NurseReview.Org Musculoskeletal System

Slide 1: MUSCULO-SKELETAL SYSTEM Nurse Licensure Examination Review

Slide 2: Review of Anatomy and Physiology  The musculo-skeletal system consists of the muscles, tendons, bones and cartilage together with the joints  The primary function of which is to produce skeletal movements

Slide 3: Muscles Three types of muscles exist in the body  1. Skeletal Muscles  Voluntary and striated  2. Cardiac muscles  Involuntary and striated  3. Smooth/Visceral muscles  Involuntary and NON-striated

Slide 4: TENDONS  Bands of fibrous connective tissue that tie bones to muscles

Slide 5: LIGAMENTS  Strong, dense and flexible bands of fibrous tissue connecting bones to another bone

Slide 6: BONES Variously classified according to shape,  location and size  Functions 1. Locomotion 2. Protection 3. Support and lever 4. Blood production 5. Mineral deposition

Slide 7: JOINTS  Thepart of the Skeleton where two or more bones are connected

Slide 8: CARTILAGES A dense connective tissue that consists of fibers embedded in a strong gel-like substance

Slide 9: BURSAE  Saccontaining fluid that are located around the joints to prevent friction

Slide 10: ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM The nurse usually evaluates this small part of the over-all assessment and concentrates on the patient’s posture, body symmetry, gait and muscle and joint function

Slide 11: ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM  1. HISTORY  2. Physical Examination  Perform a head to toe assessment  Nurses need to inspect and palpate  The special procedure is the assessment of joint and muscle movement  Usually, a tape measure and a protractor are the only instruments

Slide 12: ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM  Gait  Posture  Muscular palpation  Joint palpation  Range of motion  Muscle strength

Slide 13: ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM LABORATORY PROCEDURES  1. BONE MARROW ASPIRATION Usually involves aspiration of the marrow to  diagnose diseases like leukemia, aplastic anemia Usual site is the sternum and iliac crest  Pre-test: Consent  Intratest: Needle puncture may be painful  Post-test: maintain pressure dressing and  watch out for bleeding

Slide 14: ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM LABORATORY PROCEDURES  2. Arthroscopy  A direct visualization of the joint cavity  Pre-test: consent, explanation of procedure, NPO  Intra-test: Sedative, Anesthesia, incision will be made  Post-test: maintain dressing, ambulation as soon as awake, mild soreness of joint for 2 days, joint rest for a few days, ice application to relieve discomfort

Slide 15: ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM LABORATORY PROCEDURES 3. BONE SCAN  Imaging study with the use of a contrast radioactive material  Pre-test: Painless procedure, IV radioisotope is used, no special preparation, pregnancy is contraindicated  Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed, Supine position for scanning  Post-test: Increase fluid intake to flush out radioactive material

Slide 16: ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM LABORATORY PROCEDURES 4. DXA- Dual-energy XRAY absorptiometry  Assesses bone density to diagnose osteoporosis  Uses LOW dose radiation to measure bone density  Painless procedure, non-invasive, no special preparation  Advise to remove jewelry

Slide 18: Common musculoskeletal problems The Nursing Management

Slide 19: Nursing Management of common musculo- skeletal problems PAIN  These can be related to joint inflammation, traction, surgical intervention  1. Assess patient’s perception of pain  2. Instruct patient alternative pain management like meditation, heat and cold application, TENS and guided imagery

Slide 20: Nursing Management PAIN  3. Administer analgesics as prescribed  UsuallyNSAIDS  Meperidine can be given for severe pain  4.Assess the effectiveness of pain measures

Slide 21: Nursing Management IMPAIRED PHYSICAL MOBILITY  1. Instruct patient to perform range of motion exercises, either passive or active  2. Provide support in ambulation with assistive devices  3. Turn and change position every 2 hours  4. Encourage mobility for a short period and provide positive reinforcements for small accomplishments

Slide 22: Nursing Management SELF-CARE DEFICITS  1. Assess functional levels of the patient  2. Provide support for feeding problems  Place patient in Fowler’s position  Provide assistive device and supervise mealtime  Offer finger foods that can be handled by patient  Keep suction equipment ready

Slide 23: Nursing Management SELF-CARE DEFICITS  3. Assist patient with difficulty bathing and hygiene  Assist with bath only when patient has difficulty  Provide ample time for patient to finish activity

Slide 24: Musculoskeletal Modalities Traction Cast

Slide 25: Nursing Management Traction  A method of fracture immobilization by applying equipments to align bone fragments  Used for immobilization, bone alignment and relief of muscle spasm

