine
Client verbalized that height has been shortened (2-3 inches)
Backpain occurs after lifting, bending or stooping
Pain is worsened by activity & relieved by rest
Laboratory Assessment:No definite laboratory test that confirm a diagnosis of primary osteoporosis
uPYR Crosslinks assay – measures urinary concentrations of pyridinium; a collagen substance found in bone & cartilage
Increased urinary levels indicate bone resorption
Radiographic AssessmentX-rays of the spine & long bones show loss of bone density & fractures
Bone density changes are evident if 25-40% of bone loss has occurred
Dual-energy x-ray absorptiometry (DEXA) – painless scan that measures
bone mineral density (BMD)
Physicians recommend that women in their 40’s have a baseline DEXA
Nursing diagnoses:Impaired physical mobility r/t decreased muscle strength, pain
Acute/Chronic pain r/t effects of acute physical illness
Interventions:MedicationsNutritional therapyExercise
Drug therapy:HRTCa supplementsVitamin D
BiphosphonatesSelective estrogen receptor moduloators (SERM’s)
Calcitonin
Hormone Replacement Therapy (HRT)
Used as primary prevention strategy for reducing bone loss among post menopausal woman
Long term effects of HRT include breast’s CA, CV disease & stroke
Parathyroid hormone – teriparatide (Forteo), SQ injection
Calcium – not a treatment for osteoporosis; it is an important part of the prevention program in promoting bone health
Ca carbonate (Tums, OsCal)
Teach clients to take Ca with food & 6-8 ounces of H20
Instruct clients to take foods rich in Ca (Milk & dairy products, green leafy vegetables)
Vitamin D for optimal Ca absorption in the small intestines
Bisphosphonates – inhibit bone resorption by binding with crystal elements in bone
alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel)
Nursing Alert:Instruct clients to take the drug early in the morning with 8 oz.
of H2O & wait 30 minutes before eating. Must remain upright during the 30 minutes before eating
Selective Estrogen Receptor Modulators (SERM’s)
Designed to mimic estrogen in some parts of the body & blocking its effect elsewhere
Raloxifene (Evista)
Calcitonin – inhibits osteoclastic activity
Diet therapy – Ca & Vitamin D intake must be increased; alcohol & caffeine consumption must be discouraged
Fall prevention – a hazard free environment is necessary
“Falling star protocol”Exercise – PT’s prescribed exercises that strengthen the
Abdominal & back muscles; active ROM exercises
Walking 30 minutes 3X a week, swimming & bicycling are recommended
Bowling & horseback riding are avoided – may cause vertebral compression
Orthotic devices or dorsolumbar orthoses – immobilize the spine during acute pain phase & provide spinal column support
Osteomalacia – softening of the bone tissue; characterized by inadequate mineralization of osteoid
EtiologyPrimary Vitamin D deficiency – lack of sunlight exposure, poor dietary intake, malabsorption of Vitamin D
HypophosphatemiaIntake of barbiturates, anticonvulsants & fluoride
Incidence:Common among non industrialized nations
Strict vegetarians without adequate supplement of Vitamin D
Muscle weaknessJoint painWaddling & unsteady gait (due to muscle weakness)
Diagnostic Assessment:X-ray – reveal a decrease in the trabeculae of cancellous bone & lack of osteoid sharpness
Classic diagnostic finding – presence of radiolucent bands (Looser’s lines/zones)
Looser’s zones – stress fractures that have not mineralized.
Bone biopsy will confirm the diagnosis
Interventions:Major treatment is Vitamin D
RDA – 400 IU
Meeting the RDA for Vitamin DAdvise clients to get sun exposure for at least 5 minutes weekly
Eat food high in Ca to promote Vitamin D absorption
Eat foods high in Vitamin D including milk & dairy products, ice cream, yogurt & cheese
Egg, swordfish, chicken, liver & cereals
Characteristic
Osteoporosis Osteomalacia
Definition Decreased bone mass
Demineralized bone
Pathophysiology
Lack of Ca Lack of Vitamin D
Radiographic Findings
Osteopenia/fractures
Pseudofractures, Looser’s zone, fractures
Calcium level Normal Low or Normal
Phosphate level
Normal Low or Normal
Parathyroid hormone
Normal High or Normal
Alkaline Phosphatase
Normal High
Osteoarthritis (Degenerative Joint Disease DGD)
most common arthritis2nd most common cause of disability among adults in U.S.
