Short note for nurses on musculo-skeletal diseases

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Rheumatoid arthritis

• It is a chronic systemic inflammatory disease which leads to the destruction of connective tissue and the synovial membrane within the joints.
• It weakens and leads to dislocation of the joint and permanent deformity and formation of pannus (abnormal osseous tissue) at the junction of the synovial tissue and articular cartilage.


• Immune complex disorder.
• Genitical factor.
• Inflammation, tenderness, and stiffness in the joints.
• Moderate to severe pain in the joints.
• Morning stiffness lasting longer than 30 minutes.
• Joint deformities and muscle atrophy are decreased with ROM exercise.
• Spongy, soft feeling in the joints.
• Low-grade temperature, fatigue, and weakness.
• Anorexia, weight loss, and anemia.
• Subcutaneous nodules in the myocardium, aorta, lung.
• It is a condition with remission and exacerbation.
Risk factor for exacerbation
• Infection.
• Fatigue and stress.
• Physical and emotional stress.
• Increased ESR.
• Positive Rheumatoid factor (RA)
o Non reactive : 0 to 39 IU/ml
o Weakly reactive: 40 to 79 IU/ml.
o Reactive: greater than 80 IU/ml.
1. Pain management

a. Salicylates (Aspirin)
• side effect:- GI upset, prolonged bleeding tinnitus.
• Nursing Responsibility
o Give with food or snack.
o Monitor for abnormal bleeding or bruising.
B. NSAIDS (Nonsteroidal anti-inflammatory drug)
• Give if no pain relief within 6-12 weeks following salicylates.
• Side effects:- GI upset, CNS manifestation. Skin rash, change in renal function.
C. Corticosteroids
• To decrease inflammatory process and to suppress immunity.
D. Antineoplastic medication
• Use in a client with life-threatening Rheumatoid arthritis.
E. Gold salt
• Give with a combination of salicylates and NSAIDs.

Reduce inflammation by the decrease in an enzyme which is necessary for immune response.
Side effects
• Metallic taste in the mouth.
• Gold toxicity.
• Dermatitis.
• Dizziness.
• Rash,
• Erythema.
Nursing Responsibility in administration of Gold Salt
• Monitor for any allergic reaction.
• Monitor renal function test.
• Maintain good oral hygiene.
• Monitor for protein urea or haematuria.
• If toxicity occurs administer dimercaprol.
• Uncontrolled DM,
• Renal and hepatic dysfunction.
• CHF.
• Eczema.
• SLE.
2. Increase physical mobility and muscle strength

• Encourage the patient to a daily program of exercise and avoid excessive exercise during the acute stage.
• Instruct the client to stop exercise if pain increase.
• Pain lasting more than half an hour after activity indicates vigorous exercise.
• Exercise slowly and smoothly in short, frequent section.
• Should perform ROM exercise and isometric exercise.
3. Optimum independence of ADL
• Self-help device can be used to help with daily activity like higher toilet seats, and chair.
• Provide extra time for the patient to perform the activity.
4. Decrease fatigue
• Provide nutritious diet, iron, folic acid, and vitamin supplement.
• Maintain rest and activity.
• Encourage weight lose if the patient is obese.
• Avoid mental stress.
5. Body image disturbance
• Give psychological support. And encourage him to express feeling.

OSTEOARTHRITIS (Degenerative joint diseases DJD)

