NLE Musculoskeletal Nursing — Degenerative, Inflammatory and Metabolic Bone DisordersSummary

Osteoarthritis is a progressive, non-inflammatory (or low-inflammatory) degenerative disorder characterized by breakdown of articular cartilage, forming osteophytes (bone spurs) and joint space narrowing. It is a 'wear-and-tear' disease that predominantly affects weight-bearing joints (knees, hips, spine) and distal finger joints (distal interphalangeal and proximal interphalangeal joints). OA typically presents asymmetrically and worsens with age, obesity, and repetitive joint use. Pain worsens with activity and improves with rest. Morning stiffness is brief (under 30 minutes). Hallmark clinical signs include Heberden's nodes (DIP joints) and Bouchard's nodes (PIP joints). Systemic symptoms are absent, distinguishing OA from inflammatory arthritides. Incidence increases with age; it is the most common type of arthritis, affecting millions worldwide and many in the Philippines, particularly among seniors and manual laborers.

Rheumatoid arthritis is a chronic, systemic, autoimmune inflammatory disorder in which the synovial membrane is attacked by immune complexes, forming a destructive pannus that erodes cartilage and bone. RA typically affects small joints first (hands, wrists, feet) and characteristically presents symmetrically (bilateral). It involves systemic manifestations including prolonged morning stiffness (over 1 hour), fatigue, low-grade fever, weight loss, and malaise. Joint deformities include ulnar deviation and swan-neck deformities. RA is confirmed by elevated inflammatory markers (ESR and CRP) and positive serologic markers (rheumatoid factor and anti-CCP antibodies). Unlike OA, RA requires disease-modifying antirheumatic drugs (DMARDs) such as methotrexate as the anchor therapy. The disease is more aggressive and carries systemic complications if untreated.

Gout is a metabolic disorder of purine metabolism resulting in hyperuricemia and deposition of monosodium urate (MSU) crystals in joints, causing acute inflammatory arthritis. The classic initial site is the great toe (podagra), though gout can affect other joints. Acute attacks present with sudden onset of a red, hot, swollen, exquisitely tender joint, often triggered by purine-rich foods, alcohol (especially beer), diuretics, or acute stress. Chronic untreated gout produces tophi (deposits of urate crystals) and can cause urate nephropathy and kidney stones. Risk factors include male sex, age over 40, family history, obesity, hypertension, chronic kidney disease, and excessive purine intake. In the Philippine context, diet-related triggers are common, including organ meats, shellfish, and alcohol consumption patterns.

Osteoporosis is a metabolic bone disease in which bone resorption by osteoclasts outpaces bone formation by osteoblasts, resulting in low bone mass and increased bone fragility prone to fracture. The disease is often silent (asymptomatic) until a fracture occurs, typically of the hip, vertebrae (causing height loss and kyphosis or 'dowager's hump'), or wrist. Risk factors include postmenopausal estrogen loss (critical in women over 50), advanced age, female sex, small thin frame, low calcium and vitamin D intake, sedentary lifestyle, smoking, excess alcohol, long-term corticosteroid use, and endocrine disorders. Diagnosis is by DEXA scan with T-score interpretation: normal (-1 or above), osteopenia (-1 to -2.5), and osteoporosis (-2.5 or below). Osteoporosis affects millions globally, including a growing number in the Philippines, particularly postmenopausal women.

Osteomyelitis is an infection of bone, most commonly bacterial (Staphylococcus aureus is the most frequent causative organism, followed by Streptococcus and gram-negative organisms). Infection reaches bone through hematogenous spread, from adjacent soft tissue infections, or direct inoculation (open fracture, orthopedic surgery, or bone biopsy). Acute osteomyelitis presents with bone pain, fever, chills, swelling, warmth, erythema, and possibly drainage if a sinus tract forms. Lab findings show elevated WBC, ESR, and CRP. Imaging or bone scan confirms the diagnosis. Chronic osteomyelitis may develop if acute infection is inadequately treated, characterized by exacerbating episodes and the formation of a sequestrum (dead bone). Treatment requires prolonged intravenous antibiotics (typically 4–6 weeks or longer), often continued at home through a central venous catheter. Surgical debridement of necrotic bone may be necessary.

Total hip replacement is a surgical procedure in which the damaged hip joint is replaced with a prosthesis (artificial joint) to relieve pain and restore function in end-stage arthritis. The critical postoperative nursing content is the set of hip precautions designed to prevent dislocation of the prosthesis, the most common complication in the early postoperative period. Hip precautions include: (1) Do NOT flex the hip more than 90 degrees—avoid low chairs, low toilet seats (use raised seats), and bending forward to pick up objects; keep knees below the level of hips. (2) Do NOT adduct the hip past the midline—use an abduction pillow between the legs and do NOT cross the legs. (3) Do NOT internally rotate the hip—keep toes pointing forward/upward. (4) Turn only as ordered, usually onto the unaffected side with a pillow between the legs. Signs of dislocation include sudden severe hip pain, a shortened and internally or externally rotated leg, inability to move or bear weight, and audible 'popping' sound. Additional postoperative care includes DVT/PE prevention (anticoagulants, sequential compression devices, early ambulation), wound and drain management, pain control, and early physical therapy. Total knee replacement requires continuous passive motion (CPM) machine therapy in some protocols.

