Alteration in Mobility and Musculoskeletal

Long bones​

humerus, radius, tibia, and femur​

-function as levers in mobility​

-composed of the diaphysis and epiphysis. ​

-The diaphysis is a long, cylindrical shaft​

Short bones

carpal bones in the hands​

tarsal bones located in the feet.​

Flat bones

bones of the skull, the ribs, scapula

Irregular bones

vertebrae and the pelvis​

Growth plate

primarily hyaline cartilage and contains four regions.​

Axial Skeleton

Forms the central axis of the body​

Appendicular Skeleton

Consists of limbs and girdle and are attached to axial​

Joints and Muscles​

Bones are connected through joints​

Most common are synovial joints and synovial fluid​

Muscles provide mobility to the skeletal system​= Skeletal​, Cardiac​, and Smooth​

Other soft tissue:​ Tendons​, Ligaments​, Fascia​

Epidemiological and Etiological Risk Factors​

Alterations in Mobility​= include sprains, strains, fractures, and diseases of the bones, muscles, or joints, can lead to immobility​, Aging increases the risk ​

Injuries​= Immobility can be temporary: ​Fractures​, Sprains​, and Strains​​

Chronic movement disorders​= Conditions affecting bones: ​osteoporosis​, osteopenia​.

-Conditions affecting muscles: ​sarcopenia​

-Chronic movement disorders: ​parkinson​, AS​, tardidiskanisa​

Comorbidities​= Clients are at risk for developing many comorbidities. ​Cardio disease​, respiratory, and Venous thrombosis​.

Physiological Changes Related to Immobility

Nervous System​= Reduced sensation​, Tingling​, Neuropathy​

Cardiovascular System​= DVT​, Decreased cardiac output​, Venous stasis​

Pulmonary System​= Pneumonia​, Decreased cough reflex​, Decreased lung expansion​

Gastrointestinal System​= Constipation​, Incontinence​, Bowel Dysfunction​, Heartburn​

Genitourinary​= UTI​, Incontinence

Integumentary=, Pressure injuries​, Infections​, Inflammation​

Neurological​= Confusion​, Depression​, Anxiety​

Considerations of the Aging Adult​

Bone density​= begins to decrease after age 30, accelerated in menopause - bones become more fragile- due to hormone changes​

Connective tissue , cartilage, and joints​= Cartilage becomes thinner -resilience in the joint declines, leads to joints that are more susceptible to damage, may lead to osteoarthritis​. Aging causes ligaments and tendons become more rigid and brittle ​

Muscle mass​= loss of muscle mass begins at age 30​, adds stress to joints and can lead to an increased risk for falling and arthritis​, regular physical activity can delay loss of muscle mass.

Synovitis​

Inflammation of the synovial membrane.​

Causes/Risk Factors:​ Contusion or sprain​, Repetitive motion​, and Rheumatologic disease​

Clinical Presentation: ​painful joints that worsen with movement​, swelling at night​, and pain with full extension​.

Diagnostic Testing: for soft tissue​= Ultrasound, MRI, aspiration of the synovial fluid​

Treatment: ​Heat or ice ​and Anti-inflammatory agents​

Osteoporosis​

Softening of the bone​

-Increased risk for fractures –worry about older patients.​ Hips, ribs and spine are most suseptiible​

Primary: aging, gonadal insufficiency, decreased Ca intake, and low vit. D levels, smoking, caffeine, h/o malabsorption​

Secondary: disease processes such as CKD, COPD, multiple myeloma, endocrine disorders, rheumatoid arthritis, and malabsorption syndromes- anorexia, celiac disease, bariatric disease.​

Diagnostic Testing: ​Dual-energy absorptiometry (DXA) scan​. Assess for lab abnormalities related to calcium, magnesium,PTH levels, liver enzymes, and tests to rule out cancer.​

Osteoporosis​ Clinical Presentation

Generally asymptomatic ​

Acute pain can occur with vertebral fractures​

Kyphosis (sway back) and Cervical Lordosis(hunch back) can result from thoracic compression​

Osteoporosis: Treatments​

Thyroid Hormone​= Regulates metabolism​, Available in nasal spray​. Monitor nasal mucosa if using nasal spray​. Report nasal discomfort, allergic reactions​

Estrogen Hormone Replacement​= Helps maintain bone density by replacing estrogen after menopause. Reduces bone resorption and fracture risk.​ Risk’s include increased chance of blood clots, breast cancer, and stroke​. Discuss benefits and risks​

Raloxifene​= A selective estrogen receptor modulator (SERM).​ Mimics estrogen’s beneficial effects. Helps prevent bone loss and reduces risk of spine fractures.​ Can cause hot flashes and risk of DVT​

Calcium Supplement​= Essential for bone health and to support other osteoporosis treatments. Recommended daily intake 1000–1200 mg/day.​ Should be taken with vitamin D to enhance absorption.​Do not exceed recommended dose – risk of kidney stones​. Maintain hydration​

Vitamin D​= Enhances calcium absorption from the gut.​ Important for bone mineralization and health.​Monitor serum vitamin D levels. Assess for signs of deficiency or toxicity.​ Encourage safe sun exposure and dietary sources ​

Bisphosphonates= First-line medications to slow bone loss and increase bone density.​Example: alendronate. Inhibit bone resorption by osteoclasts, reducing fracture risk.​ Must be taken with specific instructions- on empty stomach​.

