MR. ALETH M.

TIBI, RN, MAN

Overview of the Skeletal System

y Hambone as a cross-

section of a typical bone y The center of the bone is filled with marrow y Surrounded by the hardened bone tissue

y The extracellular matrix of the bone is composed of

collagen with Ca3(PO4)2 deposited in it. y Bone tissue is composed of repeating, circular units called Haversian Systems. y In each Haversian system, there is a central canal where blood vessels and nerves can be found.

Bones of the Skeletal System

y cranium- bones of the skull surrounding the brain, not including the face

bones y mandible- jaw bone, so the hinge of the jaw is joined by the temporal bone by the temporo-mandibular joint
y vertebrae- bones which make up the spine, which include:

a. cervical vertebrae - vertebrae in the neck region b. thoracic vertebrae- vertebrae with ribs attached c. lumbar vertebrae- vertebrae in the lower back d. sacrum- five fused as one vertebra which are joined to the pelvis e. coccyx- four fused as one vertebra which comprise the tailbone

y y y y y y y y y y

ribs- bones protecting the chest cavity (twelve pairs) sternum- breastbone clavicle - collar bone scapula- shoulder blade humerus- top of the arm ulna- little finger side of the lower arm which also forms the elbow radius- thumb side of the lower arm carpals- wrist bones metacarpals- palm of the hand phalanges- fingers

y (os) coxa- hip bones y ilium- big bone on top that we think of as the hip y ischium- bones on which we sit y pubis- lower front hip bone

y (os) coxa- hip bones y ilium- big bone on top that we think of as the hip y ischium- bones on which we sit y pubis- lower front hip bone

y femur- thigh bone y patella- kneecap y tibia- thick, inside (big-toe side) shinbone

fibula- thin, outer (little-toe side) shinbone y tarsals- heel bones y metatarsals- arch of the foot, the sole y phalanges- toes

The Muscular System

y more than 650 individual muscles which are attached

to the skeleton, providing the pulling power for movement.

Function of the Muscles

y Provide movement for the body

Types of Muscle Tissues

y Voluntary muscles: muscles controlled by the will y Involuntary muscles: muscles not controlled by the

will

Types of Muscle Tissues

y Cardiac Muscles: found in the heart a. striated b. contracts through the sliding filament c. it forms branching fibers d. involuntary y Skeletal Muscles: makes up about 40 % of an adult body weight. e.g. biceps, triceps a. it has stripe-like markings, or striations b. composed of long muscle fibers c. muscle fiber has a cell which contains several nuclei d. controlled by the nervous system during contraction e. many of the skeletal muscle contractions are automatic

Smooth Muscles: the internal organs are made up of smooth muscles. e.g. bladder, bronchi a. non-striated b. controlled by the nervous system and hormones
y

Joints, Ligaments and Tendons

y Joints: also known as articulations, it is where two

bones meet. y Tendons: fibrous connective tissues that connects to the periosteum of the bones; it enables the bones to move when skeletal muscles contract. y Ligaments: dense bands of connective tissue that connect bones to bones.

Functional Classification of Joints

Type Synarthroses Description Immovable joints Examples Skull, first rib and munubrium of the sternum Vertebral joint, symphysis pubis joint Shoulder, hip and limb joints

Amphiarthroses Diarthroses

Slightly movable joints Freely movable joints

Structural Classification of Joints

Type Fibrous Cartilaginous Synovial Description Example Permit little movement; Skull short connective tissue Immovable Intervertebral Discs Freely movable; synovial Limbs fluids and filtrate of blood plasma

ssessment
y Chief Complaint and History y Physical Examination: focus on

a. Inspection: color, swelling, atrophy, deformity, symmetry, posture and gait, muscle strength, discharge , and movement (ADL) b. Palpation: deviation/limitation in ROM, warmth, tenderness, deformity of joints, muscle size and strength, crepitation on joint movement, and presence of subcutaneous nodules. c. Palpation: turgor, tenderness, masses, and body temperature

Pott s Disease Osteomyelitis

Pott s Disease
y Other Names: TB of the spine; Pott s Caries, David's

Disease, and Pott's Curvature; Tuberculous Spondylitis y It is named after Percivall Pott (1714-1788), a London surgeon. y Most common site of bone infection in TB. y Most common site: lower thoracic and upper lumbar vertebrae .

