1. Nursing Assessment

2. Physical Assessment Chief complaints and activity level
Health history: medical and surgical
Physical signs or symptoms
Examination for:
Bone integrity
Posture
Joint function
Muscle strength
Gait
ADL’s

3. Physical Signs and Symptoms
Deformities
Crepitus
Scoliosis
Kyphosis
Lordosis
Contractures
Dislocations

4. Common Structural Disorders
Scoliosis
Kyphosis
Lordosis
Cleft Palate
Flatfoot

6. Scoliosis
S curve

7. Kyphosis
Forward curve

8. Lordosis
Forward curve at lumbar spine

9. Cleft Palate Congenital defomity Opening in roof of mouth
Mouth communicates with nasal cavity
Infant difficulty nursing (sucks in air)
Surgical correction

11. Flatfoot Tendons and ligaments that support arch of foot are weak
Foot flattens
Caused by excess weight, poor posture, hereditary failure of arch to form
Difficulty or pain walking

13. Assessing Articular Joints
Deformities
Nodes
Pulses in extremities
ROM
Edema
Fever

14. Range of Motion Ability to change position Muscular strength
Coordination
Size of muscles
Active
Passive

15. Neurovascular Assessment
Following trauma, surgery, casting, splinting, bandaging: Assess the 7 P’s
Pulselessness
Paresthesias
Paralysis or paresthesias
Polar temperature
Pallor
Puffiness (edema)
Pain

16. Skeletal Changes in Aging
Loss of calcium salts
Loss of protein in bone
Decreased collagen in bone, tendons and ligaments
Loss of height (0.5 in/20y)
Chest diameter decreases about 1 in and less flexible

17. MEDICATIONS

18. Medications Skeletal muscle relaxants Antigout medications
Antiarthritic medications
Osteoporosis prevention and treatment

19. Skeletal Muscle Relaxants
Used to prevent/relieve muscle spasms, treat spasticity associated with spinal cord lesions, painful musculoskeletal disorders
Contraindicated in severe liver, renal, heart disease
Should not be taken with CNS depressants

20. Skeletal Muscle Relaxants
Act directly on neuromuscular junction
Act directly on muscle OR
Act indirectly on the CNS
Depress neuron activity in the brain or spinal cord

21. Skeletal Muscle Relaxants
Side effects:
Dizziness/hypotension
Drowsiness
Dry mouth
GI upset
Photosensitivity

22. Skeletal Muscle Relaxants
Baclofen (Lioresal)
Causes CNS effects
Frequently causes nausea, constipation, retention
Can be given by physician through intrathecal pump

23. Skeletal Muscle Relaxants
Dantrolene (Dantrium)
Acts directly on skeletal muscles to relieve spasticity
Liver damage most serious adverse effect
Monitor LFT’s
Can cause GI bleeding, impotence, photosensitivity, rash

24. Skeletal Muscle Relaxants
Cyclobenzaprine (Flexeril)
Contraindicated in clients who have taken MAOI s within 14 days of initiation (can lead to ↑BP, HTN crisis)
Caution in clients with hx urinary retention, glaucoma, or increased intraocular pressure
Short term (2-3 weeks) use

25. Skeletal Muscle Relaxants
Methocarbamol (Robaxin)
May cause urine to turn brown, black or green
Notify MD if blurred vision, nasal congestion, urticaria occur
Parenteral form can cause hypotension, bradycardia, anaphylaxis, seizures

26. Skeletal Muscle Relaxants
Chlorzoxazone (Paraflex, Parafon Forte)
Monitor for hypersensitivity reactions
May cause malaise and urine discoloration
Carisoprodol (Soma)
Take with food to prevent GI upset
Report hypersensitivity to MD

27. Antigout Medications Decrease inflammation
Reduce uric acid production, increase uric acid secretion
Use cautiously in clients with GI, renal, cardiac or hepatic disease
Allopurinol can increase effect of warfarin and oral hypoglycemic agents

28. Antigout Medications Side effects HA N/V Blood dyscrasias
Flushed skin, rash
Uric acid kidney stones
Sore gums
Metallic taste

29. Nursing Considerations
Monitor serum uric acid levels
Monitor I&O
Monitor CBC and LFT’s
Do not give large doses of Vitamin C with Allopurinol
Avoid foods high in purines; ie wine, alcohol, organ meats, sardines, salmon, gravy
Concurrent ASA; increased uric acid level, gout attack

30. Antigout Medications Examples: Allopurinal (Zyloprim) Colchicine
Losartan (Cozaar)
Probenecid

31. Osteoporosis Prevention
Calcium and Vitamin D supplementation
Estrogen replacement therapy after menopause
Calcitonin (Calcimar)

