This document discusses assessment and management of patients with chronic musculoskeletal system disorders. It provides details on rheumatoid arthritis, gouty arthritis, osteomyelitis, osteoporosis, and osteomalacia. For each condition, it describes etiology, clinical manifestations, diagnostic tests, and pharmacological and non-pharmacological treatment approaches. The overall objective is to educate students on identifying these joint, connective tissue, and bone disorders as well as implementing appropriate nursing care.

1. Assessment & Management For The Patient
With chronic Musculoskeletal System
Disorders
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2. Session objectives
 Upon completion of this System, the students should
be able to:
– Identify joint and connective tissue disorders with
their respective causes, c/m, pp and management
– Describe metabolic bone disorders
– Implement nursing process for all disorders
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3. Joint & Connective Tissues
Disorders
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4. Rheumatoid Arthritis
 A chronic systemic disease characterized by recurrent
inflammation of diarthrodial joints and related structures
 Onset can be acute or insidious
 Characterized by periods of remissions and exacerbation.
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6. Rheumatoid Arthritis
Etiology
 Infection
 Autoimmunity
 Genetic
C/M
 Nodules
 Arteritis
 Neuropathy
 Scleritis
 Pericarditis
 Lymphadenopathy
 Splenomegaly
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8. Rheumatoid Arthritis (Lab Dx)
 Elevated Erythrocyte Sedimentation Rate (ESR)
– reflects inflammatory activity
 Elevated Rheumatoid Factor (RF)
– Measures the presence of unusual IgG and IgM.
 Anemia (Decreased RBC)
 C-Reactive protein (CRP) and antinuclear antibody (ANA) may
also be positive
 Arthrocentesis
– Needle aspiration of synovial fluid: fluid is cloudy, milky, or
dark yellow, containing WBCs
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9. Rheumatoid Arthritis (Management)
 Pharmacologic Therapy (Disease modifying drugs)
– Methotrexate, 7.5mg P.O., once per week. Increase dose gradually
to a maximum of 25mg per week. Plus
– Folic acid 5mg P.O., per week with methotrexate at least 24 hours
after the methotrexate dose. OR/Plus
– ChloroQuine phosphate, 150mg P.O., (as base) daily for 5 days of
each week for 2–3 months. OR
– SulfasalaZine, 500mg P.O., 12 hourly.
 Oral corticosteroids:
– Prednisolone, 40mg P.O., daily for 2 weeks during acute flares
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10. Rheumatoid Arthritis (Management)
 NSAIDs:
– Ibuprofen, 800mg, P.O.,TID with meals. Or
– Diclofenac, Immediate or delayed release tablet: 150-
200mg/day P.O., in 2-4 divided doses.
– Indomethacin, 25-50mg P.O., BID TO TID; maximum
dose: 200mg/day.
 Nutritional: weight control,
 Reconstructive Surgery
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11. Rheumatoid Arthritis (Management)
 Rest and Activity
– Naps, avoid over-exertion
– Avoid positions of flexion
– Energy conservation
– Exercise therapy – for flexibility, strength, endurance, to
maintain joint mobility/function
 Joint protection
– Splints for acutely inflamed joints
 Cold therapy – for inflammation during flare-ups
 Heat therapy – for chronic stiffness
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12. Gouty Arthritis
 Most common inflammatory arthritis in elderly
– Increasing prevalence with age (75-85 years high)
– Men > women, (for < 65years)
 Deposition of urate crystals in tissue
 Gout in women
– Usually > 65 years.
– Loss of estrogens induced uricosuric effect
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14. Gouty Arthritis (Risk factors)
 Purine rich foods & nutritional supplements (animal
product consumers)
 Some drugs (low dose aspirin, thiazides, niacin,
pyrazinamide, ethanbutol….)
 Obesity & excessive weight gain
 Moderate to heavy alcohol intake, high BP
 Abnormal kidney function
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16. Gouty Arthritis (Management)
NSAIDs:
 Aspirin up to 500mg
 Ibuprofen up to 800mg
 Indomethacin 25-50mg
Corticosteroids:
 prednisone 30-40 mg/d for 5 days
 Prednisolone 5mg
 Bethamethasone 6mg/ml
 Methylprednisolone 16-32 mg
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17. Osteomyelitis
 Is an infection of the bone that becomes
infected by one of the three modes.
– Extension of soft tissue infection (e.g. Vascular
ulcer, incisional infection)
– Direct bone contamination from bone surgery, or
traumatic injury (e.g gun shot)
– Hematogenous spread from other sites of infection
(e.g. upper respiratory infections).
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19. Osteomyelitis (C/M)
 painful,
 swollen and
 extremely tender
Osteomyelitis (lab Diagnosis)
 Elevated leukocyte levels and elevated sedimentation
rate.
 Wound and blood culture studies
 Standard x-ray studies
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20. Osteomyelitis (Management)
 Antibiotic therapy for 3-6 weeks.
– Amoxicillin-clavulanate 875 mg/125 mg PO Q12h or.
– Ciprofloxacin 750 mg PO Q12h plus clindamycin 300-450 mg PO
Q6h or.
– Levofloxacin 750 mg PO daily plus clindamycin 300-450 mg PO
q6h.
 Supportive measures such as hydration, high protein & vitamins.
 Immobilize the affected area to prevent pathogenic fracture.
 Internal fixation or external supportive device may be need.
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Metabolic Bone Disorders