Pathophysiologic Mechanisms
results from haematogenous spread of tuberculosis from other sites particularly to the spine disc tissue dies and is broken down by caseation

infection then spreads from two adjacent vertebrae into the adjoining disc space

vertebrae collapses and spinal damage occurs

the intervertebral disc, which is avascular, cannot receive nutrients and collapses.

a dry soft tissue mass often forms known as GIBBUS

Signs and Symptoms

Signs and symptoms

y back pain y fever y night sweating y anorexia y weight loss y Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of the legs

Other Manifestations
y Localized back pain y Para-vertebral swelling y Neurological signs like paraplegia

Diagnostic Tests
y Needle biopsy of bone or synovial tissue: Numbers of

tubercle bacilli present are usually low but are pathognomonic y Acid-fast stain and culture for Mycobacterium Tuberculosis y Elevated Erythrocyte Sedimentation Rate

Imaging
y Spinal x-ray will show vertebral destruction and

narrowed disc space. y Magnetic Resonance Imaging is useful to demonstrate the extent of spinal compression and can show changes at an earlier stage than plain radiographs. Bone elements visible within the swelling, or abscesses, are strongly indicative of Pott s disease as opposed to malignancy. y CT scans and Nuclear Bone Scan

T R E A T M E N T

Isoniazid (INH)

Rifampin (Rifadin)

Ethambutol (EMB) Streptomycin (SM) Pyrazinamide (PZA)

Anti-infective agents

Other Management
y Spinal Immobilization with a Brace: Jewette Brace y Surgery is required if there is spinal deformity or

neurological signs of spinal cord compression: debridement and fusion with bone grafting

Complications
y Severe Kyphosis y Sinus Formation y Paraplegia: Pott's Paraplegia

Nursing Responsibilities on Drug Therapy

y INH: taken before meals; causes peripheral

neuropathy (competes with Vitamin B6 absorption). y Rifampicin: Best taken with empty stomach but causes gastric irritation hence should be taken with food; causes discoloration of urine; should be kept in dark containers.

more on responsibilities
y PZA: Hepatotoxic; ototoxic; nephrotoxic; gastric

irritation; protect from light. y EMB: optic neuritis (causing red and green color indiscrimination); skin rashes .

Nursing Care
y Isolation y Skin Care: Braces

Pr v

ti

y Osteomyelitis is an infection of bone or bone

marrow, usually caused by pyogenic bacteria or mycobacteria.

y Staphylococcus aureus is the organism most common. y Bloodstream-sourced osteomyelitis is seen most

frequently in children, and nearly 90% of cases are caused by Staphylococcus aureus.

Predispositions
y An open injury to the bone: open fracture with the bone ends y y y

piercing the skin. An infection from elsewhere in the body: urinary tract infection that has spread to the bone through the blood. A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria. Bacteria in the bloodstream, which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site. A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection.

On predispositions
y People with diabetes y Patients receiving hemodialysis y People with weakened immune systems y People with sickle cell disease y Intravenous drug abusers y Elderly

Pathophysiology
Predisposition like: Open wound, surgery, Soft tissue infection like boils, enous stasis, DM Pus forms, followed by edema and ascular congestion

Bacteria enters, lodge and multiply

Infection reaches outer surface or margin of the bone, raising the periosteum

Phagocytes attempt to contain infection by releasing enzymes that destroys e entually bone tissue

Disruption of blood supply and Necrosis results

Bacteria adheres to damaged bone coating underlying bone with protecti e film

Manifestations
Bacteria can tra el into the bone through the bloodstream from other infected areas in the body Pain and/or tenderness in the infected area Swelling and warmth in the infected area Fe er Nausea, secondarily from being ill with infection General discomfort, uneasiness, or ill feeling Drainage of pus through the skin Excessi e sweating Chills Lower back pain Swelling of the ankles, feet, and legs Changes in gait (walking pattern that is a painful, yielding a limp)

