NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)

J.G. GAYATIN, RMT, RN, MAN

FINALS
PPT 1: MUSCULO-SKELETAL  Comminuted- bone that has been broken in three or
more places; napudpod
CONDITIONS  Compression- cause your vertebrae to collapse, making
MUSCULOSKELETAL TRAUMA them shorter; lifting heavy objects
 FRACTURES  Depressed- a break in a cranial bone (or "crushed"
 CONTUSION, SPRAINS, STRAINS portion of skull) with depression of the bone in toward
 JOINT DISLOCATION the brain; flat bone; skull; vehicular accidents
 Epiphyseal- partially involves the physis and then
 People who exercise/athletes = denser bones extends through the epiphysis into the joint; mobility
 Strength= density of bones affected
 “Wolff’s Law”- your bones will adapt based on the - Epiphyseal plate- longitudinal growth of bones
stress or demands placed on them; becomes  Greenstick- bone cracks on one side only, not all the way
denser when it heals through the bone; may part pa nga cartilage
- Ossification- hardening of the bones; incomplete
especially in children (similar to a fresh branch of a
FRACTURE
tree, flexible and not completely ossified)
 Is a complete or incomplete disruption of in the
 Impacted- broken ends of the bone are jammed
continuity of bone structure
together by the force of the injury
 Results when bone is subjected to stress more than it
 Oblique- bone is broken at an angle/diagonally
can absorb
- Nondisplaced- the ends ARE ALIGNED and the
CAUSES
fracture is stable
 Direct blows
- Displaced- the ends are NOT aligned
 Crushing forces
 Open- here is an open wound or break in the skin near
 Sudden twisting motions
the site of the broken bone.
 Extreme muscle contraction
EFFECT TO SURROUNDING STRUCTURES  Pathologic- caused by disease, often by the spread of
cancer to the bone; brittle, spontaneously cracks, no
 Soft tissue edema
crushing force
 Hemorrhage into muscles and joints
 Simple- a fracture that does not penetrate or protrude
 Joint dislocation
through the skin
 Ruptured tendons
 Spiral- twisting motion
 Severed nerves
 Stress- tiny cracks caused by repetitive force; heavy
 Damaged blood vessels
objects
 Injury  edema (leakage of fluid into tissues)  Transverse- horizontal; line of the break goes all the way
 Tendons- attaches muscles to bones through the bone; complete fractures
If a tendon ruptures = bone dislocation  Linear- vertical; there is a break but it doesn’t move the
 Ligaments- attaches bones to bones; tougher than bone; common in skull
tendons
 Sprain & strains- pwede pa sa hilot but fractures
must be referred to a physician STAT!
CLASSIFICATION OF FRACTURES
1. Location
- Proximal, Midshaft, Distal
2. Type of Fracture
- Greenstick, comminuted, etc.
3. Extent of Fracture
- Closed Fracture (Simple Fracture)
- Open Fracture (Complex or Compound Fracture)
- Intra-articular Fracture
In Long Bones,
 Epiphysis- edge
 Diaphysis- midshaft

TYPES OF FRACTURES
 Avulsion- a bone fragment separates from the rest of
the bone by a soft tissue attached to it; pulling force

LORRAINE ANNE SABLA-ON,SN CSAB 1

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
CLINICAL MANIFESTATIONS
 Pain
 Loss of Function
 Deformity
 Shortening
 Crepitus- grinding, popping, crackling sound of a joint
 Localized Edema and Ecchymosis