Slide 26: Traction  Skin traction  Skeletal traction

Slide 27: Traction  Pulling force exerted on bones to reduce or immobilize fractures, reduce muscle spasm, correct or prevent deformities

Slide 30: Nursing Management Traction: General principles  1. ALWAYS ensure that the weights hang freely and do not touch the floor  2. NEVER remove the weights  3. Maintain proper body alignment  4. Ensure that the pulleys and ropes are properly functioning and fastened by tying square knot

Slide 31: Nursing Management Traction: General principles  5. Observe and prevent foot drop  Provide foot plate  6. Observe for DVT, skin irritation and breakdown  7. Provide pin care for clients in skeletal traction- use of hydrogen peroxide

Slide 32: Nursing Management CAST  Immobilizing tool made of plaster of Paris or fiberglass  Provides immobilization of the fracture

Slide 33: Nursing Management CAST: types 2. Long arm 3. Short arm 4. Spica

Slide 34: Casting Materials  Plaster of Paris  Drying takes 1-3 days  If dry, it is SHINY, WHITE, hard and resistant  Fiberglass  Lightweight and dries in 20-30 minutes  Water resistant

Slide 35: Nursing Management CAST: General Nursing Care  1. Allow the cast to dry (usually 24-72 hours)  2. Handle a wet cast with the PALMS not the fingertips  3. Keep the casted extremity ELEVATED using a pillow  4. Turn the extremity for equal drying. DO NOT USE DRYER for plaster cast

Slide 36: Nursing Management CAST: General Nursing Care 5. Petal the edges of the cast to prevent crumbling of the edges 6. Examine the skin for pressure areas and Regularly check the pulses and skin

Slide 37: Nursing Management CAST: General Nursing Care 7. Instruct the patient not to place sticks or small objects inside the cast 8. Monitor for the following: pain, swelling, discoloration, coolness, tingling or lack of sensation and diminished pulses

Slide 38: Common Musculoskeletal conditions Nursing management

Slide 39: METABOLIC BONE DISORDERS Osteoporosis  A disease of the bone characterized by a decrease in the bone mass and density with a change in bone structure

Slide 40: METABOLIC BONE DISORDERS Osteoporosis: Pathophysiology  Normal homeostatic bone turnover is altered rate of bone RESORPTION is greater than bone FORMATION reduction in total bone mass reduction in bone mineral density prone to FRACTURE

Slide 41: METABOLIC BONE DISORDERS Osteoporosis: TYPES  1. Primary Osteoporosis- advanced age, post-menopausal  2. Secondary osteoporosis- Steroid overuse, Renal failure

Slide 42: METABOLIC BONE DISORDERS RISK factors for the development of Osteoporosis  1. Sedentary lifestyle  2. Age  3. Diet- caffeine, alcohol, low Ca and Vit D  4. Post-menopausal  5. Genetics- caucasian and asian  6. Immobility

Slide 43: METABOLIC DISORDER ASSESSMENT FINDINGS  1. Low stature  2. Fracture  Femur  3. Bone pain

Slide 44: METABOLIC DISORDER LABORATORY FINDINGS  1. DEXA-scan  Provides information about bone mineral density  T-score is at least 2.5 SD below the young adult mean value  2. X-ray studies

Slide 45: METABOLIC DISORDER Medical management of Osteoporosis  1. Diet therapy with calcium and Vitamin D  2. Hormone replacement therapy  3. Biphosphonates- Alendronate, risedronate produce increased bone mass by inhibiting the OSTEOCLAST  4. Moderate weight bearing exercises  5. Management of fractures

Slide 46: METABOLIC DISORDER Osteoporosis Nursing Interventions 1. Promote understanding of osteoporosis and the treatment regimen  Provide adequate dietary supplement of calcium and vitamin D  Instruct to employ a regular program of moderate exercises and physical activity  Manage the constipating side-effect of calcium supplements

Slide 47: METABOLIC DISORDER Osteoporosis Nursing Interventions  Take calcium supplements with meals  Take alendronate with an EMPTY stomach with water  Instruct on intake of Hormonal replacement

Slide 48: METABOLIC DISORDER Osteoporosis Nursing Interventions 2. Relieve the pain  Instruct the patient to rest on a firm mattress  Suggest that knee flexion will cause relaxation of back muscles  Heat application may provide comfort  Encourage good posture and body mechanics  Instruct to avoid twisting and heavy lifting

Slide 49: METABOLIC DISORDER Osteoporosis Nursing Interventions  3. Improve bowel elimination  Constipation is a problem of calcium supplements and immobility  Advise intake of HIGH fiber diet and increased fluids