Bacteria enter the body's tissues through a wound and tra el to the bone (like after an injury or trauma)

Blood supply to that area of the bone is disrupted. (older people with atherosclerosis)

Typical Appearance of Osteomyelitis

Diagnostic Tests
y Blood tests: When testing the blood, measurements are taken to confirm an infection: 1. complete blood count (CBC), which will show if there is an increased white blood cell count 2. ESR (erythrocyte sedimentation rate) and/or CRP (Creactive protein) in the bloodstream, which detects and measures inflammation in the body. (NV=0-15mm/hr) y Blood culture: A blood culture is a test used to detect bacteria. A sample of blood is taken and then placed into an environment that will support the growth of bacteria. By allowing the bacteria to grow, the infectious agent can then be identified and tested against different antibiotics in hopes of finding the most effective treatment.

y Needle aspiration: a needle is used to remove a sample of fluid and

cells from the vertebral space, or bony area.

y Biopsy: A biopsy (tissue sample) of the infected bone may be taken

and tested for signs of an invading organism.

y Bone scan: a small amount of Technetium-99 pyrophosphate, a

radioactive material, is injected intravenously into the body. If the bone tissue is healthy, the material will spread in a uniform fashion. A tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen.

Treatment
y Drainage: needle aspiration of open wound. A needle

is inserted into the infected area and the fluid is withdrawn. y Medications: Antibiotics help the body get rid of bacteria in the bloodstream that may otherwise reinfect the bone. Type of antibiotics is based on culture results; commonly used is Methacillin.

y Splinting or cast immobilization: to immobilize the

affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible y Surgery: destroyed bone is scraped out. y Physiotherapy: to build up strength of the muscles

Nursing Care
y Risk for Infection related to compromised immune

system: Hand washing and maintain dietary kcal and CHON intake. y Hyperthermia related to infection and inflammatory process: maintain cool environment; light clothing; ensure daily fluid intake of 3L.

y Impaired physical mobility related inflammation and

use of immobilizers: maintain functional position; maintain rest and avoid weight bearing activities; ensure PROME. y Pain related to swelling: splint area; use of analgesics; use of distraction; minimal manipulation or handling of affected area.

Scoliosis

Scoliosis
y abnormal curvature of the spine y "S" or a "C" curvature of the spine y bones are rotated slightly, making the person's waist or

shoulders appear uneven.

Predispositions
y If someone in a family has scoliosis, the likelihood of

an incidence is much higher: approximately 20 percent y Children: It is usually develop in middle or late childhood, before puberty, and is seen more often in girls than boys y Adult: Degeneration as in osteoporosis

Etiology
y "idiopathic," meaning the cause is unknown.

Manifestations
y Uneven shoulders y One shoulder blade that appears more prominent than

the other y Uneven waist y One hip higher than the other y Leaning to one side

y Ribs on one side of the body to stick out farther than

on the other side y Back pain and difficulty breathing

Diagnostic Tests
y Physical examination: examination of the spine as

well as the shoulders, hips, legs and the rib cage for signs of scoliosis. y X-rays: initial X-ray to confirm the diagnosis and determine the curve angle. Periodic X-rays are done to monitor the curve and help make treatment decisions.

Descriptions
y Shape: Curves develop side-to-side as a C- or S-shaped curve. The rotation of the spine causes the ribs and muscles near the spine to move out of normal alignment. y Location: The curve may occur in the upper back area (thoracic), the lower back area (lumbar) or in both areas (thoracolumbar) y Direction: The curve can bend to the left or to the right. y Angle: A normal spine, viewed from the back, is at 0 degrees a straight line

Treatment
y

Braces: prevents further progression of the curve

a. Underarm or low-profile brace: made of modern plastic materials and is contoured to conform to the body. *Also called a thoracolumbosacral orthosis (TLSO), this closerfitting brace is less visible under the clothes as it fits under the arms and around the rib cage, lower back and hips. b. Milwaukee brace. This full-torso brace has a neck ring with rests for the chin and for the back of the head. The brace has a flat bar in the front and two flat bars in the back. A Milwaukee brace may be used for curves in the upper spine. This brace is not commonly used.

y Surgery: "Fusion" means joining two pieces together.