Common cause of disability worldwide
Progressive deterioration & loss of cartilage in 1 or more joints
Affects weight bearing joints (hips, knees, vertebral column)
Cartilage becomes soft fissures/pitting develop cartilage thins joint space narrows bone spurs formed
inflammatory enzymes enhance tissue deterioration
repair process fails
Causative mechanism of primary Osteoarthritis at the cellular level has not yet identified
Predisposing factors:DevelopmentalGeneticMetabolicTrauma
Age – strongest risk factorAbout ¾ of people older than 55 y/o has joint changes seen in X-rays
Health promotion/ Illness prevention:
Keep weight within normal limits
Avoid/limit activities that promote stress on joints (jogging)
Limit participation in recreational sports, risk seeking activities to prevent trauma
Assessment: Ask questions about the course of the disease
Collect information specific for OA (nature/location of joint pain)
Ask clients about their occupation, nature of work, Hx of trauma, weight history & exercise
Physical Assessment:Middle-aged/older women who complains of chronic joint pain or stiffness
Pain during palpation/ROM
CrepitusEnlarged jointsHeberden’s nodes – (distal interphalangeal joint)
Bouchard’s nodes – (proximal interphalangeal joint)
Atrophy of skeletal musclesHip/knee pain cause the client to limp
Laboratory assessment:Elevated erythrocyte sedimentation rate (ESR)
High-sensitivity C-Reactive Protein
Radiographic assessment:Structural joint changesCT scan MRI
Nursing Diagnoses:Chronic pain r/t muscle spasm, cartilage degeneration & joint inflammation
Impaired physical mobility r/t pain & muscle atrophy
Major concern is pain controlNon-surgical management:AnalgesicsRestPositioningThermal modalities
Acetaminophen (Tylenol) – drug of choice
NSAID’sDirect injection with cortisone
RestLocal rest – immobilizing a joint with a splint or brace
Systemic rest – immobilizing the whole body – nap
Psychological rest – relief from daily stress
Positioning – joint in functional position; small pillow under the neck or head
Elevate the legs (8-12 inches)Thermal modalities:Heat application (hot showers, baths, hot packs, compresses & moist heating pads)
Weight controlTranscutaneous Electrical Nerve Stimulation (TENS)
Stem cell therapy
Surgical Management:Total joint arthroplasty – surgical creation of a joint
Arthroscopy- less invasive procedure to remove damage cartilage
Total hip arthroplasty – performed among clients greater than 60 y/o
Common complication - subluxation
Position client in supine position with the head slightly elevated with abduction pillow in between the legs to prevent adduction
Life threatening complication – Deep Venous thrombosis (DVT) & pulmonary embolism
Use thigh high stockings & sequential compression devices
Anticoagulant:Low molecular weight heparin
Aspirin
Client getting out of bed – stand on the side of affected leg; client assumes sitting position, client stands on the unaffected leg & pivot to the chair with assistance
Client must not flex the hips more than 90 degrees
Partial weight bearing allowed for the 1st few weeks/x-ray evidence of bony growth
Characteristic Rheumatoid Arthritis (RA)
Osteoarthritis (OA)
Age of onset 35-45 y/o > 60 y/o
Gender Affected
Female (3:1) Female (2:1)
Risk factors/cause
Autoimmune (Genetic)
Aging, genetic factor, obesity, trauma, occupation
Disease process
Inflammatory Degenerative
Disease pattern
Bilateral, symmetric, multiple joints, usually affects upper extremities firstDistal interphalangeal joints of hands sparedSystemic
Unilateral, single joint, affects weight bearing joints & hands,spineMetacarpophalangeal joint sparedNon-systemic
Lab findings Elevated rheumatoid factor, antinuclear antibody, ESR
Normal or slightly elevated ESR
Dug therapy NSAID’s, Corticosteroids, Methotrexate, Leflunomide (Arava
NSAID’s, Acetaminophen
Osteomyelitis – inflammation/Infection of bone tissue
Exogenous osteomyelitis – infectious organisms enter from outside of the body (from open fracture)
Endogenous osteomyelitis (hematogenous osteomyelitis)– organisms are carried by the blood stream from other areas of infection
Contiguous bone infection results from skin infection of adjacent tissues
2 Major types of Osteomyelitis:Acute hematogenous infection – results from bacteremia, underlying disease or non- penetrating trauma
Subchronic/chronic osteomyelitis – due to inadequate treatment.