• Progressive degeneration of the joints as a result of wear and tear.
• This causes a formation of bony build-up and loss of articular cartilage in the joints.
Predisposing factor
• Anatomical abnormality.
• Trauma.
• Excessive joint use.
• Obesity.
• Systemic diseases like DM.
Common affecting joints are:- Knees, Toes, and lower spine.
• Pain and swelling in one or more joints particularly after activity.
• Pain decreased with rest.
• Stiffness can occur after activity but no morning stiffness.
• Symptoms are aggravated by temperature change.
• Joint enlargement.
• Limited ROM.
• Difficulty in getting up after prolonged sitting.
• Inability to perform ADL.
• Compression of the spine as manifested by radiating pain, stiffness, and muscle spasm in one or both extremities.
• Heberden’s node- boney enlargement that occurs on the distal end of the finger.
• Bouchard’s node- Nodular boney enlargement on the proximal joint of the finger.
• Pain management.
• Provide rest for all joints.
• Use splint, cervical collar, and traction.
• Use the hot application to relieve pain and spasm.
• Corticosteroids can be injected into the joint.
• Administer NSAIDs , salicylates, and muscle relaxants.
• Maintain the balance between rest and activity.
• Provide bed or foot cradle to avoid bed sheet pain.
• Provide 10 hr sleep at night and 1 to 2 hr Nap.
• Provide only single pillow under the neck.
• Weight reduction is very important.
• Provide well-balanced diet.
• Perform exercise same like RH.
Surgical management
Osteotomy: -bone is cut to correct joint deformity and promote realignment.
• Total joint replacement.
• Tendon repair surgery.


• It is an age-related metabolic diseases characterized by bone demineralization result in loss of bone mass leading to fragile. (Easily broken) and porous bone with subsequent fractures.
Risk factor
• Aging, family history, smoking.
• Early menopause, use of alcohol.
• Female gender.
• White or Asian race.
• Decrease intake of calcium.
• Sedentary lifestyle.
• Thin small frame.
Common affecting parts are:- Wrist, hip, and vertebral column.
• Back pain after lifting, bending or stooping.
• Back pain that increases with palpation.
• Pelvic or hip pain especially with weight bearing.
• Problem with balance.
• The decline in height form vertebral compression.
• Kyphosis of the dorsal spine.
• Constipation, abdominal distension and respiratory impairment as a result of movement restriction and spinal deformity.
• Pathological fracture.
• The appearance of thin porous bone on X-ray.
• Safety is the priority.
• Assess the risk of injury.
• Provide a safe and hazard free environment.
• Use side rails to prevent falls.
• Move the client gently when turning and repositioning.
• Encouraging ambulation and assist with ambulation to prevent bone reabsorption.
• Instruct to use an assistive device such as cane and walker.
• Provide the range of motion (ROM) exercise.
• Use good body mechanics.
• Provide exercise to strengthen abdomen and back muscle to improve posture and to provide spinal support.
• Avoid activities that cause vertebral compression.
• Apply a back brace during an acute phase to immobilize the spine and provide spine and spinal column support.
• Use firm mattress only.
• Adequate fluid intake to prevent renal calculi.
• Avoid alcohol and coffee.
• Administer estrogen and androgens to decrease the rate of bone reabsorption.
• Administer calcium, vitamin D, and phosphorus.
• Administration of calcitonin to inhibit bone loss.
• Administer analgesics, muscle relaxants, and anti-inflammatory drug.


• It is a systemic disease in which urate crystals deposit in joints and other body tissue.
• It leads to the abnormal amount of uric acid in the body as a result of purine metabolism.
• Primary (due to a problem with purine metabolism).
• Secondary (due to other diseases and any medication).
• Asymptomatic
No symptoms.
Serum uric acid level is elevated.