Fusion involves connecting two or more vertebrae with pieces of bone taken from the pelvis. Eventually, the vertebrae and the pieces of bone fuse together preventing further progression of the curve.

Complications from Surgery

y bleeding, infection, pain, nerve damage, arthritis and

disk degeneration.

y It involves the use of metal rods, hooks, screws or wires

(instrumentation) to the spine to hold the vertebrae together during the months after surgery while the bones fuse. y The instrumentation is left in the body, even after the bones have fused, to avoid another surgery.

Complications
y Lung and heart damage:

1. a curve greater than 70 degrees the rib cage may press against the lungs and heart, making it more difficult to breathe and harder for the heart to pump. In very severe scoliosis 2. a curve greater than 100 degrees damage to the lungs and the heart can occur. Any time breathing is compromised, the risk of lung infections and pneumonia increases.

y Back problems: chronic back and if untreated may

develop arthritis of the spine.

y Body image: child might feel isolated and develop a

poor body image from wearing a brace during childhood and teenage years.

Conservative Treatment
y Electrical Stimulation y Traction y Active and Passive ROME y Weight reduction

Nursing Care
y Risk for injury related to bracing and other related

factors: Assess for skin irritation; use of undergarments to reduce friction; frequent change of undergarments during warm weather; teach to avoid use of powders and lotion; loosen brace during meals and for the first 30 minutes after meals.

y Risk for peripheral neurovascular dysfunction related

to brace and cast application: assess for movement, color and sensation.

Osteoarthritis Rheumatoid Arthritis

Osteoarthritis
y Also known as degenerative joint disease or

osteoarthrosis y characterized by the breakdown of joint cartilage those in fingers, hips, knees, lower back and feet. y Initially it may strike only one joint. But if fingers are affected, multiple hand joints may become arthritic.

Causes
y combination of factors: including being overweight,

the aging process, joint injury or stress, heredity, and muscle weakness.

Manifestations
y Often develops slowly, and some people may not experience any signs or symptoms y Pain in a joint during or after use, or after a period of inactivity y Discomfort in a joint before or during a change in the weather y Swelling and stiffness in a joint, particularly after using it y Bony lumps on the middle or end joints of the fingers or the base of the thumb known as Heberden s node y Loss of joint flexibility

Areas
y Fingers: Bony knobs called Heberden s node can enlarge in the finger joints, creating a gnarled appearance y Painful or stiff and numb joint. y Nodes tend to run in families and affect more women than men.

y Spine: Slow deterioration of disks between the bones along the spine can lead to back, neck pain and stiffness.

In osteoarthritis, disks narrow and spurs form. Where bone surfaces rub together (facets), cartilage becomes worn and may be painful.

y Weight-bearing joints: The parts of the body that bear the majority of the weight like hips, knees and feet y As cartilage slowly deteriorates over the years, chronic pain or varying amounts of discomfort when standing and walking

The hip joint on the left is normal, but the hip joint on the right shows deterioration of cartilage due to osteoarthritis.