About 50% of cases due to gram negative bacteria
IncidenceHematogenous osteomyelitis is the most common type
More common among children; increasingly common in adults
Men experience osteomyelitis more frequently than women
Bone tissue in vertebrae & long bones are common sites of infection
AssessmentBone pain – common complaint of client’s with bone infection
Constant, localized, pulsating sensation that intensifies with movement
Fever (> 38° C)Area of infected bone swells; tender to palpation
ErythemaDraining ulcers
Elevated WBC countElevated ESR valueBone scan using technetium or gallium is helpful in the diagnosis
Definitive diagnosis – bone biopsy
Nursing Diagnoses:Acute/Chronic Pain r/t inflammation
Hyperthermia r/t pathogenic invasion of the bone
Ineffective tissue perfusion (peripheral) r/t tissue swelling
Interventions:IV antibiotics Hyperbaric Oxygen Therapy – affected area is exposed to a
high concentration of O2 that diffuses in the tissues to promote healing
Sequestrectomy – to debride the infected bone; allow revascularization of tissues
Common Health Problems Across the Life Span:FracturesTraction
Fracture – break or disruption in the continuity of bone
Caused by direct blow, crushing force, sudden twisting motion or extreme muscle contraction
Classification of fractures:According to the extent of the break:
Complete fracture – break is across the entire width; bone is divided into 2 distinct sections
Incomplete fracture – partial break in the bone; break is confined through only part of the bone
According to the extent of associated soft tissue damage:
Open (Compound) – skin over broken bone is disrupted; soft tissue injury & infection are common
These are graded to define the extent of tissue damage:
Grade 1 – least severe injury; skin damage is minimal
Grade 2 – accompanied by skin & muscle contusions
Grade 3 – damage to the skin, muscle, nerve tissue & blood vessels
Wound is more than 6-8 cms.
Closed (simple) fracture – skin over the fractured area remains intact
Pathologic ( spontaneous) – occurs after minimal trauma to a bone that has been weakened by a disease
Greenstick fracture – one side of bone is broken, the other is bent, most commonly seen in children
Classification According to pattern:
Transverse fracture – bone is broken straight across
Oblique fracture – the break extends in an oblique direction; slanting direction
Spiral fracture – the break partially encircles the bone
Classification as to appearance:
Comminuted – bone is splintered or crushed with 3 or more fragments
Impacted – when fractured end of bones are pushed into each other
Compression fracture – produced by a loading force applied to the long axis of cancellous bone
Depressed – usually occurs in the skull; broken bone driven inward
Longitudinal – break runs parallel with bone
Fracture dislocation – fracture is accompanied by a bone out of joint
Fatigue or stress fracture results from excessive strain or stress on the bone
Fractures
Classification in relation to the joint:
Intracapsular within the jointExtracapsular – outside the capsule
Intra-articular – within the joint
Classification as to Location:
ProximalDistalMid-shaft
Clinical Manifestations:Pain or tenderness over the involved area
SwellingLoss of function
Obvious deformityCrepitus – grating sensation either heard or felt
Erythema, EdemaMuscle spasm/impaired sensation
Bleeding from an open wound with protrusion of fractured bone
Principles of fracture treatment:
Reduction of bone fragments to normal position & immobilization
Maintenance of reduction until healing is sufficient to prevent displacement
Preservation & restoration of musculoskeletal function
Stages of bone healing: 1. Hematoma formation – blood accumulates into the area between & around the fragments. The clot begins 24 hrs after the fracture occurs
2. Cellular proliferation – (within 5 days) hematoma undergoes organization. Fibrin strand form with the clot creating a network for revascularization & invasion of fibroblast & osteoblast.
Beginning of external cartilaginous callus formation.(osteoid tissue)
3. Callus formation – (2-3 weeks) minerals are being deposited in the osteoids forming a large
mass of differentiated tissue bridging the fractured bone.
4. Ossification – mineral deposition continues & produces a firmly reunited bone. Final ossification takes
3-4 months.