Osteoporosis: ​Nursing Care & Client Education​

Evaluate risk factors - age, gender, family history, diet, lifestyle and alcohol use. ​

Monitor for signs of fractures, esp. in hips, spine, and wrists. Assess pain levels and mobility limitations.Assess pain​

Encourage intake of calcium-rich foods (dairy, leafy greens). Promote vit. D intake through diet and safe sun exposure.​

Encourage weight-bearing and muscle-strengthening exercises​

Ensure the environment is free of hazards- stairs, where work, what is their baseline​

Encourage use of assistive devices – walkers, canes​

Wear nonslip footwear.​

Client Education: ​Explain osteoporosis and impact on bone health.​ Teach about medication adherence & side effects.​ Discuss lifestyle modifications - stop smoking, limit alcohol and caffeine.​ regular bone density screenings.- per provider

Osteomyelitis​

Bone infection caused by bacteria or other microorganisms - enter bone tissue through bloodstream, direct trauma, or spread from nearby infected tissue​

-Can affect any bone in the body - most commonly in the long bones of arms and legs​

-Acute or chronic, with chronic cases being more challenging to treat ​

Inflammatory response leading to increased pressure within bone, reduced blood flow, and potential bone death (necrosis)​

Can lead to systematic problems, want to treat quickly​

Osteomyelitis Clinical presentations

Fever​

Chills​

Severe pain, worsens with movement,​

swelling/redness/warmth​

osteomyelitis​ Types

Direct Invasion: result of an invasive procedure. ​

Indirect Invasion: invades from the bloodstream, preexisting​

Osteomyelitis Diagnostic Testing

Wound Culture​

MRI​

CT​

Bone Scan​

Osteomyelitis: Nursing Management & Client education

Priority nursing interventions - administering prescribed antibiotics, usually long-term IV therapy, monitor changes, and complications.​

Monitor vitals​, Pain management ​

monitor for complications - sepsis, pathological fractures, chronic infection​

Regular assessment for signs of inflammation, drainage, or changes inROM​

Coordinate care with other healthcare providers, including infectious disease specialists and orthopedic surgeons.​

Sterile technique​

Client Education: ​Educate client about long-term IV treatments/medications, procedures such as joint replacement and the importance of keeping follow-up appointments. ​

Body part should be immobilized​

Arthritis​

More than 100 types of arthritis and many different causes​

Inflammation of the joint​= Joint pain​, Stiffness​, Swelling, Decreased mobility​

Treatment- rest​

-Immobilization​ and Anti-inflammatory medication

Most common disease of the joints, Chronic degeneration of the joints​

Most common in weight bearing joints such s hands, hips, knees and vertebrae

Osteoarthritis​

Degenerative condition that involves damage to articular cartilage - cartilage breaks down leading to inflammation & damage to joint.Most common type of arthritis. ​

-Degenerative: Not reversible, progressive - can lead to chronic pain, bone cyst, or spurs. ​

-Bone becomes sclerosed (hardened) from wear, and causing inflammation & discomfort, Most painful when affecting weight-bearing joints - spine, knees, hip -but can affect any joint. Most common in weight-bearing joints - hands, hips, knees & vertebrae​

Risk Factors & Causes: age, injury, overuse, repetitive trauma, genetics, joint malalignment, sedentary lifestyle, cardiovascular disease, diabetes, obesity, hemochromatosis (genetic disorder, body absorbs too much iron)​

Bone spurs and cysts: ​Bone spurs can start to grow from the friction of bone-on-bone as cartilage degenerates and bone erodes​..

-Bone Cysts - fluid-filled cavities in bone, can form in damaged joints due to dysfunctional movement & overload of damaged joints ​

Osteoarthritis: Impact onOverall Health​

Psychosocial ​

Health promotion and prevention​

Considerations for aging​

Pain, change in mobility

Osteoarthritis: Clinical Presentation​ and Lab Testing

joint pain​, fatigue​, mobility limitations​, stiffness​, swelling​, and Crepitus- hear crack or pop when move ​

Lab testing and diagnostic studies: X-ray first to identify and is cheaper. Radiography​, MRI, Ultrasound​, ESR​

-Arthrocentesis- joint aspiration​

-the C-reactive protein (CRP) - inflammation biomarker​

Osteoarthritis:Treatments​

Non-Opioid Treatments:​ Acetaminophen- 1st line, monitor how much takingand monitor liver function (LFT)​, Ice​, NSAIDs: ibuprofen, Aleve, etc.​ Corticosteroid injections ​

-viscosupplementation: treatment for osteoarthritis ofknee - injection of hyaluronic acid (HA) into the joint ​

Opioids (tramadol, hydrocodone, oxycodone): ​moderate to severe pain​

Muscle Relaxants: ​Cyclobenzaprine

Rheumatoid Arthritis (RA)​

chronic inflammation affecting joint & surrounding tissue resulting in pain, stiffness, swelling, and lack of function​

RA differs from osteoarthritis in that it is a chronic autoimmune disease, not an inflammatory response disease ​

body attacks itself - autoantibodies mistake healthy tissue as a threat​, autoantibodies target healthy cells of the joint causing damage - joints are most affected, but can also affect eyes, mouth, heart, and lungs​

Process= Synovial fluid becomes inflamed, immune system attacks it mistakenly​, Causes chronic pain, deformity of affected joints, difficulties with normal function and movement, including a lack of balance ​

-inflammation & deformity can be severe, causing locking of joints and making movement of affected joints nearly impossible. Specific cause unknown​