Pathophysiology
mechanical stress imbalance of enzymes released from the cartilage cells or from the lining of the joint

joint cartilage breaks down faster

cartilage wears down completely, lea ing the bone rubbing on the other bone .

damaged end of the bones

Risks
y 45 years old or older and female y hereditary conditions like defective cartilage and

malformed joints y joint injuries caused by physical activity or sports y obesity y weak thigh (quadriceps) muscles leading to osteoarthritis of the knees

Diagnostic Tests
y Fluid may be withdrawn from a joint for analysis

(joint aspiration) y X-rays, bone scans, computerized tomography (CT) scans, magnetic resonance imaging (MRI) scans y Arthrography an image taken after dye has been injected into the joint. Imaging techniques can reveal bone spurs, worn-down cartilage and loss of joint space

Treatment
y Medications: to treat pain and mild inflammation and therefore improving joints' functioning 1. Topical pain relievers: creams, gels, ointments and sprays to temporarily relieve arthritic pain,

Examples: trolamine salicylate include Aspercreme and Sportscreme; methyl salicylate, menthol and camphor like Icy Hot and Ben-Gay. Capsaicin: a cream made from the seeds of hot chili peppers, may relieve pain in joints close to the skin surface, such as fingers, knees and elbows.

y 2. Acetaminophen: Acetaminophen (Tylenol) can relieve pain but doesn't reduce inflammation. y It has been shown to be effective to relieve mild to moderate pain. y Side Effect: liver damage, especially if taken with alcoholic beverages

y 3. NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs): It relieves pain and fight inflammation y Examples: aspirin, ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve); ketoprofen (Orudis), diclofenac (Cataflam, Voltaren) and nabumetone (Relafen). y Side Effects: ringing in the ears, gastric ulcers, cardiovascular problems, gastrointestinal bleeding, and liver and kidney damage. y Consuming alcohol or taking corticosteroids while using NSAIDs increases the risk of gastrointestinal bleeding.

y 4. COX-2 inhibitors: Considered as effective for managing pain and inflammation y Example: celecoxib (Celebrex) y Side Effects: fluid retention and causing or exacerbating high blood pressure; has been linked to an increased risk of heart attack and stroke.

y 5. Tramadol: (Ultram) centrally acting analgesic; has no anti-inflammatory effect y Used for short-term treatment of acute flare-ups; given in combination with acetaminophen to increase pain relief y y Side Effect: nausea and constipation.

Surgery
y Joint replacement: (Arthroplasty): damaged joint is removed and replaces it with a plastic or metal device called a prosthesis; hip and knee joints common sites. y Joint replacement is most successful in large joints, such as hips and knees these replacement joints last at least 20 years in about 80 percent of those who had replacements. y Joint replacement surgery can help resumes an active, painfree lifestyle. In smaller hand joints, it also can improve appearance and comfort and may improve joint's mobility.

Knee replacement surgery can repair damage from osteoarthritis and other inflammatory conditions. The artificial joint has metal alloy caps for thighbone and shinbone and high-density plastic to replace eroded cartilage within the joint and on the kneecap.

Gradual deterioration of cartilage that occurs in osteoarthritis is the most common reason for hip replacement surgery. Implanting an artificial joint eliminates pain and restores near-normal movement

y Arthroscopic lavage and debridement: During arthroscopy, lavage and debridement or both are done. y Lavage involves using saline to flush out blood, fluid or loose debris inside the joint. y Debridement removes loose fragments of bone or cartilage inside the joint. y These procedures may provide short-term pain relief and improved joint function

y Repositioning bones: known as osteotomy y Fusing bones: known as arthrodesis to increase

stability and reduce pain. The fused joint, such as an ankle, can then bear weight without pain, but has no flexibility.

Nursing Care
y Emphasize benefits of Exercise regularly: walking is a good starter exercise; stationary bicycle or do hand or arm exercises. y Instruct patient as she moves, maintain a slow, steady rhythm. No jerk or bouncing. y Instruct not to hold your breath, as this can temporarily deprive muscles of oxygen and tire them. y Maintain good posture while doing exercise. y Avoid exercising tender, injured or severely inflamed joints. y If there is new joint pain, stop!

y Control weight: Excess weight puts added stress on joints of the back, hips, knees and feet. y Eat a healthy diet: A healthy diet emphasizing fruit, vegetables and whole grains can help control the weight and maintain overall health.

y Apply heat: Heat will ease pain, relax tense, painful muscles and increase the regional flow of blood. y Instruct patient to apply heat before exercising. y One of the easiest and most effective ways to apply heat: a 15-minute hot shower or bath. y Other options: hot pack, an electric heating pad on its lowest setting or a radiant heat lamp with a 250-watt reflector heat bulb. y Precautions: If the skin has poor sensation or have poor circulation, don't use heat treatment.

y Choose appropriate footwear: Wearing comfortable cushioned shoes that properly support the weight y Apply cold for occasional flare-ups: Cold may dull the sensation of pain during the first day or two. Cold also has a numbing effect and decreases muscle spasms.