EMERGENCY MANAGEMENT
 Immobilization –splinting and bandaging.
- When removing clothing at the Emergency  When traveling, inform security that a fixator is
Department patient’s clothing can be cut away present
from uninjured side to injured side. Fractured  MRI can’t be performed with internal fixators
extremity should be moved as little as possible to  Elevate the affected extremity only for 5-10 minutes
avoid more damage. then rest.
 Assessment of neurovascular status. (Pain, Pulse,  Impaired comfort, Impaired mobility
Pallor, Paresthesia, Paralysis, Poikilothermia)
 Cover injured area with sterile dressing (for open  Immobilization
fractures).  Internal fixation –internal fixators
 External fixation -bandages, casts, splints,
 Do not move the area.
continuous traction and external fixators
 Check for s/sx of the injury
 Maintaining and Restoring Function
 Immobilize
 Reduction and Immobilization –to promote bone
 Check neurovascular status (6Ps)- assess everyday
and tissue healing
 Compress the area proximal to the site
 Managing Edema –elevate injured extremity and
- Use tourniquet to stop the bleeding
ice application as prescribed
 Pain- injured/compressed nerves
 Monitoring of neurovascular status
 Paresthesia- numbness
 Management of restlessness, anxiety and
 Paralysis- difficulty moving distal part
discomfort –reassurance, position changes, pain
 Pulse- injured blood vessel
relief strategies and medication
 Pallor- bleeding
 Isometric and Muscle setting exercises –minimize
 Poikilothermia- compromised circulation; affected
atrophy and promote circulation
extremity is colder;  Blood flow
 Participation in ADLs and gradual resumption of
activities as advised.
MEDICAL MANAGEMENT
 Passive ROM- Movement applied to a joint solely by
 Fracture Reduction –restoration of the fracture another person or persons or a passive motion
fragments to anatomic alignment and positioning. Done machine; no muscle contraction by the patient
as early as possible to prevent loss of elasticity of tissues  Active ROM- movement of a joint provided entirely
by hemorrhage and edema. by the individual performing the exercise. In this
- Closed Reduction –bones are brought to anatomic case, there is no outside force aiding in the
alignment though manipulation and manual movement
traction. Cast, splint and or traction devices are - Isotonic- “same tension”; weight on muscles
used to stabilize. X-rays are done to verify that bone stays the same; shortens muscles (e.g flex
fragments are properly aligned. elbowshortens biceps); to build strength
- Open Reduction –Fracture fragments are aligned - Isometric- “same length”; engages the muscle
through surgical approach. Internal and/or without muscle shortening (e.g. pushing against
external fixation devices (metallic pins, wires, the wall); to increase strength and endurance
screws, plates, nails or rods) may be used to hold
the bone fragments in position until solid bone
healing occurs. HYPERBARIC OXYGEN CHAMBER- used to speed up
 Traction- to restore the length of the bone; esp. in healing of wounds and other medical conditions by
impacted fracture supplying you with 100% oxygen inside the special
 Internal Fixators- to set and stabilize the fractures chamber; 3 minutes- 2 hours
bones; not removed except if it causes symptoms
or complications
 External Fixators- removed
LORRAINE ANNE SABLA-ON,SN CSAB 2
NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
NURSING MANAGEMENT (CLOSED FRACTURES)
 Patient Education:  Occur within 24-72 hours after the injury
 Methods to control edema and pain Epiphysis- red bone marrow (hematopoiesis)
 Exercises to maintain health of unaffected muscles Diaphysis- yellow bone marrow (fats)
and increase strength of muscles needed for
transferring and using assistive devices (crutches, Cracked bones  parts of yellow bone marrow goes
walkers and special utensils) to blood stream fat
embolismclogsalveolipulmonary
 How to use assistive devices safely (c/o Skills Lab)
embolismmay need to intubate pt.
 Self care, medication information, potential
complications.
Delayed Complications
 Maintain independent functioning
 Delayed union
NURSING MANAGEMENT (OPEN FRACTURES)  Malunion
 Risks: Osteomyelitis, Tetanus, Gas Gangrene  Non-union
 Main Goal: Prevent Infection and promote healing  Avascular Necrosis/ AVN of bone
 Complex Regional Pain Syndrome/ CRPS (aka Reflex
 Wound Irrigation and Debridement
Sympathetic Dystrophy)
 Minimize edema
 Heterotrophic Ossification
 Monitor neurovascular status
 Clostridium tetani- tetanus
 Pseudomonas aeruginosa- gas gangrene Manifested after 72 hours to months
Most important health education to prevent infection: Delayed Union- takes longer to heal
- hygiene- aseptic technique - Common healing time (3-6 months)
- Monitor neurovascular status Malunion
- bone fragments unite but not reduced to
its original anatomical composition
FRACTURE HEALING AND COMPLICATIONS - if bone is not splinted properly, cast not
Fracture healing takes weeks to months depending on applied properly, fracture not managed
the type and extent of fracture. Factors that affect properly
healing include: - makes it look like its “bent”
 Vascularity (blood supply) of the area Non-union
 Presence of infection - not reduced to anatomical alignment
 Adherence to treatment - body’s inability to heal a fracture
 Malignancy - caused by infection, malignancies
 Medications (e.g. corticosteroids) Avascular Necrosis
 Age
- aka “osteonecrosis”; death of bone tissue
 Other disease processes (malignancies)
due to lack of blood supply
CRPS
 Adequate blood supply distal to the affected - chronic pain caused by nerve damage
area - nerves doesn’t heal as perfectly as other
1. Check capillary refill (<2 secs) tissues scar formation
2. Check temperature (must be warm) - on post fracture pt. (pain during temp.
 Encourage aseptic technique changes, unusual impulses)
 Completion of antibiotic therapy- infection with Heterotrophic Ossification
resistant organisms - the formation of extraskeletal bone in
muscle and soft tissues.
- Common in comminuted fractures
Early Complications
 Hypovolemic Shock (Hemorrhage)
 Fat Embolism
 Venous Thromboembolism/ VTE 9e.g. Deep Vein FAT EMBOLISM SYNDROME (FES)
Thrombosis/ DVT)
 Occurs when fat emboli enter the circulation following
 Pulmonary Embolism
orthopedic trauma (especially long bones). Fat Globules
may occlude small blood vessels that supply blood to
lungs, brain, kidneys and other organs.