Juvenile RA – (under 16)​

Rheumatoid Arthritis: ​Risk Factors​

Age​

Genetics​

Female gender at birth​

Obesity​

Smoking​

Stress​

Immune dysfunction​

Type I diabetes​

Bacterial or viral infection​

Epilepsy​

systemic inflammation from related conditions begins before manifestations present themselves and a RA diagnosis is made​

Rheumatoid Arthritis: ​Clinical Presentation and Diagnostic testing​

low-grade fever​

Malaise​

Pain​

Weakness​

joint stiffness, swelling, deformities- usually in hands​

nodules, ​

xerostomia (dry mouth)​

systemic inflammation with fatigue, weight loss, malaise.​

joint pain and swelling, increase in synovial edema. ​

chronic inflammation leads to deformities and breakdown of the joints​

Diagnostic Testing: combination of lab tests and diagnostic studies. ​

Serology: ESR (elevated), ANA (positive), CRP (elevated indicates inflammation), CBC (elevatedWBC’s during exacerbation), RF (1:40 to 1:60 is correlated with RA; other diseases can elevateRF)​

Imaging: X-ray, MRI, Ultrasound​

Synovial fluid aspiration – elevated WBC count, turbidity​

Rheumatoid Arthritis: ​Medication management​

NSAIDs - ibuprofen, naproxen​

-Nursing Considerations: ​Monitor renal and GI function, typically prescribed with GI-acid reducing agents, taken with food, avoid alcohol​

COX-2 Enzyme Blockers - Celecoxib​

-Nursing Considerations: ​Cause less GI upset, monitor blood glucose levels, watch for signs of infection, assess blood pressure and electrolytes,taper doses gradually to avoid adrenal insufficiency​

Corticosteroids - Prednisone, methylprednisolone​

-Nursing Considerations: ​Monitor blood glucose and for signs of infection, assess BP and electrolyte balance, taper doses, take with food, what toreport to provider ​

Disease Modifying anti-rheumatic drugs (DMARDs) - Hydroxychloroquine (antimalarial agent), Minocycline (antibiotic), Sulfasalazine(Sulfonamide), Etanercept (biologic response modifiers). ​

-Nursing considerations: ​Monitor liver function, watch for signs of infection due to immunosuppression, educate about slow onset of action (weeksto months), ensure adherence to scheduled lab monitoring, educate client to report symptoms like fever, sore throat,bruising, or unusual bleeding immediately and to avoid live vaccines - avoid alcohol to prevent liver damage, Take with food​

Rheumatoid Arthritis:​Therapeutic Treatments​

Plasmapheresis: Removalantibodies in the plasma, reducesflare-ups. Used for life-threateningexacerbations. ​

Total joint arthroplasty: Surgicalrepair of severely deformed jointsthat are not responsive totreatment​

Synovectomy: Surgical removal ofthe synovial membrane​

Rheumatoid Arthritis: Nursing Care & Client Education​

Managing Symptoms/Pain: administer prescribed medications, use heat/cold therapydepending on symptoms- stiffness heat, swelling then cold, encourage balanced rest andactivity to reduce stiffness​

Psychosocial impact: provide emotional support, encourage participation in support groups​

Health promotion and prevention: diet high in vitamins, protein, and iron – small, frequentmeals are best, exercise as appropriate. ​

Considerations for aging: Older clients with RA have a higher incidence of falls - could be onmore medications related to other conditions and have more complex side effects​

Safety & Mobility: assist with joint protection techniques - encourage PT and gentle exercises.– use assistive devices​

Client Education: importance of proper/safe medication management - promote use of assistive devices (Velcro, zippers, etc.) - report swelling, fever, side effects, and increased pain.

Lupus

chronic autoimmune disease, can be moderate to fatal​

Lupus involves atypical immune response to healthy tissues: ​T-cell dysfunction leads to hyperfunction of B-cells and inability to recognize the difference between self and foreign tissue​

-causes production of autoantibodies to attack tissues & form immune complexes​. complexes deposit throughout the body - triggers the inflammatory response from the immune system​

Two types:​

-Systemic lupus erythematosus (SLE)​= Most common type​, Inflammation occurs in multiple organs, Arthritis can develop, late stages can progress to osteoarthritis​

-Discoid lupus erythematosus (DLE)​= Immune system directly attacks skin​, Red, scaly, lesions on the skin​. Can lead to permanent hair loss and scarring​. DLE can progress to SLE​

Lupus: Epidemiological and Etiological Risk Factors​

Triggers can lead to flare ups;​ Hormones – Ex: Estrogen​, Genetics – linked to over 50 genes​, Infection​

Stress​, Medications​, Toxins: medications such as phenytoin, hydralazine, isoniazid​. Epstein-Barr virus​UV light​, Silica dust​

SLE Occurs mostly in females​

Inflammatory effects​

Kidneys – may require dialysis​

Central nervous system​

Cardiovascular system​

Serositis (inflammation of the pleura or pericardium or the peritoneum) ​

This can impact multiple major organs​

Lupus: Clinical Presentation​

SLE: ​Systemic: skin rash (butterfly)- across nose and cheeks, arthritis, inflammation of feet and eyes, fatigue, low grade fever, malaise, weight loss, swelling and stiffness to joints, Raynaud’s phenomenon, oral ulcers, photosensitivity​

-Body Systems: Renal (proteinuria, hematuria, lupus nephritis), cardiovascular (pleuritis, pericarditis, chest pain), neurologic (headaches, seizures, cognitive dysfunction), hematologic(anemia, leukopenia, thrombocytopenia)​