• Acute
Excruciating pain and inflammation of one or more small joints especially the great toe.
• Intermittent
The client is in the asymptomatic period between acute attacks.
• Chronic phase
Repeated episodes of acute gout.
Result in deposits of urate crystals under the skin and within the major organ especially the renal system.
• Excruciating pain in the involved joints.
• Swelling and inflammation at the joints.
• Low-grade fever.
• Malaise and headache.
• Pruritis.
• Presence of renal stone.
• Elevated uric acid level.
• Tophi (hard, fairly, large, and irregularly shaped deposits in the skin) that may break open and discharge a yellow gritty substance.
• Avoid purine diet ex: organ meat, red wine, aged cheese.
• Increased fluid intake of 2000 ml/day.
• Encourage weight reduction diet if required.
• Avoid alcohol and starvation diet because that may precipitate a gout attack.
• Increase the urinary ph above 6 by eating alkaline ash food such as milk and dairy products to prevent kidney stone.
• Administer NSAIDS and anti-gout medicine.
Antigouts medicine Action
• Decrease uric acid production.
• Increase uric acid excretion.
• Decrease inflammation.
Side effects
• headache, Prolonged use can cause eye damage.
• Nausea, vomiting, diarrhea.
• Skin rash. Flushed skin.
• Uric acid kidney stone.
• Bone marrow suppression.
• Metallic taste in the mouth.
• Blood dyscrasias. (Blood are abnormal or are present in abnormal quantity.)
Ex: Allopurinol, colchicines. Benemid (Probenecid)
Nursing Responsibility
• Decrease intake of vitamin C along with Allopurinol because of formation of kidney stone.
• Increase fluid intake.
• Do RFT.


• Paget’s diseases is a skeletal disorder resulting from the excessive proliferation of osteoclast (multinucleated bone cell) which leads to excessive bone destruction and unorganized bone repair.
The function of osteoclast:-Absorb and remove osseous tissue.
Affecting part:-Long bone, skull, and vertebra.
Cause: – Unknown
Predisposing factor: – Age above 80 yrs, Family history, Common in men.
• Asymptomatic.
• Severe pain.
• Joint destruction.
• Pathological fracture.
• Spinal Deformity.
• Tinnitus. Vertigo.
• Decrease hearing as a result of skull enlargement.
• For pain NSAIDs and aspirin.
• Administration of calcitonin is the drug of choice of Paget’s diseases.
• Access pain and functional ability.
• Access for cardiovascular complication.
• Access for auditory symptoms like tinnitus, vertigo, and hearing loose.
• Assist the patient with activity as necessary.
• Avoid sedation and narcotic which may increase the risk of fall.
• Provide helping device for ambulation.
• Teach safety measure.
• Encourage follow up care.


Dysplasia of the Hip (congenital dislocation of hip)

• It is a malposition of the head of the femur from the acetabulum.
• This can be mild to severely dislocation.
• It is a unilateral problem.
• Abnormal development of joints caused by fetal position.
• Genetic factor or family history.
• Abnormal relaxation of capsule and ligament of joints caused by the hormonal factor.
• Asymmetry of the gluteal and thigh skin folds.
• Thigh creases deeper on the affected side.
• Limited ability to abduct the hip when the infant is lying on his back with hips and knee flexed at 90 degrees.
• Trendelenburg sign (downward tilt of pelvis on the affected side).
• The shorter limb on the affected side.
• Delayed walking.
• Waddling gait usually in bilateral hip dysplasia.
• X-ray.
• Barlow maneuvers.
The infant on a firm surface and examiner grasp the symphysis pubis in front and sacrum at back with one hand. With second hand grasp the thigh on the side of the hip being tested. Slight outward and downward pressure is applied to the proximal thigh by the thumb to dislocate the hip out of the socket. The sensation of abnormal free movement indicates a dislocation.
• Ortolani’s maneuver
The thigh is brought away from the midline of the body into a position of abduction, upward and inward direction. The sensation of clicking or jerking into a place may be detected by reduction of the head into the socket.
• Splinting the hip in abduction by means of the double diaper or by a hip spica cast.
• Pavlik harness (belt-like device )
o Uses in infants.
o Should be worn in full time for 3 to 6 months or until the hip is stable.
o It should be removed only sponge bath.
o Should check the skin area 2 to 3 time a day.
o Avoid use of soap and powder.
o Place diaper under the strap.
• Bryan’s traction
Commonly used for children under the age of 6 to 18 months it is a skin traction.