LORRAINE ANNE SABLA-ON,SN CSAB 3

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS

Clinical manifestations: (FES Triad) OSTEOMYELITIS

1. HYPOXEMIA –s/s: hypoxia, tachypnea, dyspnea  An infection of the bone that results in inflammation,
with tachycardia, substernal chest pain, low grade necrosis and formation of new bone.
fever, crackles, respiratory failure, ARDS  Most common causative agent is Staphylococcus aureus
2. NEUROLOGIC COMPROMISE–s/s: restlessness, and MRSA. Other pathogens include streptococci,
agitation, seizures, focal deficits & encephalopathy enterococci and pseudomonas
3. PETECHIAL RASH –result of microcirculation and/or
thrombocytopenia (commonly assessed on chest
and mucous membranes) Staphylococcus aureus
Prevention and Management: Methicillin-resistant Staphylococcus aureus (MRSA)
 Immediate immobilization, fixation, minimal - normal flora on the skin
fracture manipulation, proper turning and - when it gets to the muscles infection
positioning. - needs higher antibiotics to manage
 Maintenance of fluid and electrolyte balance Streptococci- saliva; normal flora in the mouth/buccal
 Treatment (supportive): vasopressors, mechanical cavity
ventilation, sometimes corticosteroids) Enterococci- normal flora in the GI
Pseudomonas- unsterile equipmenthospital acquired
COMPARTMENT SYNDROME wound infection
 Characterized by elevation of pressure within an
anatomic compartment that is above normal perfusion CLASSIFICATION OF OSTEOMYELITIS
pressure resulting to neurovascular compromise. When
 Hematogenous Osteomyelitis (due to bloodborne
perfusion to tissues is impaired it may lead to cell death,
spread of infection)
tissue necrosis and permanent dysfunction.
 Contiguous-focus osteomyelitis (due to contamination
 Assessment and Diagnosis: Checking of 6 P’s, use of
from bone surgery, open fracture or traumatic injury
tissue pressure monitoring device
[e.g. gunshot wound])
 Medical Management: Bi-valving of cast or opening of
 Osteomyelitis with vascular insufficiency (seen most
splint, Fasciotomy
commonly among patients with diabetes and peripheral
 Nursing Management:
vascular disease, most commonly affecting the feet)
 Regular Monitoring of pain and neurovascular ASSESSMENT
status
 High fever, chills, increased pulse, general malaise
 Limb should be maintained in a functional position
 Infected area becomes painful, swollen and extremely
at the level of the heart to promote optimal blood
tender
flow
 Patient may describe a constant pulsating pain that
 Assessment of intake and output, urinalysis (to
intensifies with movement
detect development of rhabdomyolysis)
 Chronic osteomyelitis presents with a non-healing ulcer
 Patient Education
that overlies the infected bone with a connecting sinus
that will intermittently and spontaneously drain with
 Enclosure can’t expand, not elastic pus.
2 possible compartments/sources
1. Compartment surrounding muscles
Fascia- covers muscles, not elastic
- Injuredswellingleakage of blood
- As swelling increases, fascia can’t
expandnerves & blood vessels are
compressed compromised circulation
(check 6 Ps)
 Fasciotomy- fascia is cut to relieve pressure DIAGNOSIS
2. Cast  Radio Isotope Bone Scan (Isotope Labeled WBC Scan)
- Irritated skininfection (esp. in  MRI
children)swelling & pus  Leukocytosis and Elevated ESR
formationpressurecompressed  Wound and Culture Studies
nerves blood vesselsblood flow  X-ray
 Remove a portion of the cast in both sides to  Anemia Associated with Chronic Infections
relieve pressure
 Meds for infection
LORRAINE ANNE SABLA-ON,SN CSAB 4
NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS

 ESR- infection Knowledge Deficit

 Culture studies- causative agent  Importance of adhering to antibiotic therapy and
 Sensitivity- medication/ antibiotic appropriate and weight bearing limitations
effective  Wound dressing procedure (Home wound care)
following aseptic technique
 Sequestrectomy & Curettage- replace with
 Importance of follow-up check up
compatible tissue
 Debridement- remove necrotic tissue
- Ensure healing; exposes healthy tissues to
regenerate
CONTUSIONS, SPRAINS, STRAINS
MEDICAL MANAGEMENT  CONTUSION–a soft tissue injury produced by blunt
 Antibiotics –longer because bone is mostly avascular force causing small blood vessels to rupture and bleed
and less accessible to the body’s immune response. into soft tissues (ecchymosis or bruising)
 Surgical Debridement
 Sequestrectomy; Saucerization
 Closed Suction Irrigation; Wound Irrigation
 Cancellous Bone Graft
 Microsurgery –to enhance blood supply
 External Supportive Devices

NURSING MANAGEMENT
 STRAIN –injury to muscle or tendon from overuse,
Acute Pain
overstretching or excessive stress.
 Immobilization; Splinting
 Monitor skin and neurovascular status
 Elevation to reduce swelling and discomfort
 Administer analgesics as prescribed
 Pain reducing techniques

Impaired Physical Mobility

 Restrict weightbearing activity, avoid bone stress
 Encourage full participation in ADLs within prescribed
limitations

Risk for Infection

 Monitor response to antibiotic therapy
 Monitor for signs of superinfection
 Ensure adequate circulation to the area
 Aseptic technique

LORRAINE ANNE SABLA-ON,SN CSAB 5

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
 SPRAIN–injury to the ligaments and tendons that
surround a joint caused by a twisting motion or
hyperextension of a joint.