DLE: Scaly, red rash on face or scalp, Sores in nose or mouth

Lupus: Diagnosis​

Serology:​

-ANA (positive in most clients): screening test for autoimmune diseases - detects presence of autoantibodies.​

-Anti-DNA Test: Specifically detects antibodies against double-stranded DNA (dsDNA) - more specific for systemic lupus erythematosus (SLE) - helps confirm diagnosis- Gold Standard​

-Serum complement levels C3, C4, CH50 – analyzed over 15proteins that destroy invading infectious agents ​

Other testing: ​Urinalysis (positive for proteins and RBC’s with renal involvement)​, Serum BUN & Creatinine (Renal involvement)​. CBC (pancytopenia)​

Imaging: Check status/damage to joints, check for infection in the lungs

Lupus: ​Medication management​

NSAIDs (Ibuprofen, naproxen): First line of treatment. Reduce pain, inflammation, and fever ​

-Nursing Considerations: monitor renal and GI function, typically prescribed with GI-acid reducing agents, taken with food, avoid alcohol​

Corticosteroids (Prednisone, methylprednisolone):  Anti-inflammatory drugs that mimic hormones produced by the adrenal glands, don't abruptly stop-taper dose​

-Nursing Considerations: monitor blood glucose and for signs of infection, assess BP and electrolyte balance, taper doses, take with food and what to report to provider (signs of infection or weight gain/swelling. ​

Antimalarial Medication (Hydroxychloroquine): Suppresses synovitis, fever, fatigue and reduces risk of development of skin lesions.​

-Nursing considerations: can cause retinal toxicity and permanent vision loss, encourage frequent eye examinations​

Immunosuppressant agents (methotrexate or azathioprine): suppress immune response​

-Nursing Considerations: monitor for toxic effects (increased liver enzymes) and infection, avoid live vaccines for 30 days prior to starting these medications

Lupus: Impact on Overall Health​

Complications: Impacts so many body systems.​

-Cardiovascular disease​= Pericarditis, myocarditis​, Stroke, Myocardial infarction​

-Chronic kidney disease​

Psychosocial Impact: Chronic pain,Fatigue, Cognitive issues, Anxiety,Depression​

Health promotion and prevention​

-Lupus cannot be prevented​

-Management and suppression of flare-ups is the goal​

-Infection prevention since infections can be a trigger​

Coping strategies​

Considerations of aging​

Lupus: ​Nursing management & Client Education​

Monitor for symptoms like fatigue, joint pain, skin rashes, fever, and organ involvement​

Assess skin for rashes – esp. malar (butterfly) rash and discoid lesions​

Observe for signs of complications (renal, cardiovascular, neuro changes)​

Administer prescribed medications such as NSAIDs, corticosteroids, antimalarials, & immunosuppressants​

Reduce infection risk - aseptic technique - hand hygiene - avoid exposure to sick individuals​

Provide emotional support and counseling - encourage participation in support groups​

Client Education: ​chronic autoimmune disease with flare-ups and remission​, importance of regular follow-up.​ Use sunscreen daily and wear protective clothing – avoid prolonged sun exposure​. balance rest & activity to reduce fatigue - maintain a healthy diet, avoid smoking​. Report new or worsening symptoms such as fever, rash, joint swelling, or breathlessness promptly

Muscular Dystrophy​

Description: a group of inherited genetic disorders characterized by progressive weakness & degeneration of skeletal muscles​

Affected muscles lose strength & function, leading to difficulties with movement, mobility, and, involvement of the heart and respiratory muscles.​

Causes/Risk Factors: Genetic disorder, significant risk factor with family history​

Clinical Presentation: ​Ptosis, impaired chewing and swallowing, loss of muscle mass and replaced with fat & connective tissue causing enlarge calves, waddling gait, difficulty running and climbing stairs, contractures, cardiac involvement in some cases​

Diagnostic Testing: Muscle biopsy (primary test) EMG(indicates origin of muscle weakness), creatinine kinase(elevated)

Muscular Dystrophy: Nursing management & ​Client Education​

no cure - goal of care is to promote mobility and prevent complication​

Develop home care plan to support client and family - ensure safe and optimal home environment for mobility​

Regularly assess muscle strength and respiratory function - monitor for signs of respiratory distress & cardiac complications.​

Evaluate mobility and risk for contractures or skin breakdown​

Encourage PT and gentle passive ROM exercises to maintain muscle function and prevent contractures​

Assist with use of assistive devices (walkers, wheelchairs) ​

Monitor nutritional status and assist with feeding - encourage balanced diet to maintain healthy weight​

Client/Family Education: Monitor for frequent falls​- Seek genetic counseling. Develop home-care program for client and family with family involvement - ensure proper clothing and footwear for client - food preparation

Gout​

Description: buildup of uric acid crystals in the joints - type of inflammatory arthritis, overproduction of uric acid from kidneys.​

-sudden, severe attacks of joint pain, redness, and swelling, most often affecting the big toe. ​

-can become chronic if untreated, leading to joint damage and to phiformation​

-results from hyperuricemia, an excess of uric acid in the blood, due to overproduction or underexcretion by the kidneys​

-Monosodium urate crystals form and deposit in joints and surrounding tissues. Crystals trigger an intense inflammatory response ​

-Repeated attacks can lead to chronic inflammation, joint destruction, and formation of tophi (deposits of urate crystals).​