• A congenital malformation of the lower extremities and of the foot.
• The defect may be unilateral or bilateral.
• Talipes equines varus (Toes touch the ground, not heel)
95% of congenital clubfoot are these type. This is the medical deviation of the foot with plantar flexion of the Sole.
• Talipes calcaneus varus
The heel alone touches the ground while standing.
• Talipes varus
The person walks on the outer edge of the foot.
• Talipes valgus: –The person walks on the inner edge of the foot.
Predisposing factor
• Genetical factor.
• Environmental factor.
• The more affecting group are male.
• Rigid type:- Very severe deformity, Correct only minimally by passive manipulation.
• Flexible type:- Can be readily corrected to the neutral position by passive manipulation.
• Manipulation of the foot into normal position with or without serial casting.
• Provide passive stretching exercise.
• Manipulation is done before feeding.
• The cast is applied from the toes to the groin with the knee flexed.
Dennis Brown splint
• Use to correct the deformity.
• It is composed of a flexible horizontal bar attached to a pair of footplate.
• Protection of foot by wearing soaks.
• Splint key to tighten the shoe against the bar if it becomes loose.
• It is an aseptic necrosis of capital femoral epiphysis secondary to ischemia.
Etiology/cause:- Unknown
Incidence:- Most commonly affected male between 4 to 10 years and white children.
Stage 1 Avascularity
• Spontaneous interruption of blood supply to the upper femoral epiphysis.
• Bone forming cells in the epiphysis die.
• There will be a slight widening of joint space.
Stage 2 Revascularization
• The growth of new vessel to supply area of necrosis.
• Bone reabsorption stop and deposition take place.
Stage 3 Reossification
• Head of the femur gradually reform.
• New bone starts to develop and the medial and lateral edge of the epiphysis become widen.
Stage 4 Post recovery period
• Without treatment head of the femur flatten and become mushroom shape there will be no connection between the head of the femur and acetabulum.
• It leads to the degenerative change in later life.
• Pain in the hips, Limb, knee, inner thigh and groin.
• Limited abduction and internal rotation of the hip.
• Mild to moderate muscle spasm.
• X-ray.
• Bone scan.
• Provide bed rest with or without traction.
• Non-weight bearing abduction cast.
• Femoral Osteotomy.

• A Lateral curvature of the spine characterized by a defect in the bone and surrounding tissue and spine.
• According to the spinal segment.
o Thoracic.
o lumbar.
o Thoracolumbar.
• According to age group.
o Infantile (birth to 3 yrs)
o Juvenile (4 to 9 yrs)
o Adolescent ( 10 to cessation of growth)
• Lateral curvature or flexion of the spine causes the trunk to shift away from the middle line.
• Changing the center of gravity and causing shortening of the spine.
• Scoliosis is increased by the weight of the trunk and disturbed the active growth in the vertebral element.
• Thoracic cavity narrows the ribs do not allow movement in a normal way which may affect the expansion of lung.
• Degenerative arthritis.
• Disturbed in cardiopulmonary function.
• Back pain.
• One shoulder higher than other.
• One hip that seems prominent.
• Uneven waste line. Lumps on back.
• Crooked neck.

• Provide Milwaukee brace for 23 hr/day.
• Only remove for a bath.
• It extends from chin up and neck pad to the pelvis.
• Do not apply lotion, creams, and powder under the Milwaukee brace.
• Instruct the child to wear a thin cotton dress under the Milwaukee brace to protect skin.
Surgical management
• Harington instrumentation with posterior spinal fusion
• V-wire instrumentation with anterior spinal fusion.
Postoperative care
• Access neurovascular function.
• Avoid twisting movement.
• Use logrolling method.
• Encourage deep breathing exercise.
• Use incentive spirometry.
• Monitor for incontinence.
• The protective cast also can apply for 6 to 12 months after spinal fusion to provide support.
• Assist with ambulation.
• Use molded plastic jacket to provide external support of the spine when resuming activity.
• Monitor for complication superior mesenteric artery Syndrome.
Cause Changing the position of abdominal content during surgery.

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