Note: Strains and Sprains are graded as: first degree (mild),
second degree (moderate), and third degree (severe)
Strain
- Muscle & tendons; milder than sprain
- 3-5 days to get better
- Without proper stretching before 7 after
exercise/activity
Sprain
- Ligaments and tendons (poor blood supply)
- 1-2 weeks
- Natipalo, na twist and joint, hyperextend
Elevate for 5-10 minutes

DISLOCATION
 A condition in which the articular surfaces of the distal
and the proximal bones that form the joint surfaces are
no longer in anatomic alignment. “Bones are out of
joint”
 Manifestations: acute pain, change/awkward
positioning of joint and decreased ROM
 SUBLUXATION–is a partial dislocation and does not
cause much deformity as a complete dislocation.

LORRAINE ANNE SABLA-ON,SN CSAB 6

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
 Phantom Limb Pain –disruption of the neuronal
pathways causing neuroplastic changes that results to
changes in cortical representation (the proprioceptive,
tactile and visual image of the body parts as perceived
by the cerebral cortex
 Joint Contracture –caused by positioning and a
protective flexion withdrawal pattern associated with
pain and muscle imbalance.

MEDICAL MANAGEMENT & REHABILITATION

NOTE:  GOAL: Healing of the amputation wound to a nontender
 Traumatic dislocations are orthopedic emergencies residual limb with healthy skin for prosthetic use.
because associated joint structures, blood supply and  A rigid cast dressing, removable rigid dressing or an
nerves are displaced and may be entrapped with elastic residual limb shrinker are used to provide
extensive pressure on them. uniform compression, support soft tissues, control
 If not reduced immediately, it can result to AVASCULAR pain an edema and prevent contractures.
NECROSIS (AVN) caused by ischemia which leads to - To prevent flexion deformity (contracture), the
necrosis and death of bone cells. residual limb should not be held up in a flexed
Nursemaid’s Elbow- toddler/children position.
- the ligament that holds the radius in place at  Rehabilitation is a collaborative effort geared towards
the elbow joint slips and the end of the radius helping the patient achieve the highest possible level of
shifts out of position. As a result, the elbow function and participation in life activities.
becomes partially dislocated.
NURSING INTERVENTIONS
Hip joint injuries- OR- anesthesia Assessment
 Neurovascular and Functional Status
 Nutritional Status
MEDICAL AND NURSING MANAGEMENT FOR
 Concurrent Health Problems
DISLOCATIONS
 Psychological Status
 Immobilize as soon as possible Diagnosis and Planning
 Reduce promptly- dipalces parts are placed back in  Acute Pain
proper anatomic position to preserve joint function
 Impaired Skin Integrity
 Analgesics, muscle relaxants and possible anesthesis are
 Disturbed Body Image
sued to facilitate reduction.
 Grieving / Risk for Grieving
 Monitoring of neurovascular status every 15 minutes
 Self-Care Deficit
until stable.
 Impaired Physical Mobility
 Progressive active and passive movement to preserve
ROM and restore strenght. Joint is supported between
NURSING MANAGEMENT
exercise sessions.
1. Relieving Pain; Phantom Limb Pain
 Educate patient and family regarding proper exercise
 Proper positioning; light sand bags on the residual limb
and activities and signs of complications (e.g.
to counteract muscle spasms
compartment syndrome). Prompt referral
 Administer analgesics as prescribed
 Evaluate pain and response to pain
 Mirror Therapy, Massage, Biofeedback, acupuncture,
AMPUTATION
repositioning, TENS, guided imagery, virtual reality
 Removal of a body part, often a digit or a limb
 Used to relieve symptoms, improve functioning or to
Phantom Limb Pain- contains nerves that is still connected
save/improve the patient’s quality of life
to spinal nerves
 Performed at the most distal point that will heal 2. Promoting Wound Healing
successfully
 Dressing changes; Aseptic Technique
 Application of consistent pressure. Keep TORNIQUET at
COMPLICATIONS
bedside.
 Hemorrhage
 If the cast or dressing comes off, immediately wrap
 Infection
residual limb with elastic compression bandage.
 Skin Breakdown (esp. if with prosthesis)

LORRAINE ANNE SABLA-ON,SN CSAB 7

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
3. Enhancing Body Image  Occupational factors-Repetitive tasks, overworking the
 Encourage patient to care for the residual limb joints and overtiring muscles that protect a joint
 Help patient regain independent level of functioning increase the risk for OA in that joint.
 Allowing expression of Grief  Genetics-osteoarthritis in all its various forms appears
 Introducing to local support groups to have a strong genetic connection. Gene mutations
may be a factor in predisposing individuals to develop
4. Helping Patient to Resolve Grieving OA.
 Create an accepting and supportive atmosphere
 Allow expression of feelings
 Orient to realistic rehabilitation goals and future
independent functioning
 Introduce to mental health and spiritual care support
groups

5. Promoting Independent Self Care

 Allow and give time to participate in self care. Provide
assistance only when needed.
 Maintain positive attitude and minimize fatigue and
frustration during the learning process