Causes/Risk Factors: Prolonged fasting, excessive alcohol intake, purine-rich diet, impaired renal function, chemotherapy for leukemia, thiazide diuretics,ASA, TB medications​

Other precipitating factors: dehydration, fever, injury​

Clinical Presentation/Diagnosis: ​Testing: Synovial fluid is analyzed, serum uric acid, 24-hour urine​Assessment: Joint inflammation is very painful, assess for elevated temperature, tenderness and cyanosis of affected areas, inflammation in great toe, multiple joint involvement

Gout: Diagnosis & Treatment​

Acute Attack Management:​ NSAIDs (e.g., ibuprofen, naproxen)​, Colchicine to decrease inflammation​Corticosteroids (oral or injectable) for severe attacks ​

Long-Term Management:​ Urate-lowering therapy to reduce uric acid levels and prevent attacks.- Allopuranol​. Probenecid to increase uric acid excretion ​

Nursing Care and Client Education:​ Monitor pain intensity, joint swelling & ROM​, Monitor serum uric acid levels and kidney function​. Observe for signs of infection or complications​

-Administer prescribed medications, Apply ice packs to affected joints​. Encourage rest of the affected joint - assist with mobility devices​

​Client Education: ​take medications as prescribed – avoid/limit purine-rich foods (red meat, shellfish), alcohol (especially beer), and sugary beverages - encourage hydration to help uric acid excretion - identify early signs of gout attacks and seek prompt treatment​

Scleroderma​

chronic autoimmune connective tissue disorder - hardening and tightening of the skin and involvement of internal organs​

-can be localized (limited to skin) or systemic, affecting multiple organs, involves autoimmune activation causing inflammation and vascular damage​. overproduction of collagen by fibroblasts, resulting in excessive fibrosis (thickening and scarring) of the skin and internal organs​

-vascular abnormalities cause reduced blood flow and tissue ischemia - combination of fibrosis and vascular injury leads to organ dysfunction​

Causes/Risk Factors: ​Genetic, immune, toxin exposure, & other environmental factors​

Clinical Presentation: ​Thickened, tight, and shiny skin, esp. on fingers and face - Raynaud’s phenomenon(color changes and pain in fingers on cold exposure)​

Other Clinical Manifestations: ​Joint stiffness and muscle weakness, difficulty swallowing, acid reflux, SOB, HTN, fatigue, weight loss, malaise, cardiac and renal impairment, protein in urine

Scleroderma: Diagnosis & Treatment​

Diagnosis: ​Clinical evaluation of symptoms​. Testing: ANA, Specific antibody testing, biopsyof organs​

​Medication: ​ Immunosuppressants: Methotrexate, mycophenolate mofetil​

-Vasodilators: Calcium channel blockers (e.g.,nifedipine) ​

-Proton Pump Inhibitors: For gastroesophagealreflux disease (GERD).​

-ACE Inhibitors: To treat HTN and/or scleroderma renal crisis.

Nursing Care and Client Education:​ Keep skin moisturized to prevent dryness and cracking​. Protect from cold to reduce Raynaud’s attacks​

-Regularly assess respiratory, cardiac, renal, and GIstatus​, Monitor for signs of complications.​ Assist with joint care and encourage gentle exercises. Provide emotional support and refer to counseling or support groups​

Client Education: ​importance of ongoing management - smoking cessation - balanced nutrition - regular, gentle exercise - proper skin care/protection​

Paget's Disease​

excessive bone reabsorption​, chronic disorder characterized by abnormal bone remodeling, leading to enlarged, misshapen, and weakened bones​. commonly affects older adults - can involve one or multiple bones, including the pelvis, spine, skull, and long bones​

Causes/Risk Factors: ​Genetic predisposition in 15-40% of cases​. measles as a child is also a risk factor.​

Pathophysiology: ​excessive bone resorption caused by overactive osteoclasts -compensatory increase in osteoblastic activity - leads to rapid disorganized new bone formation​

Clinical Presentation (initially asymptomatic): Abnormal bone remodeling​; Bone pain, bone deformities, fractures due to fragile bones, joint pain and stiffness, nerve pain, numbness, weakness, increased head size​.

Paget’s Disease: Diagnosis & Treatment​

Diagnostic Testing:​ X-ray, Serum alkaline phosphate (positive)​, Bone scan ​

Medication: ​Bisphosphonates: First-line treatment to inhibitbone resorption ​

-Calcitonin: Alternative therapy that helps regulate bone metabolism​

-Analgesics: NSAIDs or acetaminophen to manage pain

Nursing Care & Client Education: ​Monitor pain levels and administer prescribed analgesics - heat or massage as appropriate​. gentle exercise and PT - assist with mobility aids/devices if needed.​ Monitor for signs of fractures or neuro symptoms​

​Client Education: ​Medication adherence and safety​, safe mobility​, prevent falls​, balance diet with calcium and vitamin D​, report signs of worsening condition.