Precaution: Don't use cold treatments if there is poor circulation or numbness

y Practice relaxation techniques: Hypnosis,

guided imagery, deep breathing and muscle relaxation can all be used to control pain. y Take your medications as recommended: By taking medications regularly instead of waiting for pain to build, will lessen the overall intensity of your discomfort.

y Teach to use assistive devices: painful knee may need a brace for support. y a. Teaching to use a cane to take weight off the joint when walking. y How: The cane should be used in the hand opposite the affected joint. y y b. If the hands are affected, various helpful tools and gadgets are available to help maintain an active lifestyle.

y 2. Know limitations. Rest when tired. Arthritis can make one prone to fatigue and muscle weakness

A rest or short nap that doesn't interfere with night time sleep may help.

3. Avoid grasping actions that strains finger joints: For example, instead of a clutch-style purse, select one with a shoulder strap. Use hot water to loosen a jar lid and avoid pressure from the palm to open it, or use a jar opener. Don't twist or use your joints forcefully. 4. Spread the weight of an object over several joints: Use both hands, for example, to lift a heavy pan. Try using a walking stick or cane. 5. Take a break. Periodically relax and stretch.

6. Use the strongest muscles and favor large joints. Don't push open a heavy glass door. Lean into it. To pick up an object, bend the knees and squat while keeping the back straight.

Use of Coping Skills

y Osteoarthritis can affect everyday activities and

overall quality of life. As a result, it's important to adopt coping strategies for dealing with the disease 1. Keep a positive attitude. Make a plan for managing arthritis. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and function better.

Complementary and Alternative Therapy

y Common forms of complementary and alternative

medicine for treatment of osteoarthritis include: a. Acupuncture b. Copper jewelry c. Homeopathy d. Magnets

Rheumatoid Arthritis
y an inflammatory condition causing joints to ache and

throb and eventually become deformed.

Cause
y unknown, but it's believed to be the body's immune

system attacking the tissue that lines the joints (synovium)

Prevalence
y two to three times more common in women than in

men y generally strikes between the ages of 20 and 50

Risk Factors
y Getting older: incidence of rheumatoid arthritis

increases with age y Being female y Being exposed to an infection, possibly a virus or bacterium, that may trigger rheumatoid arthritis in those with an inherited susceptibility y Inheriting specific genes y Smoking cigarettes over a long period of time.

Pathophysiology
Predisposition like Infection proteins damages cartilage, bone, tendons and ligaments. white blood cells whose usual job is to attack unwanted in aders, such as bacteria and iruses mo e from the bloodstream into the syno ium

joint loses its shape and alignment

Inflammation of the syno ial joints

release of proteins that cause thickening of the syno ium

Pain and swelling in the joints, especially in the smaller joints of hands and feet Generalized aching or stiffness of the joints and muscles, especially after sleep or after periods of rest Loss of motion of the affected joints Loss of strength in muscles attached to the affected joints Fatigue, which can be se ere during a flare-up Low-grade fe er Deformity of joints o er time General sense of not feeling well (malaise)

Manifestations
y Pain and swelling in the joints, especially in the smaller joints of the hands and feet y Generalized aching or stiffness of the joints and muscles, especially after sleep or after periods of rest y Loss of motion of the affected joints y Loss of strength in muscles attached to the affected joints y Fatigue y Low-grade fever y Deformity of the joints over time y General sense of not feeling well (malaise)

Rheumatoid arthritis typically strikes joints, causing pain, swelling and deformity. As the synovial membranes become inflamed and thickened, fluid builds up and joints erode and degrade.