6. Helping Patient Achieve Physical Mobility

 Proper positioning and transfer techniques
 ROM Exercises; Exercise and Strengthen muscles to be PATHOPHYSIOLOGY
used for assistive devices.  characterized by remodeling of the anatomy of the joint
 Assess and enhance strength and endurance & proliferation of new bone, cartilage & connective
tissues in the form of osteophytes, as well as by local
 Modify environment.
degeneration of articular cartilage.
 Teach proper use of assistive devices and/or prosthesis
 Symptomatic failure of the joint characterized by
progressive degeneration of the articular cartilage with
fibrillation, fissuring, ulceration and eventually full
thickness focal loss of articular cartilage at sites of joint
loading

PPT 2: MUSCULO-SKELETAL
CONDITIONS
ARTHRITIS
Osteoarthritis
Gouty Arthritis (Gout)
Rheumatoid Arthritis

OSTEOARTHRITIS
 A degeneration & atrophy of the cartilage &
calcification of the ligaments
 Primarily affects the weight-bearing joints, spine & CLINICAL MANIFESTATIONS
hands  Pain, stiffness and muscle spasms, which are more
ETIOLOGY pronounced after exercise, at night and in the early
 Osteoarthritis is associated with obesity, aging, trauma, morning
genetic predisposition and congenital anomalies.  Limited motion in affected joints
RISK FACTORS  Joint “grating” or “grinding” with movement (Crepitus)
 Obesity-Generally, the more weight a person carries,  Deformity; Flexion contractures, primarily in the hip and
the greater the pressure on weight-bearing joints of the knee
body.  Joint tenderness
 Past injury in a joint-There is an increased risk of  Heberden’s & Bouchard’s nodes
developing OA in a joint that is not properly aligned or  Bony growths “Bone Spur”
one that has been injured.

LORRAINE ANNE SABLA-ON,SN CSAB 8

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
 Health and behavior modifications -physical therapy,
exercise, weight loss.
 Administration of medications (Nursing Considerations)

GOUTY ARTHRITIS
 Gouty arthritis is a metabolic disease marked by urate
crystal deposits in joints throughout the body, causing
local irritation and inflammatory responses.
 Commonly affects men older than age 30.
PATHOPHYSIOLOGY:
 Disorder in purine metabolism that leads to high levels
of monosodium uric acid in the blood & the deposition
of uric acid crystals (tophi) in tissues, especially joints;
DIAGNOSIS followed by an inflammatory response
 Signs and symptoms
 History and physical examination ASSESSMENT
 X-Rays  Sudden attacks, usually at night, with periodic
 Blood Tests remissions and exacerbations
 Analysis of Joint Fluid  Pain, usually monoarticular, acute, crushing and
ARTHROSCOPY pulsating
 a day surgery that is done using instruments and a  Joint edema and inflammation
camera that are placed into the joint through small  Tophi
holes.  Intolerance to the weight of the bed linens over the
 Arthroscopy can be helpful to both diagnose and treat affected joint
arthritis.  Pruritus or skin ulceration over the affected joint
 Recovery from knee arthroscopy is much faster than  Signs of renal involvement (oliguria, low back pain,
recovery from traditional open knee surgery. hypertension) in severe disease
 In most cases arthroscopy is not a permanent solution
to arthritic joint pain. LABORATORY AND DIAGNOSTIC STUDY FINDINGS
 Arthrocentesis reveals urate crystals in synovial fluid
MEDICAL MANAGEMENT (Polarized light microscopy of synovial fluid)
Nonsurgical  Serum uric acid level is increased (NV: 2.5–7.0 mg/dl)
 Health and behavior modifications -physical therapy,  Radiograph may show joint damage in advanced
exercise, weight loss. disease,
 Drug therapy –Paracetamol; NSAIDS; COX2 Inhibitors
Glucosamine and/or chondroitin sulfate; Opioid and MEDICATIONS
narcotic analgesic  Allopurinol
 Intra-articular injections –steroids, hyaluronates  Colchicine NSAIDS, COX2 Inhibitors
(viscosupplementation)  Intra-articular injection of hyaluronate can be helpful if
Surgical not responsive to steroids
 Arthroscopy -Day surgery, done through small holes  Glucosamine and/or chondroitin sulfate
 Arthroplasty -Total Joint Replacement  Opioid and narcotic analgesics

SURGICAL INTERVENTION INTERVENTIONS

 Synovectomy –removal of the enlarged synovial SURGICAL
membrane before bone & cartilage destruction occurs  Synovectomy
 Arthrodesis –fusion of a joint performed when the joint  Arthrodesis
surfaces are severely damaged  Reconstructive Surgery
 Reconstructive surgery –replacement of a badly MEDICAL
damaged joint with a prosthetic device.  Heat packs, ice packs TENS on affected joints
 Exercise of affected extremities
NURSING MANAGEMENT OF OSTEOARTHRITIS
 Pain Management
 Optimal Functional Ability
 Use of Assistive Devices