Arthroscopy​

Endoscope used to visualize the status of a joint - used knee &shoulder joints - biopsy or minor repair can be performed​

Performed in the operating room - sterile conditions - local orgeneral anesthesia used​

Indications: joint injury, joint pain, crepitus, instability- clean outto promote for joint to heal.​

Contraindications: Infection of the joint or immobility​

Potential Complications - Infection​

Nursing considerations: Can stop from progression​, Assess dressing, neurovascular status of that joint, pain, color sensation, elevate extrematiy​. Administer pain medication as ordered - ice and elevate extremity​. notify provider of signs of infection, signs of thrombophlebitis, increased joint pain​

Dual-Energy X-ray Absorptiometry​

DEXA scan - most commonly of the hip or spine - can also determine the presence osteoporosis and its severity ​

Two beams of radiation used, patient is provided a score that indicates bone density compared to others with similar demographics​

Indications: Loss of height, bone pain, fractures, age- changes in hormone levels. ​

Contraindications: Pregnant or breastfeeding​

Nursing considerations: ​Remove metal jewelry or objects​, Follow-up is needed if bone loss is indicated to prevent further loss or complication

Electromyography and Nerve Conduction Studies (EMG)​

Determine the presence of and cause of muscle weakness- nerve conduction studies​

Uses electrodes attached to skin or needle electrodes to muscle - oscilloscope records the muscle contraction activity response to stimulus​

Can be done at the beside or EMG lab​

Indications: to diagnose neuromuscular disorders,motor neuron disease or peripheral nerve disorderssuch as carpal tunnel

Other Diagnostic Testing​

Provide detailed images of body structures and surgical hardware ​

Indications: Injuries to tendons or ligaments - fractures to bones​

-X-ray​= Nursing considerations: Assess for pregnancy. ​

-MRI​= Nursing consideration: allergy to contrast, metal implants, jewelry, accessories, or devices, false eyelashes​

-CT Scan​= Nursing considerations: allergy to contrast, ensure adequate fluid intake - assess for pregnancy.​

-Ultrasound​

-Adam’s Test: evaluate for scoliosis- bend over and touch toes, see if have curveture in spine.​

-Stork Test: evaluate for interarticular defects- hands on hip on one leg and streches spine back- pain in lumbar indicates positive test.​

Strain

Injury to a muscle or tendon caused by overstretching or tearing​

Causes: Overuse, sudden twisting, or heavy lifting.​

Clinical Manifestations: Muscle pain, swelling, spasms, limited movement.​

Sprain

Injury to a ligament caused by stretching or tearing.​

Causes: Trauma, fall, sudden twist involving joint​

Clinical Manifestations: Joint pain, swelling, bruising, and instability.​

Risk Factors for Both: Obesity, poor physical conditioning, overuse, previous injury or deformities​

Strains Assessment and Nursing care

First degree: mild inflammation, little bleeding, tenderness​

Second degree: partial tearing of muscle and tendon, impaired muscle function​

Third degree: rupture muscle or tendon, separation from muscle, severe pain and immobility.​

Treatment: Cold/heat, exercise or activity restrictions, NSAIDS, surgical repair ​

Sprains Assessment and Nursing care

First degree: Stretching/slight tear of ligament fibers - mild tenderness andswelling, minimal joint instability​

Second degree: Partial tear of ligament - moderate pain, swelling, bruising,some joint instability​

Third degree: Complete tear or rupture of ligament - severe pain, swelling,joint instability, loss of function.​

Treatment: RICE- rest, ice, compression, elevation, second degree -immobilization, third degree - surgical repair​

Fractures​

Direct injury or a pathological process such as cancer, osteoporosis, or infection ​

-Complete or partial​

-Direct injury or pathological process (osteoporosis- decreased bone density)​

-Open (break in skin) or closed ​

Risk factors: ​Occupation or activities​, traumatic events (MVA or fall)​, softening of bones related to underlying condition​, physiological changes related to aging​. genetic disorders​. repetitive force (stress fractures)​.

Fractures:Impact on Overall Health​

Psychosocial​= Fear of falling​, Economic impact due to disability & ability to afford care​. Increased absences to school and work​

Considerations for Aging Adults​= Increased risk of fractures​, Osteoporosis risk increases with age​. Aging clients - medications that increase risk of falls​

Clinical Presentation and Diagnosis of Fractures​

• Pain at fracture site​

• Swelling​

• Tenderness​

• Bruising​

• Shortening of a limb​

• Deformity​

• Displacement​

Diagnosis: X-ray, MRI​

Nursing Management of a Fracture​

Assess for pain, swelling, deformity, bruising, and loss of function​

“6 P’s” assessment frequently - Pain, Pallor, Polar,Paresthesia (pins and needles), Pulses, Paralysis-KNOW!!​

Immobilize joints above and below - use splints or supports to prevent further injury​

Cover open wounds with dressing​

Elevate fracture extremity, reduces swelling and pain​

Apply ice to affected extremity​

Assist with fracture reduction: reduce & immobilize​

-Closed: external manipulation to realign bones​

-Open: Surgical realignment​

Maintain traction​

Cast care​

What are the 6 Ps assessment for Fractures

Pain, Pallor, Polar, Paresthesia (pins and needles), Pulses, Paralysis

Complications of Fractures​

Integumentary​= Risk of infection​, Pressure ulcers​

Respiratory​= Risk of atelectasis or pneumonia​

Sleep/Rest​= Risk for inadequate rest or sleep​

Compartment Syndrome- KNOW!!​= Impaired circulation that leads to tissue death and nerve injury. Unreleaved pain, parastesis, coolness, pallor to extremity​

Other Complications:​ DVT​, Complex regional =CRPS- severe chronic pain following severe trauma, common in small bone caused, rule everything out first.​ Infection​

-Fat Embolism- chest pain, decrease pulse ox, peteciai on chest- supportive care, fluid ​

Compartment Syndrome

Impaired circulation that leads to tissue death and nerve injury. Unreleaved pain, parastesis, coolness, pallor to extremity​