5. Consolidation & remodeling – final stage of fracture repair consists of removal of any remaining devitalized tissue & reorganization of new bone
Interventions for Fracture:ReductionFixationTractionCasts
Reduction – restoring the bone to proper alignment
Closed Reduction – performed by manual manipulation
Maybe performed under local/general anesthesia
Open Reduction – involves surgical intervention
Treated with internal fixation devices
Client may be placed in traction or cast following the procedure
Fixation Internal fixation – follows open reduction
Involves the application of screws, plates, pins, nails to hold the bone fragments in alignment
May involved the removal of damaged bone & replacement with a prosthesis
Provides immediate bone strength
Risk of infection is associated with this procedure
External fixation – an external frame is utilized with multiple pins applied through the bone
Provides more freedom of movement than with traction
Roger Anderson External Fixator (RAEF)
For fracture of the tibia, radius, ulna done under anesthesia
Ilizarov fixator – for severe comminuted fracture, bone lengthening
Plaster cast – a temporary immobilization device which is made up of gypsum sulfate
Undergoes unhydrous calcinations when mixed with water, swells & forms into a hard cement
Made of rolls of plaster bandage, wet in cool water & applied to the body
Cools after 15 minutesRequires 24-72 hrs to dry completely
Non-plaster cast –(fiberglass cast)
Lighter in weight, stronger, water resistant & durable
Impregnated with cool water-activated hardeners & reach full rigidity in minutes
Diminish skin problems
Functions:To immobilizeTo prevent or correct deformity
To support, maintain & protect realigned bone
To promote healing & early weight bearing
Materials for casting:StockinetteWadding sheetPlaster of Paris
Complications of cast:1.Neurovascular compromise
Watch out for 6 P’s:PainPulselessnessPallor
ParesthesiaParalysisPoikilothermia
2. Incorrect alignment3. Cast syndrome – (Superior
mesenteric artery syndrome) occurs with body casts; any cast that involves the abdomen
Decreases the blood supply to the bowel
Signs/Symptoms:Abdominal pain, nausea & vomiting
4. Compartment syndrome –increased pressure within a limited space, compromises the function & circulation in the area
Long arm posterior moldFracture of radius/ulna with open wound, swelling or infection
Mechanical Aids for Walking:Canes:Standard straight-legged caneTripod or crab caneQuad cane – provides the best support
Standard cane – 36 inches in length
The length should permit the elbow to be slightly flexed
Health Teachings:Hold the cane with the hand on the stronger side of the body
Position the standard cane 6 inches to the side & 6 inches in front of the near foot.
When Maximum Support is Required:
Move the cane forward 1 foot while the body weight is borne by both legs
Move the weak leg forward to the cane while weight is borne by the cane & stronger leg
Move the stronger leg forward ahead of the cane & weak leg while the weight is borne by the cane & weak leg.
Walkers – for ambulatory clients needing more support than a cane provides.
Client needs to bear at least partial weight on both legs
Hand bar below the client’s waist & client’s elbow slightly flexed
Crutches Axillary crutch with hand bars
Loftstrand bar – extends only to the forearm; substitute to cane
Canadian or Elbow Extensor Crutch – made of single tube of aluminum with lateral attachments, a hand bar, cuff for the forearm & has a cuff for the upper arm
Nursing Alert:The weight of the body must be borne by the arms rather than the axillae (can injure the radial nerve, eventually can cause crutch palsy)
Crutch Palsy – weakness of the muscles of the forearm, wrist & hand
Measuring Clients for Crutches:
To obtain the correct length for the crutches & the correct placement of the handpieces
2 ways to measure the crutch length:
Client in supine position, the nurse measures from the anterior axillary fold to the heel of the foot & add 1 inch.
The client stands erect. The shoulder rest of the crutch is at least 3 finger widths, that is 1-2 inches below the axilla.
The angle of the elbow flexion must be 30 degrees.
Tip of the crutch is 6 inches from the side & 4 inches from the front of the foot.
Crutch stance (Tripod Position) –proper standing position with crutches.
Crutches are placed 6 inches in front of the feet & 6 inches laterally.
Crutch gait – gait a person assumes on crutches by alternating body weight on one or both legs & the crutches.
5 Standard Crutch Gaits:Four Point GaitThree Point Gait2 Point GaitSwing toSwing through
Four Point- Alternate Gait – most elementary, safest gait; client needs to bear weight on both legs
The nurse ask the client to:Move the right crutch ahead 4-6 inches.