Osteoarthritis, the most common form of arthritis, involves the wearing away of the cartilage that caps the bones in the joints. With rheumatoid arthritis, the synovial membrane that protects and lubricates joints becomes inflamed, causing pain and swelling. Joint erosion may follow.

Diagnostic Tests
y Blood tests: (ESR or sedimentation rate) can indicate

the presence of an inflammatory process y People with rheumatoid arthritis tend to have elevated ESRs. y The ESRs in those with osteoarthritis tend to be normal.

y Blood test for antibody called rheumatoid factor

Differential Characteristics
y 1. 2.

3.

Rheumatoid Arthritis Systemic Disease: fever, malaise and fatigue Inflammation sites: fingers and proximal interphalangeal joint Nodules: subcutaneous extraarticular nodules around the joints

y 1. 2.

3.

Osteoarthritis Local Joint Disease: no systemic symptoms Inflammation sites: distal interphlangeal joints Nodules: no periarticular of subcutaneous nodules; Heberden s nodes are present

4. ESR: Elevated; elevated serum rheumatoid factor 5. Who are predispose: young adults to older adults

4. ESR: normal

5. Who are predispose: adults in later years

Treatment
y Corticosteroids: prednisone and methylprednisolone (Medrol), reduce inflammation and pain, and slow joint damage. y Side Effects: easy bruising, thinning of bones, cataracts, weight gain, a round face and diabetes

y Immunosuppressants: It tames the immune system, which is out of control in rheumatoid arthritis. y It attacks and eliminate cells that are associated with the disease. y Examples: leflunomide (Arava), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune) and cyclophosphamide (Cytoxan). y Side Effect: increased susceptibility to infection.

y Abatacept (Orencia). Abatacept, a type of costimulation modulator, it reduces the inflammation and joint damage caused by rheumatoid arthritis by inactivating T cells a type of white blood cell. y Side Effects: headache, nausea and mild infections, such as upper respiratory tract infections. Serious infections, such as pneumonia

y Rituximab (Rituxan): Rituximab reduces the number of B cells in the body. B cells are involved in inflammation. Rituximab is administered as an infusion into a vein in arm. y Side effects: flu-like signs and symptoms, such as fever, chills and nausea; extreme reactions to the infusion: difficulty breathing and heart problems.

Nursing Care
y Pain related to joint inflammation and stiffness:

apply heat or cold prior to exercise and at bedtime; change position frequently; provide rest periods; use of resting splints during acute pain y Impaired physical mobility related to joint destruction: encourage regular active exercise of joints; assist and support during exercise; avoid exercise during acute pain

y Potential for injury related to weakness and impaired

movement: avoid positions of flexion, encourage active ROME; encourage ambulation with assistance; use ambulatory devices like cane; use shoes than slippers when ambulating; teach use safety devices such as grab bars on tubs and showers

y Self Care Deficits related to pain and limitation of

movement: provide time for ADL; use comfort measures as needed before required activities; use assistive device in dressing, feeding and ADL y Body Image Disturbances related to deformed joints: provide opportunities to discuss feelings; identify personal strengths; allow maximum independence; identify and anticipate needs

y Knowledge Deficit related to control and

management of arthritis: teach the following: a. nature of the disorder b. medication c. exercise program d. activity e. nutrition

Club Foot Congenital Hip Dysplasia

Clubfoot
y Feet point down and inward y It does not cause pain in the newborn child y It can cause long-term abnormalities in gait y It may lead to complications such as chronic skin

ulcers

Mechanisms
y The tendons on the inside and the back of the foot are

too short. y The foot is pulled then toes point down and in, and it is held in this position by the shortened tendons.