Treatment and Therapies​

Immobilization ​

-Splint​

-Cast- avoid getting wet​​

-Traction- Skeletal or skin​​

-Fixation​

Surgery= Closed reduction or realignment (Bedside or in the OR)​

-Open reduction is done in the operating room​

-Internal/External Fixation​​

Treatments & Therapies: Nursing Care of a Client in a Cast

fiberglass material with a cotton lining ​

avoid getting cast wet - do not put anything in the cast - trim edges​

keep the affected limb elevated to reduce swelling and pain​

How to best manage pain and discomfort ​

Notify the provider immediately if the cast is too tight, or unrelenting pain in the extremity

Treatments & Therapies: Nursing Care of a Client in a Splint/Immobilizing Devices:

Splints and immobilizers are used to immobilize the fractured area ​

Promote mobility and allowing for free movement​

Splints and immobilizers can be removed for bathing and dressing​

After bathing, skin should be completely dry before reapplying​

Educate client to elevate limb to reduce swelling and pain

Treatments & Therapies: Traction​

Skeletal or skin traction. Methods of stabilizing a fracture and maintaining alignment. Usually short-term, reposition as ordered to prevent pressure injuries.​

Types: ​

• Manual Traction: pulling force applied by hands of provider, temporary and done under anesthesia​

• Skin Traction: Uses adhesive straps, boots, or cuffs attached to the skin - applies a pulling force to align bones or reduce muscle spasms​

• Examples: Buck’s traction, Russell’s traction - used for short-term treatment, 5-10 pound weights.​

• Skeletal Traction: Involves pins, wires, or screws surgically inserted into the bone - stronger, more precise pull for bone alignment - used for longer-term treatment of complex fractures – 5-45 pound weights​

• Balanced Suspension Traction: Combines skeletal traction with slings or supports to suspend the limb and maintain alignment - allows some mobility while maintaining traction​

Goals: prevent soft tissue injury, decrease spasms/pain, correct deformities, realign bone fragments​

Traction: Nursing Management​

Ensure the traction rope and pulley device are free from kinks and wear​

Ensure the weight hangs freely and does not touch the floor​

Maintain skeletal alignment​

Stabilize the weight during repositioning of client​

Skeletal traction - assess pin sites once per shift for manifestations of infection- assess everyshift to monitor for infection​

Skeletal traction - perform pin care once per shift using soap and water​

Encourage client to increase fluid and fiber intake to prevent constipation, UTI or renal stones​

Encourage/teach deep breathing and coughing exercises to reduce respiratory complications ​

Manage pain - encourage proper nutrition - prevent infection ​

Open reduction internal fixation (ORIF) ​

uses hardware and fixation to return the limbto proper alignment​

most common treatment options for fracturesin older adults, facilitates early mobilization​

monitor neuro status distal to the surgical site.Observe site for signs of infection or delayed healing.​

External reduction and closed fixation (ERCF)

may be tried first. ​

Provider manipulates the fracture to reduce it -external hardware or cast used to keep fracture in place ​

Frequent neuro checks distal to fixation site -inspect pin sites daily for redness, swelling,drainage, or odor

Hip Fracture: Nursing Care​

Assessment and Stabilization​= Assess pain level, deformity, and limb alignment​. Medical Emergency - blood supply to bone is often compromised - monitor neuro status - pulses, LOC, skin color, temperature, sensation, and movement​. Immobilize affected leg to prevent further injury - prepare for imaging and surgical intervention​

Pain Management​= Administer analgesics​. Use non-pharmacologic methods like ice packs​

Preoperative Care​= Maintain NPO status as ordered - assess allergies​. Monitor vitals and fluid/electrolyte balance​. Educate client and family about surgery and postop expectations​

Postoperative Care​= Monitor for complications - infection, deep vein thrombosis, pulmonary embolism.​Encourage early mobilization with PT - No hip flexion > 90 degrees –KNOW!​

-Assist with safe transfers and use of assistive devices​. Provide wound care and monitor surgical site​

Prevent Complications​= prevent pressure ulcers​, Promote adequate nutrition and hydration​. Monitor for signs of delirium, especially in older adults​

Back Pain​

Pain experienced along the spinal cord​

-Acute - duration of about 4 weeks​

-Sub-acute - 1 – 3 months​

-Chronic - > 3 months​

Impaired strength, sensation, and reflexes​

Nerve root and/or spinal cord may be affected​

Etiology and Risk Factors​= Disorders of spinal structures are most common causes​

-mechanical - herniated disks, nerve root pain, compression fractures, osteoarthritis, muscle or tendon strain, and spinal stenosis ​

-Less common causes - cancer, infection, inflammation, serious non-mechanical such as abdominal aortic aneurysm, aortic dissection, angina, and meningitis ​

Back Pain: Impact onOverall Health​

Physiological​= One of the most common reasons healthcare is sought​, Leads to potential disability. Changes in lifestyle often needed​

Psychosocial​= Financial burden, reduced work​. Fear of returning to work​. Chronic Pain can lead to anxiety and depression​

Considerations of aging population​= Rule out other conditions such as AAA (Aortic Aneuyrism) or cancer​Medications can affect older clients differently​

Back Pain: Diagnostic Studies​

Stork test​

Adam’s test​

X-ray​

MRI​

CT scan​

Electromyography and nerve conduction velocity-can be done on back pain

Back Pain Treatmentsand Therapies​

Non-Pharmacologic: Rest, massage, PT, stretching, spinal manipulation, immobilization, acupuncture, TENS unit, heat/cold therapy, deep tissue message​