Move the left front foot forward, to the level of the left crutch
Move the left crutch forward
Move the right foot forward
3 Point GaitClient bears entire body weight on the unaffected leg
Both crutches & affected leg advances
Unaffected leg advances
Two-Point Alternate Gait Partial weight bearing on each foot
Faster than 4 point gait
Move the left crutch & the right foot together
Move the right crutch & the left foot ahead together
Swing – To Gait – paralysis of the legs & hips
Move both crutches ahead together
Lift body weight by the arms & swing to the crutches
Swing –Through Gait Move both crutches forward together
Lift body weight by the arms & swing through beyond the crutches
Going up the StairsNurse stands behind the client
Placing weight on crutches while moving the unaffected leg onto the step
Going down the StairsThe nurse stands 1 step below
Moving the crutches & affected leg to the next step
Traction – is the act of pulling and drawing which is usually associated with counter traction
Provides proper bone alignment & reduces muscle spasm
For support, reduce bone fracture
Nursing responsibility:Maintain proper body alignment
Ensure that the weights are hanging freely
Ensure that pulleys are not obstructed; pulleys move freely
Place knots in the ropes to prevent slipping
Types of traction:Manual traction – done with the use of the hands of the operator
Skeletal traction – pin is driven across the bone to provide an excellent hold while a weight is attached
Use of pins, tongs & wires
Crutchfield tongsFor fracture of cervical spineC1-C5 cervical spine tensionUse for 4 weeks
Vinke’s skull caliperC1-C5 cervical spine tension
Use for 4 weeks
Nursing responsibility:Monitor color, motion & sensation of affected extremity
Monitor the insertion site for redness, swelling or infection
Provide insertion site care as prescribed
Skin traction – applied by the use of elastic bandages or adhesive straps to the skin while a pull is applied by a weight
2 Types:Non-adhesive type – uses laces, buckles, leather & canvas
Ex. Head halter strap
Adhesive type – uses adhesive tape or elastic bandages
Ex. Dunlop skin traction
Cervical skin traction – relieved muscle spasm & compression in the upper extremities & neck
Uses a head halter & chin pad
For cervical spine affectation
For Pott’s disease
Principles of traction:1.Patient must be in dorsal recumbent position
2.Line of pull should be in line with the deformity. Consider the position of diagonal bar & positioning of pulley.
1st pulley in line with the thigh, 2nd pulley in line with the knee or screw, 3rd pulley in line with the 2nd & 3rd pulleys
Weight bag must be at the level of the bed frame
3.Traction must be continuous. Emphasized the importance of manual traction.
4. Avoid friction – rope should be running along the groove of the pulley, knots away from the pulley. Weights should be hanging freely. Observe for wear & tear of ropes.
5. Provide counter traction. For every traction there must be a counter traction (Patient’s body weight)
Nursing Care of Patients with Traction:
1. AssessmentAssess patient as to level of understanding/consciousness
2. Provision of general comfort
Skin care – head to toe; focus on the sponging of affected extremity
3. Potential Complications:Upper respiratory – Pneumonia – back tapping & deep breathing
Bed sore – good perineal care; proper skin care, turning, lift buttocks once in a while
Urinary & kidney problem – good perineal care, increase fluid intake
Bowel complication – fear of apparatus, no privacy, lack of fluids/perineal care
Pin site infection – observe for signs & symptoms of infection; loosening pin tract, pus coming out from insertion site, foul smelling odor, fever
Deformity – contracted knees, atrophy of muscles, foot drop, joint contractures
4. Provision of Exercises:ROM exercises with the use of trapeze
Deep breathing exercisesStatic quadriceps exercise – alternate contraction & relaxation of quadriceps muscles
Toe pedal exercises
5. Nutritional status6. Psychological aspectFear of the unknown, fear of death, fear of apparatus, fear of losing a job, financial fear
7. Provision of supportive therapy
Offer books to read, listen to radio or TV, discover interest
8. Spiritual aspect
Know patient’s religion, encourage relatives to give spiritual communication, visiting chaplain
Divertional activities – divert attention for any pain
Knee Injuries Medial/lateral meniscus – act as shock absorbers; can tear.
Tearing – result of twisting the leg when the knee is flexed & foot is placed firmly on the ground.
Medial meniscus tear – due to internal rotation
Lateral meniscus tear – due to external rotation
“Bucket handle injury” – causes the knee to lock; torn cartilage jams between the femur & tibia thus preventing the extension of knees.