Pathophysiology
failure to keep pace with the de elopment of the foot posterior and medial tendons and ligaments (in the back and inside)

tendons and ligaments tether

posterior and medial parts of the foot point downwards and the twist inwards

Bones are mis-shapened

Etiology
y Associated with other congenital malformations such

as spina bifida y No known cause of the deformity has been established

Prevalence
y It tends to be more common in boys, although girls are

not exempted. y A positive family history is a predisposition

Manifestations
y It does not cause pain in the infant y If uncorrected in the older child, it is very unsightly

and very crippling y Patient walks on the outside of his foot which is not meant for weight-bearing y Skin breaks down, and the development of chronic ulceration and infection.

Treatment
y Manipulating the foot to get it to the best position

possible, and then holding the correction in a cast. (Ponseti Method) y The cast is changed on a weekly basis, with manipulation before each casting, to obtain further correction. y After the first 6 weeks surgery can be planned, the foot is manipulated and cast applied every 2 weeks.

Surgery
y Releasing all the tight tendons and ligaments in the posterior and medial aspects of the foot, and repairing them in the lengthened position. y The lateral ligaments are released to allow a complete release. y Objective: Plantigrade and Flexible foot a. "Plantigrade" means the child stands with the sole of the foot on the ground, not on heels or the outside of foot. b. "Flexible" means one can move the foot around freely without pain.

y After surgery, the foot needs to be casted at biweekly

intervals for 6 weeks, followed by the use of a thermoplastic brace known as Wheaton Brace Purpose: to hold the correction. The brace is used fulltime for about 6 weeks, followed by night use only till the child starts to walk at one year of age

Wheaton Brace

Nursing Care
1. Check for NEUROVASCULAR Integrity How: observe for color and sensation 2. Regularly inspect the cast for irritation 3. Provide diversional activities

Congenital Hip Dysplasia

y It is a disorder in children that is either present at

birth or shortly thereafter. y During gestation, the infant's hip should be developing with the head of the thigh bone (femur) sitting perfectly centered in its shallow socket (acetabulum). y The acetabulum should cover the head of the femur as if it were a ball sitting inside of a cup.

y In congenital hip dysplasia, the development of the

acetabulum in an infant allows the femoral head to ride upward out of the joint socket, especially when weight bearing begins.

Congenital Hip Dysplasia

Prevalence
y more females affected than males. y related to common practice of swaddling and using

cradleboards for restraining the infants. It places the infant's hips into extreme adduction (brought together) y higher in infants born by caesarian and breech position births.

y greater chance in the first born compared to the

second or third child.

Manifestations
y Reduced joint mobility y A low clunking sound can be heard when the leg is

gently rotated, which is the sound of the femur engaging the socket. y The stretch of skin between the anus and the genitals (perineum) is unusually wide.

y For unilateral dislocation symptoms include:

a. The skin creases of the buttocks don t match. b. One knee joint looks higher than the other.

Diagnostic Test
y Ortolani Test: begins with each of the examiner's

hands around the infant's knees, with the second and third fingers pointing down the child's thigh. With the legs abducted (moved apart), the examiner may be able to discern a distinct clicking sound with motion. y If symptoms are present with a noted increase in abduction, the test is considered positive for hip joint instability.

Ortolani Test Barlow Test

y Barlow Test : with the infant's hip brought together

with knees in full bent position y The examiner's middle finger is placed over outside of the hipbone while the thumb is placed on the inner side of the knee. The hip is abducted to where it can be felt if the hip is sliding out and then back in the joint.

Ortolani Test Barlow Test

y X-ray films can be helpful in detecting abnormal

findings of the hip joint. y X rays may also be helpful in finding the proper positioning of the hip joint for treatment of casting.

Treatment
y Objective: is to replace the head of the femur into the

acetabulum and, by applying constant pressure, to enlarge and deepen the socket. y In the past, stabilization was achieved by placing rolled cotton diapers or a pillow between the thighs, thereby keeping the knees in a frog like position.

Pavlic Harness

Nursing Care
1. Check for NEUROVASCULAR Integrity How: observe for color and sensation 2. Regularly inspect the cast for irritation 3. Provide diversional activities