Low back pain is the most common musculoskeletal complaint globally and in the Philippines, affecting workers, elders, and sedentary populations. Most acute low back pain is mechanical, stemming from muscle strain, ligament sprain, or degenerative disc disease. A herniated intervertebral disc can compress a nerve root, causing radicular pain down the leg (sciatica), numbness, and weakness. Symptoms may include buttock pain, leg pain, foot numbness, and weakness in specific dermatomal distributions. Management of most acute mechanical back pain is conservative: brief activity modification (prolonged bed rest is discouraged), NSAIDs, muscle relaxants, and heat or cold therapy. Proper body mechanics education is essential: bend at the knees (not the waist), keep objects close to the body when lifting, avoid twisting, maintain good posture, sleep on a firm mattress, strengthen core muscles, and maintain healthy weight. Red-flag findings requiring urgent evaluation and possible surgical intervention include new onset bowel or bladder incontinence, saddle anesthesia (loss of sensation in the saddle area), and progressive leg weakness—these suggest cauda equina syndrome, a neurosurgical emergency. Imaging (MRI or CT) is indicated for persistent symptoms refractory to conservative care or when red flags are present. Confirmed herniated discs may require discectomy or laminectomy; postoperative teaching includes log-rolling to maintain spine alignment and assessment for CSF leak.

Common NANDA nursing diagnoses applicable to patients with degenerative, inflammatory, and metabolic bone disorders include: Acute Pain or Chronic Pain (related to joint inflammation, bone pathology, or muscle guarding); Impaired Physical Mobility (related to joint pain, stiffness, or structural limitations); Risk for Falls (related to joint instability, weakness, or balance impairment—especially in osteoporosis); Risk for Infection (in osteomyelitis or postoperative joint replacement); Deficient Knowledge (regarding disease process, medication, diet, or precautions); Disturbed Body Image (related to joint deformities or limb shortening); Social Isolation (related to mobility limitations); and Ineffective Coping (related to chronic illness). Using Maslow's hierarchy of needs, physical safety needs (pain control, fall prevention, infection prevention) are prioritized before higher-level needs (self-actualization, coping).

Pharmacologic management varies by disorder: (1) Osteoarthritis: acetaminophen is first-line analgesia; NSAIDs (ibuprofen, naproxen) added as needed; topical agents (capsaicin, diclofenac gel). (2) Rheumatoid Arthritis: methotrexate is the anchor DMARD (monitor for hepatotoxicity, bone marrow suppression, and teratogenicity; give folic acid to reduce side effects); NSAIDs and short courses of corticosteroids for inflammation; biologic agents (TNF inhibitors like etanercept) for refractory disease (increase infection risk). (3) Gout: acute flares managed with colchicine (watch for GI toxicity) or NSAIDs; chronic prevention with allopurinol (xanthine oxidase inhibitor; do NOT initiate during acute attack; encourage fluids; monitor for rash); probenecid promotes uric acid excretion (second-line). (4) Osteoporosis: calcium (1000–1200 mg/day) and vitamin D (800–1000 IU/day); bisphosphonates (alendronate, risedronate) inhibit osteoclastic resorption—CRITICAL teaching: take on empty stomach with full glass of plain water in the morning; remain upright for at least 30 minutes to prevent esophageal erosion/esophagitis. (5) Osteomyelitis: prolonged IV antibiotics (typically 4–6 weeks)—common first-line: nafcillin or oxacillin for S. aureus (if methicillin-sensitive); vancomycin if resistant; fluoroquinolones for some gram-negative infections.

OA is degenerative (cartilage wears away), while RA is autoimmune inflammatory (immune system attacks synovium). This distinction drives different treatment approaches: OA uses analgesics and joint protection, while RA requires DMARDs and immunosuppression. Understanding this relationship prevents treatment errors.

Gout is acute, episodic, and diet-triggered (purine/alcohol), while OA is chronic, progressive, and activity-worsened. Gout flares respond to colchicine/NSAIDs and are prevented by dietary modification, whereas OA requires weight reduction and joint protection. This distinction affects patient education and management.

Osteoporosis involves bone resorption-formation imbalance (making bone fragile and fracture-prone), while osteomyelitis is bacterial bone infection (causing localized bone destruction and systemic symptoms). Management differs: osteoporosis is preventive/medical, while osteomyelitis requires antibiotics and possible surgery. However, both increase fracture risk and require careful handling.

The prosthesis has a reduced range of motion compared to a native joint. Hip precautions (no flexion beyond 90°, no adduction past midline, no internal rotation) maintain the prosthetic in its stable position. Understanding the anatomic basis of these precautions helps nurses teach them more effectively to patients and families.

Mechanical pain (muscle strain, disc bulge) is usually managed conservatively with rest, NSAIDs, and exercise. Neuropathic pain with red flags (cauda equina syndrome) requires urgent imaging and possible surgery. The presence or absence of neurologic signs drives the urgency and intensity of intervention.

RA is not just a joint disease; it causes systemic inflammation (fever, weight loss, fatigue), increases cardiovascular disease and infection risk (especially with biologic agents), and requires monitoring of liver and marrow function. This systemic nature distinguishes RA from OA and drives comprehensive nursing care beyond the joints.

Bisphosphonates inhibit bone resorption but must be taken correctly (empty stomach, upright 30 min) to be absorbed and prevent esophageal complications. Poor adherence results in inadequate bone protection and fracture risk. This relationship emphasizes the importance of patient teaching and follow-up.

Inadequate antibiotic duration or poor adherence to IV therapy leads to treatment failure and chronic infection. Nurses must educate patients and families about completing the full course (often 4–6 weeks), managing central lines, and recognizing signs of persistent infection. This relationship highlights the extended nature of bone infection treatment.