Diagnostic tests:McMurray test – examiner flexes & rotates the knee & then presses on the medial aspect while slowly extending the leg.
Positive test – if clicking is palpated or heard
Clinical manifestations:PainSwelling
Tenderness in the kneeClicking/snapping sound
Management:Locked knee – manipulation; casting for 3-6 weeks
Meniscectomy – Partial/total
Open meniscectomy – requires a surgical incision
for the removal of all or the part of the meniscus
Closed meniscectomy – accomplished through an arthroscope
Client begins leg exercises immediately after the procedure to strengthen the leg, prevent thrombophlebitis & reduce swelling.
Elevate the affected leg to 1 or 2 pillows
Apply ice to reduce swellingFull weight bearing restricted for several weeks
Dislocations/Subluxations Occurs when articulating surfaces are no longer in proximity
Common in shoulder, hip, knee & fingers
Etiology:TraumaCongenital/pathologic - arthritis
Clinical manifestations:PainImmobilityAlteration in contour of jointDeviation in length of extremityRotation of extremity
Management:Closed manipulation/reduction
Cast – immobilized the joint until healing
Traction/splint
Strain (muscle pull) – excessive stretching of a muscle or tendon when weak or unstable
Etiology:FallsLifting of heavy itemsExercise
Classification according to severity:
1.1st degree (mild) strain – mild inflammation, little bleeding, swelling, ecchymosis & tenderness
2. 2nd degree (moderate) strain – tearing of muscle or tendon fibers without complete disruption; muscle function might be impaired
3. 3rd degree (severe) strain – ruptured muscle or tendon, involving separation of muscle to muscle, muscle to tendon or tendon from bone
ManagementCold & heat applicationsExerciseActivity limitationsNSAIDs
Muscle relaxantSurgical repair
Sprains – excessive stretching of a ligament
Etiology : twisting motion from falls; sports activity
Classification according to severity:
1.1st degree (mild) sprain – involves tearing of a few fibers of a ligament; joint function not affected
2. 2nd degree (moderate) sprain – more fibers are torn; stability of joint remains intact
3. 3rd degree (severe) sprain – marked instability of joint
Clinical manifestations: Pain Swelling
Management:1st degree sprain:RestIce (24-48 hrs.)
Application of compression bandage (reduce swelling; provide support)
Elevation
2. 2nd degree sprain – immobilization (elastic bandage, splint or cast), partial weight bearing until ligament heals
3. 3rd degree (severe) sprain – immobilization (4-6 weeks); surgery
Amputation – removal of the part of the body
Note: The nurse recognizes that the psychosocial effect of the procedure is more devastating than the physical impairment
Loss experienced is complete & permanent causing a change in body image & self esteem
Amputation – ranges from removal of part of a digit to removal of nearly half of the entire body.
1. Open (guillotine) method – for clients with infection, for those who most likely to develop infection
Wound remains open, drains allow exudates to escape until infection clears
Surgeon suture the skin flaps over the wound at a later time
2. Closed (flap) method – surgeon pulls the skin flaps over the bone end & sutures them in place. 1 or more drains are inserted.
Traumatic amputation – occurs when body a part is severed unexpectedly; attempt of replantation is possible
Levels of amputation:Lower extremity amputation performed frequently
Syme amputation – most of the foot removed; ankle preserved
for peripheral vascular disease
Advantage – weight bearing can be achieved without the use of prosthesis & without pain
Below knee amputation (BKA) – preserve the knee joints
Above knee amputations – cause of amputation extends beyond the knee
The higher the level of amputation more energy is required for ambulation
Complications of amputations:
HemorrhageInfection
Phantom limb painNeuroma – sensitive tumor found in severed nerve endings
Flexion contractures
Phantom limb pain – frequent complication of amputation
More often after AKAFelt during the early post op period
Common among clients who experienced chronic limb pain before the surgery
Client complains of pain (intense crushing/burning) in the removed body part most often shortly after surgery
Incidence/Prevalence:More than 100,000 amputations yearly in US
Half of these among clients with DM
Middle aged or older man with DM & a lengthy history of smoking
2nd largest group affected young men involved in vehicular accidents (Motorcycle)
Injury at work (industrial equipment)
Diagnostic assessment:Measurement of segmental limb BP – Ankle-brachial index – Ankle systolic pressure/Brachial systolic pressure
Normal ABI=1 or greater
Doppler ultrasonographyLaser Doppler flowmetryTranscutaneous Oxygen Pressure
Angiography
Ultrasonography – measures the velocity of blood flow in the limbs
TcPO2 – measures the oxygen pressure to indicate blood flow in the limb
Nurse’s Primary Focus:Monitor for signs that there is sufficient tissue perfusion but no hemorrhage
Pain Management:Phantom limb pain – recognize that pain is real; It is not therapeutic that the limb can’t hurt because it is missing.