LORRAINE ANNE SABLA-ON,SN CSAB 9

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
NURSING MANAGEMENT  Positive C-reactive protein & antinuclear antibody (ANA)
 Administration of anti-inflammatory & antigout agents test
 Alkaline-ash diet to increase the pH of urine to
discourage precipitation of uric acid & enhance the
actions of drugs.
 Elimination of foods high in purines such as organ
meats, shellfish & beans
 Weight loss is encouraged
 Instruct the client to rest the joint during attacks
 Carefully align joints so they are slightly flex during acute
stage; encourage regular exercise, which is important in
long term management.
 Increase oral fluid intake to 2000 to 3000 ml daily to
prevent calculi formation.
 Provide education regarding drug therapy & avoidance
of excess alcohol intake
MEDICAL AND SURGICAL MANAGEMENT
RHEUMATOID ARTHRITIS  Corticosteroids, anti-inflammatory, analgesics,
 RA is a chronic, systemic inflammatory disorder that immunosuppressive drugs.
may affect many tissues and organs, but principally  Physiotherapy to minimize deformities
attacks the joints producing an inflammatory synovitis  Application of heat; paraffin dips
that often progresses to destruction of the articular  Surgical intervention (e.g. hip replacement)
cartilage and ankylosis of the joints
 Characterized by inflammatory changes in the body’s NURSING MANAGEMENT
connective tissue, particularly areas that have a cavity &  Promote rest & position to ease joint pains
easily moving surfaces.  Performs ROM exercise up to the joint pain, recognizing
 Cause is unknown although theories include that some discomfort is always present
autoimmunity  Emphasize the need to remain active, but incorporate
rest periods
 Encourage client to verbalize feelings
 Encourage use of assistive devices to help conserve
energy & maintain independence
 Encourage diet rich in nutrient-dense foods such as
fruits, vegetables & whole grains
 Apply warm compress as ordered
 Administer medications as ordered

ASSESSMENT
SIGNS AND SYMPTOMS:
 Stiffness after periods of inactivity, particularly in the
morning
 Joint pain
 Paresthesia
 Joint inflammation & deformity
DIAGNOSTIC TESTS:
 Elevated ESR
 Presence of rheumatoid factor
LORRAINE ANNE SABLA-ON,SN CSAB 10
NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
PPT 3: MUSCULO-SKELETAL  Vit. D – Adults up to 70 y.o. = 600 IU/day; 71 y.o. above
= 800 IU / day
CONDITIONS  Biphosphonates, estrogen agonists/antagonists,
OSTEOPOROSIS receptor activator of nuclear factor kappa-B ligand
 A bone disease characterized by reduce bone mass, (RANKL) inhibitors
deterioration of the bone matrix and diminished bone 2. Regular Weight Bearing Exercises
architectural strength. 3. Fracture Management
 Bone resorption (by osteoclasts) > Bone Formation (by  E.g. Spine = Percutaneous vertebroplasty / kyphoplasty
osteoblasts) =  total bone mass
NURSING MANAGEMENT
 Bones become progressively porous, brittle and fragile.
 Acute Pain r/t fracture, muscle spasms
ANATOMY & PHYSIOLOGY REVIEW:  Risk for constipation r/t immobility
 Osteoblast and Osteoclast Activity  Risk for injury r/t additional fractures
 Vitamin D = Calcitriol  Deficient knowledge
 Hormone Levels:  Patient Education: Prevention is better than cure!
- Calcitonin
- Parathyroid Hormone (PTH)
- Estrogen

RISK FACTORS:
 Small frame, Low BMI
 Age; Menopause; decreased estrogen
 Poor nutrition
 Gastrointestinal diseases; malabsorption
 Lack of activity/weight bearing exercise; sedentary
lifestyle
 Smoking and alcohol
 Family History
 Medications: e.g. corticosteroids

ASSESSMENT:
Manifestations:
 Fractures (compression fractures of the vertebrae, hip
fractures, Colle’s fracture)
 Kyphosis (Dowager’s hump)
Diagnostics:
 DEXA – Dual-Energy X-ray Absorptiometry = reveals 
BMD = osteopenia
 FRAX – Fracture Risk Assessment Tool
 Laboratory Studies: minerals, hormone levels