32. Antiarthritic Medications
(Source: ATI Testing Tutorial)
Types of Drugs
NSAIDS
Tx. Pain and inflammation
Glucocorticoids
Disease-Modifying Antirheumatic Drugs
Target: Musculoskeletal system

33. Antiarthritic Medications
Disease-Modifying Antirheumatic Drugs
“DMARD”
↓ joint inflammation
↓ joint damage
Initially given with NSAIDS  slow onset of therapeutic effects. NSAIDS may be discontinued when DMARDs begin exerting therapeutic effect

34. Antiarthritic Medications
DMARD I
Category: Major Non-biologic
Antimetabolite Drug: interferes with normal metabolic process
Protogype Drug: Methotrexate (Rheumatrex
Other: Leflunomide (Arava)
NOTE: DMARDs suppress the immune system (a primary effect)

35. Antiarthritic Medications
DMARD I (cont.)
Can slow or stop progression of RA
Can tx. Cancer in larger doses
Adverse effect/side effects:
Liver damage
Bone marrow suppression (↓platelets, RBCs, WBCs)
↑ risk for infection
GI ulceration
Pulmonary Fibrosis

36. Antiarthritic Medications
DMARD I (cont.)
Methotrexate = Cat. D Pregn. (can damage developing fetus & can pass through breast mild)
Leflunomide = Cat. X pregn.

37. Antiarthritic Medications
DMARD I (cont.)
Nursing considerations:
Monitor for: ↓ platelets, wbc’s, rbc’s
S/sx. Infection
LFT, Observe for jaundice
GI bleed (Methotrexate)
Respiratory distress, ↓ oxygenation

38. Antiarthritic Medications
DMARD I (cont.)
Nursing considerations (cont.)
Dosing and Administration:
Methotrexate – 1x / week (po, sq, im)
Weekly folic acid supplement (↓ risk toxicity)
Drink oz. Glasses water/day
Report: jaundice skin/eyes; s/sx infection; ulcerations of mouth, tongue; abdominal bldg, bruising, petechaeie; blood in vomit or stool; dyspnea, SOB

39. Antiarthritic Medications
DMARD I (cont.)
Nursing considerations (cont.)
Avoid: 1. giving DMARD I drugs during pregnancy and for 6 months after completion of treatment
2. ingestion of alcohol
Precautions: (while on DMARD I tx.)
↑ risk for active bacterial or viral infection
Peptic Ulcer Disease
Ulcerative Collitis
Contraindications: (to DMARD tx.)
Liver Insufficiency
Hepatitis
Renal Insufficiency
Women who are pregnant

40. Osteoarthritis Prevention and Treatment
Biphosphonates
Inhibit osteoclast mediated bone resorption, increases total bone mass
Examples
Etidronate (Didronel)
Alendronate (Fosamax)
Pamidronate (Aredia)
Risedronate (Actonel)

41. Osteoporosis Prevention
Biphosphonates
Fosamax-taken after rising in AM with full glass water
No eating/drinking for 30 min after taking med, do not lie down for 30 min after taking med

42. Osteoporosis Prevention
Estrogen receptor modulators (Evista)
Mimic effect of estrogen in bone by reducing bone resorption
Teriparitide (Forteo)
Stimulates new bone formation
Used to treat osteoporosis in men and post menopausal women at high risk for fractures

43. Laboratory and Diagnostic Examinations

44. Radiographic Studies
Most common
X-ray
Diagnostic imaging

45. Laboratory and Diagnostic Examinations
Radiographic studies
Myelogram
Electromyography
Bone scan
Bone mineral density
X-ray
Endoscopic examination
Arthroscopy

46. Radiographic Studies
Reveals presence of fluid in joint, irregularity of joint, spur formation, and changes in size or contour of the joint
Visualizes fractures, length, tumors, and cavities of bone
Pregnant women should not have an x-ray, unless it is absolutely necessary, to prevent potential damage to the fetus

47. Laminography/planography or body section roentgenography
Radiographic Studies
Laminography/planography or body section roentgenography
Locates small cavities, foreign bodies and
lesions that are overshadowed by opaque
structures

48. Scanography Radiographic Studies
Uses a series of parallel beams that eliminate size
distortion when producing a radiograph of internal body organs
Allows accurate measurement of the length
of the bone

49. Used to determine the presence of herniated discs or tumors
Myelogram
Used to determine the presence of herniated discs or tumors

50. Myelogram
An x-ray study in which dye is injected into the spinal fluid. (The spinal cord is not visible on a normal x-ray.)
Injection of this dye outlines the spinal cord, and makes it visible on the x-ray.