Drug therapy:IV Infusion of Calcitonin (Calcimar) – during the week of amputation
Alternative treatment:Transcutaneous Electrical Nerve Stimulation (TENS)
MassageDistraction therapyPrevention of Infection:Initial pressure dressings/drains usually removed in 48-72 hrs after surgery.
Promotion of ambulation:Start muscle-strengthening exercises before the surgery
Arrange for a client to see a certified prosthetist-orthotist (CPO)
Older clients with PVD – fitted after the residual limb has healed
Wrapping with elastic bandages – to reduce the edema, shrink the limb & hold the wound dressing in place
Reapply the bandages every 4-6 hrs when loose
Figure 8 wrapping prevents restriction of blood flow
Common Health Problems of the Young Adult
Multiple SclerosisMyasthenia Gravis
Chronic, progressive neurologic disease of the CNS
Unknown etiology
Progressive demyelinization of the white matter of the CNS
Occurs between ages 20-40Affects women twice as often as men
Whites are affected compared to Hispanics, Blacks or Asians
Etiology: UnknownImmunogenetic viral disease
Inmmune mediated demyelination triggered by viral infection
15-20 times more common in primary relatives of affected patients
InfectionPhysical injuryEmotional stressPregnancyFatigue
Formation of plaque along myelin sheath
Inflammatory reaction; Edema
Scarring/destruction of myelin sheath
Primary demyelination
Death of oligodndrocyte
Incomplete remyelination of nerves
Optic nervesCerebrumCervical SC
WeaknessParesthesia of 1 or more extremities
Vision loss (optic neuritis)Incoordination
Bowel/bladder dysfunction (SC involvement)
Fatigue common symptom that worsens as the day progresses
History/ Clinical findings2 episodes of neurologic dysfunction in different locations in the CNS
Spinal fluid evaluationMRI- brain, SC – presence of MS plaques
Relieve symptomsHelp the patient to function
Corticosteroids
Chronic autoimmune disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body.
Antibody mediated attack against the acetylcholine receptors in the neuromuscular junction
Cardinal features:Muscle weakness/ fatigue
Worsens with exercise; improves with rest
Etiology: unknownOnset: early onset 20-30 yrs old
Predilection to womenLate onset: after age 50 men are more susceptible
Increasing weakness with sustained muscle contraction – primary feature
Depletion of Acetylcholine receptors (NMJ)
Elevated antibody titers
Muscle weakness
Clinical presentation – testing the response of anticholinergic drugs
Endrophonium – Tensilon test
Neostigmine methylsulfate (Prostigmin) longer duration of effect (1-2 hrs)
EMG – confirm the diagnosis
Muscle weaknessPtosisDiplopiaExpressionless face
Drooping eyelidsOpen mouthSevere cases respiratory muscle arrest
No treatment availableShort acting anticholinesterase compounds – achieved maximum muscle strength & endurance
Corticosteroids – prednisone – decrease levels of serum Ach receptor antibodies
Complications:Myasthenic crisis experience worsening condition
Increase dose on anticholinergic drugs
Cholinergic crisis – overmedication
Abdominal cramps, diarrhea, excessive pulmonary secretions
PlasmaphereisThymectomy – alter immunologic control mechanism that affect production of antibody to ACH receptor
Common Health Problems of the Older Adult:
Parkinson’s DiseaseAlzheimer’s disease
Parkinson’s disease- is a progressive neurological disorders that results from degeneration of neurons in a region of the brain that controls movement
Parkinson Disease (Paralysis agitans)
3rd most common neurologic disorder of older adult
Debilitating disease affecting motor ability
4 Cardinal Symptoms:TremorRigidityAkinesia (slow movement)Postural instability
Pathophysiology:Degeneration of Substantia Nigra
Decrease dopamine production
Decrease ability to refine voluntary movement
Organ/ System affected- Brain
( substantia nigra & basal ganglia)
- Neuromuscular system
Neuromuscular system- combination of the
nervous system & muscles.