LOW BACK PAIN

 Low back pain is a symptom, not a disease, and has
many causes.
 It is generally described as pain between the costal
margin and the gluteal folds
 Characterized by an uncomfortable or acute pain in the
lumbosacral area associated with severe spasm of the
paraspinal muscles, usually with pain radiating to the
lower back
MEDICAL MANAGEMENT:
1. Medications: COMMON CAUSES OF LOW BACK PAIN
 Calcium – Women 50-70 y.o. = 1000 mg / day; 71 y.o. MUSCULOSKELETAL
above = 1200 mg/day  Scoliosis, Osteoporosis, osteoarthritis of the spine
 Disc Herniation, intervertebral disc problems,
LORRAINE ANNE SABLA-ON,SN CSAB 11
NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
 Myofascial Pain Syndrome
 Retroperitoneal tumors- rare growths that
 Strains
originate from within the retroperitoneal spaces
 Unstable lumbosacral ligaments and weak muscles
rather than the major retroperitoneal organ
 Unequal leg length
 Abdominal aortic aneurysm- happens when the
 Spinal Stenosis
main artery that carries blood from the heart to
 Nerve root compression; Sciatica; Radiculopathy
the tummy (the aorta) becomes weakened.
Causes a bulge in the part of your aorta that runs
OTHERS/NON-MUSCULOSKELETAL
through your belly. It usually causes no
 Depression
symptoms, but some people have deep pain in
 Smoking their lower backs or a pulsing sensation in their
 Alcohol abuse bellies
 Obesity
 Stress
ASSESSMENT
 Poor Posture
 Pain
 Kidney disorders, pelvic problems, retroperitoneal
 Location (axial or peripheral/neurogenic) ; character;
tumors and abdominal aortic aneurysm
severity; timing, including onset, duration, and
frequency; alleviating and aggravating factors; and
associated signs and symptoms.
 Paresthesia, numbness and weakness of lower
extremities, sensation, muscle strength
 History
 Effect of pain on ADLs

DIAGNOSTICS
 Plain Radiography; X Ray of the Spine – to detect
fractures, dislocation, infection, scoliosis, osteoporosis
 Bone Scan and Bone studies – to detect infections,
tumors and marrow abnormalities
MEDICAL VOCABULARY ENHANCEMENT  Magnetic Resonance Imaging to detect any pathology (
 Disc Herniation- a condition affecting the spine in disk herniation, soft tissue injury)
which the annulus fibrosus is damaged enabling the  Computed Tomography of the spine to detect arthritic
nucleus pulposus (which is normally located within changes, degenerative disk disease tumor & other
the center of the disc) to herniate. This can abnormalities
compress the nerves or spinal cord causing pain and  Myelography to confirm and localize disk herniation
spinal cord dysfunction.  Electromyography – to detect nerve changes related to
 Myofascial Pain Syndrome- chronic condition that back pathology
affects your muscles and the fascia (thin  Ultrasound to detect tears and other forms of injury to
connective tissue) around them. the ligaments, muscles, tendons and soft tissues
 Spinal Stenosis- happens when the space inside the MEDICAL MANAGEMENT
backbone is too small. This can put pressure on the Pharmacologic:
spinal cord and nerves that travel through the spine.  Analgesics: NSAIDS, Opioids
Spinal stenosis occurs most often in the lower back  Muscle Relaxants
and the neck. Some people with spinal stenosis have  Antidepressants (given for radiculopathy)
no symptoms  Anticonvulsant
 Sciatica- a type of nerve pain, which is usually a  Lidocaine Patch
burning, stabbing or shooting feeling. It radiates
from your buttock down the back of your leg. It Non-Pharmacoclogic:
often gets worse when you walk, cough, strain on  Rest and avoidance of strain
the toilet or go up stairs. Most people only have  Thermal Applications (hot or cold)
symptoms in one leg.  Spinal Manipulation (chiropractic therapy)
 Radiculopathy- Commonly referred to as a pinched  Lumbar Support, Traction
nerve, radiculopathy is injury or damage to nerve  Orthopedic shoe inserts
roots in the area where they leave the spine  Physical therapy, TENS acupuncture, Massage
 Cognitive Behavioral (e.g. yoga, biofeedback)

LORRAINE ANNE SABLA-ON,SN CSAB 12

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
SURGICAL MANAGEMENT PROPER POSTURE AND BODY MECHANICS
Surgical Interventions:
1. Laminectomy
2. Spinal Fusion
3. Diskectomy

NURSING DIAGNOSIS
 Acute / Chronic Pain
 Impaired Physical Mobility

NANDA Domains on:

 Activity/Rest – e.g. Sleep Deprivation
 Role Relationships – e.g. Impaired Parenting
 Self Perception – e.g. Situational Low Self Esteem

NURSING INTERVENTIONS:
Relieving Pain
1. Advice to stay active & avoid bed rest, in most cases
2. Non pharmacologic measures to relieve pain (DBE,
diversional activities, backrub)
3. Keep pillow between flexed knees while on side lying
position
4. Apply heat (moist towels; hydrocollator packs) or ice as
prescribed
5. Administer medication (refer to pharmacologic
interventions)
Promoting Motility
1. Encourage Rom of all uninvolved muscle groups.
2. Suggest that gradual increase of activities & alternating
activities with rest in semi-fowlers position
3. Avoid prolonged periods of sitting, standing or lying
down
4. Encourage patient to discuss problems that may be
contributing to backache
5. Encourage patient to do prescribe back exercises

PATIENT EDUCATION & HEALTH MAINTENANCE

 Use good body mechanics when standing, sitting &
lifting or moving about
 Alternate periods of activity with periods of rest
 When standing for any length of time, rest one foot on
a small stool or platform to relieve lumbar lordosis
 Avoid fatigue which contribute to spasms of back
muscles
 Daily exercise is important in the prevention of back
problem
1. Do prescribe back exercises twice daily
2. Walking outdoors is recommended
3. Lose Weight as recommended

LORRAINE ANNE SABLA-ON,SN CSAB 13

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
PPT 4: MUSCULAR DYSTROPHY CLINICAL MANIFESTATION

MUSCULAR DYSTROPHY
 Muscular dystrophy is a group of inherited diseases
characterized by weakness and wasting away of muscle
tissue, with or without the breakdown of nerve tissue.
 Muscles, primarily voluntary muscles, becomes
progressively weaker
 In some types of muscular dystrophy, heart muscles,
other involuntary muscles and other organs are affected
 The most well known of the muscular dystrophies is
Duchenne muscular dystrophy (DMD), followed by
Becker muscular dystrophy (BMD).