51. Myelogram
The injection of dye may be done in the cervical or lumbar area
Before the dye is injected, a sample of spinal fluid is collected from the patient and is submitted to the laboratory for analysis.

53. Myelogram
Water based dye is used most often because the body will reabsorb it and will be excreted in the urine
Oil-based dye will be removed because it may cause irritation within the subarachnoid space

54. Myelogram
Headache is most common after a myelogram but seizure, infection, numbness, or paralysis may occur

55. Myelogram Prior to procedure: Post-procedure Informed consent
Provide hydration 12h before test
Assess for allergies
Premedicate as ordered
Post-procedure
VS/neuro checks as ordered
If water based dye used, HOB up degrees for 8 h
If oil based dye used, flat for 6-8 h
If air used, head lower than trunk
Force fluids, monitor I&O

56. Electromyography (EMG)
Measures electrical potential associated with skeletal muscle contractions
Needles inserted into muscle; electrical activity traced on recording paper
Informed consent
Needle insertion uncomfortable
No stimulants/sedatvies 24h prior to procedure
Slight bruising at insertion sites

57. Electromyography
Your doctor has ordered this test to help determine the cause of your pain.
This test is specifically performed to identify if abnormal nerve function is present.
The small electric pulses cause a mild tingling feeling.

58. EMG are using a transcutaneous electrical nerve stimulator (TENS) unit
Inform your physician if you:
are using a transcutaneous electrical nerve stimulator (TENS) unit
are taking blood thinners
have hemophilia
have a cardiac pacemaker
Do not apply lotion to the arms or legs on the day of the test.

59. Nuclear Scanning
Uses scanners or camera detectors that record images on radiographic film
Doses of radioactive isotopes are low; no need for precautionary measures as required for radium therapy

60. Nursing Interventions
Obtain written consent
Informing patient that radioactive isotopes will not affect family/visitors
Follow instructions as outlined by the nuclear medicine department as to special preparation for the specific scans

61. Magnetic Resonance Imaging
Used to detect pathological conditions:
Cerebrum
Spinal Cord
Currently used to detect herniated nucleus pulposes (herniated disc)

62. MRI
Involves use of
Magnetism and Radio Waves to make images of cross sections of the body
Very detailed pictures of fluid-filled soft tissue and blood vessels

63. Nursing Considerations
Patient preparation
Remove any metal
No jewelry, clothing with metal fasteners, glasses, and hair clips

64. Nursing Considerations
CANNOT HAVE MRI if patient has a metal prostheses:
Heart valves
Orthopedic screws
Cardiac pacemakers or defibrillators

65. Nursing Consideration
Patient must be able to lie still for 45 to 60 minutes
Enters the tunnel head first anxiety and/or claustrophobia
May need sedative
Relaxation therapy can help
However: No use of relaxation techniques that require flexing and relaxing of muscles – Pt. HAS TO LIE MOTIONLESS!
After test:
Routine vital signs
Pretest activities can be resumed

66. Computed Axial Tomography CT Scan
Views body sections from different angles
CT scanner produces a narrow x-ray beam
Produces a three-dimensional picture of structures
100 times more sensitive than x-ray
Should not be used unnecessarily because of radiation exposure
Iodine contrast is sometimes used
Used for the head and body

67. CT or CAT Scan Useful in locating
Injuries to ligaments or tendons
Tumors of soft tissue
Identifying fractures in difficult areas
Performed with or without contrast (iodine) dye

68. Patient Preparation Consent form
Check Allergies to iodine and seafood (shellfish)
NPO 3 to 4 hours before test if dye is used (dye can cause nausea/vomiting)
Baseline vital signs
Void
Remove jewelry and hairpins
Lie still; may feel warm and slightly nauseated for a few minutes when dye is injected

69. Nursing Consideration
After the test:
Observe for delayed allergic reaction
Encourage fluids
Pretest diet and activity can usually be resumed

70. Bone Scan
A bone scan is a nuclear scanning test that identifies new areas of bone growth or breakdown.
It can be done to evaluate damage to the bones, detect cancer that has spread (metastasized) to the bones, and monitor conditions that can affect the bones (including infection and trauma).
A bone scan can often detect a problem days to months earlier than a regular X-ray test.

72. Bone Scan
For a bone scan, a radioactive tracer substance is injected into a vein in the arm.
The tracer then travels through the bloodstream and into the bones.
A bone scan may be done on the entire body or just a part of it.