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Loss of bone exceeds rate of
bone formation which
usually increases in older
women, white race and null
parity.

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24. Osteoporosis
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 C/M:
 Mostly ‘silent disease’ b/c of lack of s/sx
 Bone pain,
 Decrease movement
 Easily breakable bones
 Ominous/worrying signs: pain in lower back,
deformity, kyphosis, loss of height, markedly aged
appearance

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26. Osteoporosis (Classification)
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 Generalized osteoporosis occurs most commonly in
postmenopausal women and men in their 60s and
70s……primary osteoporosis (because of
inadequate intake or absorption of calcium, estrogen
deficiency, and sedentary life)
 Secondary osteoporosis results from an associated
medical condition such as hyperparathyroidism,
long-term drug therapy, long-term immobility.
 Regional osteoporosis occurs when a limb is
immobilized.

27. Osteoporosis diagnosis methods
 X-rays
 CT – scans
 Serum calcium, phosphorous and alkaline
phosphatase levels,
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28. Osteoporosis (Management)
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 There is no cure! But as a supportive
management:
 Calcium.. … to enhance bone strength
 Vitamin D … to support bone metabolism
 Estrogen replacement… to decrease bone resorption
 Estrogen with progestin …
 SERM (Selective Estrogen Receptor Modulator) with anti-
estrogens

29. Osteoporosis (Management)
 Exercise
 Avoid caffeine intake
 Improve protein, K,..intake
 Providing hazard free environment to avoid fall
 Safety for pathologic fracture (Health education)
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31. Osteomalacia
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 Softening of the bone tissue characterized by
inadequate mineralization of osteoid.
Causes:
 Lack of activated Vitamin D (this results in poor
utilization of calcium and phosphorous)
 Hyperparathyroidism leads to skeletal decalcification
and thus to osteomalacia by increasing phosphate
excretion in the urine.
 Prolonged use of antiseizure medication (phenytoin,
phenobarbital) poses a risk for osteomalacia, as does
insufficient vitamin D (dietary, sunlight).

32. Osteomalacia
 Osteomalacia may result from failed calcium absorption
(malabsorption syndrome) or from excessive loss of
calcium from the body.
 Gastrointestinal disorders (eg, celiac disease, chronic
biliary tract obstruction, chronic pancreatitis, small bowel
resection) in which fats are inadequately absorbed
 In addition, liver and kidney diseases can produce a lack
of vitamin D because these are the organs that convert
vitamin D to its active form.
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33. Diagnosis method of osteomalacia
 X-rays
 CT – scans
 Serum calcium, phosphorous and alkaline
phosphatase levels,
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34. Osteomalacia
C/M: easily breakable bones,
Management:
 vitamin D from exposure to sunlight
 Nutritional / proteins, minerals/
 Physical, psychological, and pharmaceutical
measures are used to reduce the patient’s
discomfort and pain.
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