PATHOPHYSIOLOGY
Dystrophin is responsible for
connecting the cytoskeleton
of each muscle fiber to the
underlying basal lamina. The
absence of dystrophin stops
calcium entering the cell
membrane affecting the
signaling of the cell, water
enters the mitochondria
causing the cell the burst.

 dystrophin absence
leads to poor muscle
fiber regeneration
 progressive replacement of muscle tissue with fibrous
and fatty tissue
 skeletal and cardiac muscle lose elasticity and strength
 Genetics
 X-linked recessive
 Xp21.2 dystrophin gene defect due to point deletion and
nonsense mutation
 one third of cases result from spontaneous mutations

PHYSICAL ASSESSMENT
 Calf pseudohypertrophy (infiltration of normal muscle
with connective tissue)
 Deep tendon reflexes present (unlike spinal muscular
atrophy)
 Lumbar lordosis
- compensates for gluteal weakness
 Gower's sign
- rises by walking hands up legs to compensate for
gluteus maximus and quadriceps weakness
 Trendelenburg sign

LORRAINE ANNE SABLA-ON,SN CSAB 14

NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS
LABORATORY type of corticosteroid, is a standard of care among DMD
 Elevated CPK levels (10-200x normal) patients.
- CPK leaks across defective cell membrane  The use of steroids has been shown to help improve
 Muscle biopsy muscle strength and function, delay the loss of
- will show connective tissue infiltration and foci of ambulation, and help maintain cardiac and respiratory
necrosis function
- will show absent dystrophin with staining
 DNA testing NURSING DIAGNOSES
- shows absent dystrophin protein  Ineffective airway clearance related to muscle weakness
 Electromyography (EMG) and decreased ability to cough.
- Myopathic  Impaired physical mobility related to muscle weakness
- decreased amplitude, short duration, polyphasic  Risk for ineffective breathing pattern
motor  Fatigue related to increased energy requirements to
- a diagnostic procedure to perform activities of daily living.
assess the health of muscles  Imbalanced nutrition more than body requirements
and the nerve cells that related to inactivity.
control them (motor  Risk for injury related to muscle weakness and unsteady
neurons). EMG results can gait.
reveal nerve dysfunction or
problems with nerve-to- INTERVENTIONS AND RATIONALES
muscle signal transmission.  Keep the right cushion and wheelchair with the right
Motor neurons transmit client
electrical signals that cause muscles to contract. Rationale: “Cushions lessen shock, pressure, vibration, pain
and fatigue”
MANAGEMENT  Intervene to maintain continence, nutrition, and
 Sadly, there is no cure for Duchenne’s, but there are hydration
ways to help improve the individual’s quality of life and Rationale: “Helps prevent pressure ulcers”
provide help for the stage they are in.  Emphasize importance of weight shifts every 15
1. Pulmonary care minutes”
 Examples of what evaluation of respiratory function Rationale: “Prevents capillary occlusion/force on skin over
should include are: bony areas”
 Spirometric measurements of FVC, FEV, and  Follow therapist’s recommendations for how clients
maximal mid-expiratory flow rate should propel manual wheelchairs to prevent upper
 Maximum inspiratory and expiratory pressure extremity pain and joint degeneration”
 Peak cough flow. Rationale: “Overuse and repetitive strain is common
 Carbon dioxide levels should also be monitored especially in those with spinal cord injury”
 Airway clearance is of importance to prevent atelectasis  Assess home environment for barriers and a support
and pneumonia. system for emergency and contingency care”
 Manually assisted coughing techniques are useful in Rationale: “Immobility and wheelchair use may pose a
patients who have a low cough peak flow rate (below threat during health crises”
160 L/min) because self-clearance of their airways are SUMMARY
not adequate.
 Expiratory force can also be increased by applying
pressure to the patient's upper abdomen during their
natural cough.
 Other manual techniques include air stacking,
glossopharyngeal breathing, and positive pressure
application.
2. Rehabilitation
 physical therapy for range of motion exercises
 adaptive equipment
 power wheelchairs
 KAFO (Knee-Ankle-Foot Orthosis) bracing
3. Pharmacologic Intervention
 In the ambulant stage, chronic cortical steroid
treatment is an accepted practice. Glucocorticoid, a
LORRAINE ANNE SABLA-ON,SN CSAB 15
NCM 116- MEDICAL SURGICAL NURSING (PERCEPTION & COORDINATION)
J.G. GAYATIN, RMT, RN, MAN
FINALS

LORRAINE ANNE SABLA-ON,SN CSAB 16