73. Bone Scan
Areas that absorb little or no amount of tracer appear as dark or "cold" spots, which may indicate a lack of blood supply to the bone (bone infarction) or the presence of certain types of cancer.
Areas of rapid bone growth or repair absorb increased amounts of the tracer and show up as bright or "hot" spots in the pictures. Hot spots may indicate the presence of a tumor, a fracture, or an infection.

74. Bone Scan Isotope excreted within 48h Hold fluids for 4 hrs. prior to
Informed consent

75. Bone Mineral Density Lose some bone mass as we age
Bones become thinner (osteopenia)
Existing bone broken down faster than new bone is made bones lose Ca⁺ and other minerals  become lighter, less dense, more porous  weaker bones; ↑ risk for fx.

76. BMD
With further bone loss, osteopenia leads to osteoporosis . So the thicker your bones are, the longer it takes to get osteoporosis.
Although osteoporosis can occur in men, it is most common in women older than age 65.

77. BMD Measures bone mass of spine, other bones and total body
Minimal radiation exposure
Used to diagnose metabolic bone disease, monitor changes in bone density with treatment

78. Arthroscopy Provides endoscopic examination of various joints
Cartilage abnormalities assessed, loose bodies removed, cartilage trimmed
Biopsy may be performed

80. Arthroscopy Interventions:
Instruct pt. to fast 8-12h prior to procedure
Informed consent
Pain med as prescribed post procedure
Elastic wrap 2-4 days post procedure
Walking without weight bearing permitted after sensation returns, limit activity for 1-4 days
Elevate extremity, ice to minimize swelling

81. Arthrocentesis
Synovial fluid aspiration, removal of pus, blood or medication instillation
Informed consent
Compression bandage post procedure
Rest joint 8-24 h afterwards
Notify physician if fever/swelling occurs

82. Laboratory Tests: Serum
Calcium
Erythrocyte sedimentation rate (ESR)
Lupus erythematosus (LE) preparation
Rheumatoid factor (RF)
Uric acid (blood)

83. Laboratory Tests: Serum
ANA, antinuclear antibodies
Detects SLE, a collagen disease
Arthritis can result from SLE
Normal = negative
Client prep
For non-fasting blood draw
Radioactive scan in last week may increase ANA level

84. Laboratory Tests: Serum
CRP, C-reactive protein
inflammation and auto-immune disorders show abnormal protein
Normal = female 1-20, male 1-13mm/h
Can get false negative
Client Prep, usually non-fasting blood draw
Meds that increase: contraceptives & IUD
Meds that decrease: NSAIDS, steroids, salicylates

85. Laboratory Tests: Serum
Uric Acid-Blood
Elevated with Gout and arthritis
Normal = male , female mg/dl
Client prep: usually non-fasting blood draw
Cause: increase: stress, ETOH, ascorbic acid, ASA, caffeine, cisplatin, diuretics, epinephrine, levdopa
Cause: decrease: x-ray contrast agents

86. Laboratory Tests: Urine
Uric Acid-Urine (24 hour collection)
Normal = ml/24hr
Client prep: no special diet, void and discard- note start time on specimen container, collect the rest of voids in container until same time next day, keep on ice or refrigerate,

87. Laboratory Tests: Serum
ESR, Erythrocyte Sedimentation Rate
Increases with inflammation, infection, necrosis, or cancer
Normal = male up to 15, female up to 20 mm/hr
Client prep: non-fasting blood draw; hold some meds
Cause increase: pregnancy, menstruation, PCN, oral contraceptives, aldomet, theophylline, vitamin A
Cause decrease: if not processed within 3 hours, ASA, quinine, cortisone

88. Laboratory Tests: Serum
RF, Rheumatoid Factor (IgM)
Elevated with autoimmune disease such as Rheumatoid arthritis and SLE
Normal = < 60 U/ml
Client prep: non-fasting blood draw
Elderly may show false positive

89. Laboratory Tests: Serum
Serum Calcium (detects calcium metabolism)
Normal = 9.0 – 10.5 mg/dl
< 6mg/dl may lead to tetany (cramps, convulsions, twitching)
> 14mg/dl may lead to coma
Client prep: non-fasting blood draw
Increase may indicate: metastatic bone tumor, Paget’s disease, acromegaly
Decrease may indicate: rickets, osteomalacia, vitamin D deficiency

90. Laboratory Tests Serum Calcium
Cause increase: vitamin D intoxication, excessive milk, calcium salts, lithium, diuretics, hyperparathyroidism
Cause decrease: anticonvulsants, ASA, calcitonin, cisplatin, corticosteroids, heparin, oral contraceptives