- work together to permit movement.
Basal gangliaintegrates feeling and movement
shifts and smoothens fine motor behavior
suppression of unwanted motor behaviors
sets the body's idle or anxiety level
enhances motivation
CaudatePutamen
Globus pallidusSubstantia nigra
Substantia nigra- controls voluntary movement, regulates mood, and produces the neurotransmitter dopamine
Causative:ToxinsHead traumaCerebral anoxiaDrug-induced
Predisposing factor:- Age- Heredity- Sex- Exposure to toxins
Tremor] Rapid shaking of the hands, arms or legs
Arms and legs become stiff and hard to move
Difficulty starting or completing movements
Lack of balance or difficulty adjusting to sudden changes in position
is a nuclear medicine imaging technique which produces a three-dimensional image or map of functional processes in the body.
is a noninvasive transthoracic graphic produced by an electrocardiograph, which records the electrical activity of the heart over time.
High risk for injury related to postural, instability & muscular rigidity
Impaired verbal communication related slowness of movement
Altered nutrition: less than body req. related to poor or pharyngeal muscle control & coordination
Knowledge deficit related to the complexity of & fluctuations in the treatment regimen.
LevodopaDopamine agonistsAmantadineCOMT inhibitorAnticholinergicBromocriptine
Levodopa- a dopamine precursor, increases the dopamine supply in neurons making more availabale to stimulate dopaminergic receptors.
Dopamine agonists- directly stimulate nerves in the brain that are not naturally being stimulated by dopamine.
Amantadine- blocks acetylcholine receptors and promotes release of dopamine
Anticholinergic- block acetylcholine
receptors that help control the muscles of the arms, legs, and body.
Ablative surgerythis procedure locates, targets and then ablates or destroys a targeted area of the brain affected by Parkinson's.
Deep brain stimulation- treats the tremors and slowness associated with Parkinson's disease. This therapy has been shown to provide greater relief of symptoms with fewer side effects than other treatments.
Pallidotomy In this procedure, a surgeon selectively destroys a portion of the brain called the globus pallidus.
can improve gait and balance.
Thalamotomy a related procedure that involves surgically destroying part of the brain's thalamus.
is useful primarily to reduce tremor.
Transplantationcalled restorative surgery
dopamine-producing cells are implanted into a certain part of the brain.
Most common form of dementia
Progressive impairment in memory, cognitive function, language, judgment & ADL
Incidence:10-15% people older than age 65
19% older than 7547% older than 85
Etiology- unknownRisk factors:GeneticsIncreasing age
Female genderViruses, toxins & previous head injury
Changes in CHON of the nerve cells of
cerebral cortex
Accumulation of neurofibrillary tangles & neuritic plaques
Degenerating nerve terminals
Changes in CHON of the nerve cells of cerebral cortex
Neurotransmitter changes
Decrease in cholinergic neurons in basal nucleus
Loss of choline acetyltransferase
Cognitive decline(Learning, reasoning, memory , recall,
language recall)
Onset is subtle/insidiousGradual decline of cognitive functioning
Short term memory impairment
Impairment in decision making
Decrease cognition
ApraxiaHyperorality – desire to take everything in the mouth
Loss of self care abilities
•Patient history•EEG•CT Scan (Non contrast)•MRI•Neuropsychological evaluation
Maximize functional abilities
Improve quality of lifeCholinesterase inhibitors Tacrine(Cognex)
Donepezil (Aricept)Reminiscence therapyArt/recreational therapy
Common Health Problems Across the Life Span
Guillain-Barre Syndrome
PolyradiculoneuritisInflammatory disease of unknown cause/involves degeneration of myelin sheath of peripheral nerves
Affects people of all ages & races
Most common cause of acute general paralysis
.75 – 2 cases/ 100000 population
Predisposing factors:Respiratory/GI infectionsViral infectionsImmune reactionsvaccination
Viral infection
Autoimmune reactions
Damage to myelin sheath (Peripheral Nerves)
ParesthesiaSymmetric progressive muscle weakness
Loss of DTRAutonomic dysfunction (Increase HR/postural hypotension)
Deep aching muscle pain in shoulder girdle
Respiratory muscle weakness – cause of death
85-90 % recover completely
History/Physical ExamCSF analysisElectrophysiologic studies
PlasmapheresisSupportive care