Pharmacologic: NSAIDs, non-opioids, opioids, corticosteroids, muscle relaxants​

Surgery: Open diskectomy, laminectomy, spinal fusion

Treatments & Therapies: Laminectomy​

surgical procedure involving removal of a portion of the vertebra called the lamina ​

relieves pressure on the spinal cord, reduces pain, numbness, weakness, and other neurological related issues.​

Indications; ​Herniated Disc​, Spinal Stenosis​, Tumors​. Bone Spurs​

Laminectomy: Nursing Management​

Assess pain level regularly​

Assess neuro and elimination status​

Administer prescribed analgesics​

Encourage proper positioning to relieve pressure on thesurgical site ​

Maintain sterile technique when changing dressings​

Monitor surgical site for s/s of infection​

Monitor vitals​

Bedrest for the first 24-48 hours - then gradual increase inactivity​

“Rise as unit” when getting out of bed​

Provide PT consultation referral​

Use supportive devices - monitor I & O​

Assess bladder for distention and encourage regulartoileting​

Straight back chairs, log-roll​

Assist with catheter care​

Teach relaxation techniques​

Educate proper body mechanics

Nursing care of clients undergoing Amputations​

Removal of all or part of a limb​

Surgical amputation - Goal to preserve as much tissue as possible while removing infection ornecrotic areas​

Indications: ​Traumatic injury​, Peripheral vascular disease: smoking, uncontrolled diabetes (feet and lower extremities),atherosclerosis​

Clinical Presentation: Pale or necrotic limb, absent pulse, area may not blanche, foul odor ​

Diagnostic Testing: doppler studies, invasive angiogram, ankle brachial index (ABI)​

Amputation: Role of the Nurse​

Safety​= ability to perform previous activities​, consider adaptations to prothesis and mobility following amputation​. properly fitted prosthesis is crucial for maintenance of mobility, Help client to ensure that home environmental is safe, risk reduction ​

Nursing Interventions​= Manage pain​, ROM activities daily, Prevent flexion contracture - avoid elevation of limb​. Connect client with resources such as PT, OT, medical supply​. Monitor for signs of complication such as infection or psychosocial indicators​. Consider psychosocial impact, implement supportive interventions​

Client education​

-Preoperative care​= Prepare client for what to expect​, Include support system​. Teach limb care, dry limb completely after cleansing to avoid skin breakdown​

-Postoperative care​= Management of amputation site​, Assessing for complications such as infection, skin breakdown related to prosthesis​, Assess site daily​. Encourage client to discuss feelings. ​

Crutch Safety and Use

Crutches assist in shifting weight from the legs to the arms and torso when lower limbs are impaired

Weight should be supported by the hands on the grips, not the underarm pads

Underarm pads should sit about how many inches below the armpits to prevent pressure on nerves or blood vessels?

2 inches

Hand grips must allow the elbow to bend approximately?

30 degrees

4 point gait?

Slow pace, requires good coordination

Weight is evenly distributed on both legs

Move the right crutch forward, Move the left foot forward, Move the left crutch forward, Move the right foot forward (similar to walking on all fours)

2 Point gait

Faster than 4-point gait and requires better balance, Partial weight bearing on each foot.

Arm movement simulate natural walking

Move the right foot and left crutch forward at the same time, Move the left foot and right crutch forward at the same time

3 Point gait

Fast gait, weight alternates between the two crutches and the unaffected leg.

Advance both crutches along with the affected foot.

Swing-to gait

Fast gait for clients with paralysis in legs or hips

Risk of muscles atrophy with prolonged use

Advance both crutches together, lift the body using arms, then swing legs to meet the crutches

Swing-Through Gait

Fast gait demanding good balance, coordination and strength

Move both crutches forward simultaneously, Lift body with arms, then swing legs beyond the crutches

Ascending stairs with Crutches

Use tripod position- crutch and unaffected leg form a stable base

Transfer weight to crutches; step up first with unaffected leg

Shift weight to unaffected leg on the step, then bring crutches and affected leg up

Descending stairs with crutches

Maintain tripod stance at the top stairs

Shift weight to unaffected leg

Lower crutches and affected leg to the next step first, then bring unaffected leg down.

Getting into a chair with Crutches

Use chair with armrests placed against a wall for stability

Position unaffected leg centered with chair back.

Hold crutches in hand on affected side; grasp chair arm with unaffected hand

Lean forward, bend knees and hips then sit down

Getting out of Chair with Crutches

Move to the front edge of the chair

Place unaffected leg slightly under or at chair edge

Hold crutches with affected hand and chair with unaffected hand, push down on crutches and chair armrest to stand.

Assume tripod stance to maintain balance before walking.

Cane safety and use

Hold the cane on strong (unaffected) side

Cane height; handle should be align with wrist or greater trochanter; arm slightly bent at elbow.

For four-pronged canes, keep flat side facing the patient and rounded side outward to reduce tripping risk. Always maintain two points of support on the ground

Walking steps; place cane 6-10 inches ahead, move leg to cane, then step forward with strong leg.

Walker Safety and Use

Walker height should match wrist level with arms at sides; elbows slightly bent- 30 degrees.

Returning to sit; Never use walker for assistance when sitting or standing, when standing, use the chair’s arms for support to lower self into chair. Not the walker to Prevent falls.

Walking steps- push walker forward, move weak leg inside the walker, then step forward with stronger leg.