Slide 50: METABOLIC DISORDER Osteoporosis Nursing Interventions  4. Prevent injury  Instruct to use isometric exercise to strengthen the trunk muscles  AVOID sudden jarring, bending and strenuous lifting  Provide a safe environment

Slide 51: Juvenile rheumatoid Arthritis  Definition:  AUTO-IMMUNE inflammatory joint disorder of UNKNOWN cause  SYSTEMIC chronic disorder of connective tissue  Diagnosed BEFORE age 16 years old

Slide 52: Juvenile rheumatoid Arthritis  PATHOPHYSIOLOGY : unknown  Affected by stress, climate and genetics  Common in girls 2-5 and 9-12 y.o.

Slide 53: Juvenile rheumatoid Arthritis Systemic JRA Pauci-articular Polyarticular FEVER MILD joint pain Morning joint and swelling stiffness and fever IRIDOCYCLITIS Salmon-pink Weight rash Bearing joints Five or more Less than 4 Five or more joints joints joints Anorexia, Very Good Poor prognosis anemia, fatigue prognosis

Slide 54: JRA  Symptoms may decrease as child enters adulthood  With periods of remissions and exacerbations

Slide 55: JRA Medical Management 2. ASPIRIN and NSAIDs- mainstay treatment 3. Slow-acting anti-rheumatic drugs 4. Corticosteroids

Slide 56: JRA Nursing Management 2. Encourage normal performance of daily activities 3. Assist child in ROM exercises 4. Administer medications 5. Encourage social and emotional development

Slide 57: JRA Nursing Management During acute attack:  SPLINT the joints  NEUTRAL positioning  Warm or cold packs

Slide 58: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS  The most common form of degenerative joint disorder

Slide 59: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS  Chronic, NON-systemic disorder of joints

Slide 60: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Pathophysiology  Injury, genetic, Previous joint damage, Obesity, Advanced age  Stimulate the chondrocytes to release chemicals chemicals will cause cartilage degeneration, reactive inflammation of the synovial lining and bone stiffening

Slide 61: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Risk factors  1. Increased age  2. Obesity  3. Repetitive use of joints with previous joint damage  4. Anatomical deformity  5. genetic susceptibility

Slide 62: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Assessment findings  1. Joint pain  2. Joint stiffness  3. Functional joint impairment limitation  The joint involvement is ASYMMETRICAL  This is not systemic, there is no FEVER, no severe swelling  Atrophy of unused muscles  Usual joint are the WEIGHT bearing joints

Slide 63: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Assessment findings 1. Joint pain  Caused by  Inflamed synovium  Stretching of the joint capsule  Irritation of nerve endings

Slide 64: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Assessment findings 2. Stiffness  commonly occurs in the morning after awakening  Lasts only for less than 30 minutes  DECREASES with movement  Crepitation may be elicited

Slide 65: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Diagnostic findings 1. X-ray  Narrowing of joint space  Loss of cartilage  Osteophytes 2. Blood tests will show no evidence of systemic inflammation and are not useful

Slide 66: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Medical management  1. Weight reduction  2. Use of splinting devices to support joints  3. Occupational and physical therapy  4. Pharmacologic management  Use of PARACETAMOL, NSAIDS  Use of Glucosamine and chondroitin  Topical analgesics  Intra-articular steroids to decrease inflam

Slide 67: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Nursing Interventions  1. Provide relief of PAIN  Administer prescribed analgesics  Application of heat modalities. ICE PACKS may be used in the early acute stage!!!  Plan daily activities when pain is less severe  Pain meds before exercising

Slide 68: DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS: Nursing Interventions  2. Advise patient to reduce weight  Aerobic exercise  Walking  3. Administer prescribed medications  NSAIDS

Slide 69: Rheumatoid arthritis A type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more women (ages 35-45) than men

Slide 70: Rheumatoid arthritis FACTORS: Genetic Auto-immune connective tissue disorders Fatigue, emotional stress, cold, infection

Slide 71: Rheumatoid arthritis Pathophysiology  Immune reaction in the synovium  attracts neutrophils  releases enzymes  breakdown of collagen  irritates the synovial liningcausing synovial inflammation edema and pannus formation and joint erosions and swelling

Slide 72: Rheumatoid arthritis ASSESSMENT FINDINGS  1. PAIN  2. Joint swelling and stiffness- SYMMETRICAL, Bilateral  3. Warmth, erythema and lack of function  4. Fever, weight loss, anemia, fatigue  5. Palpation of join reveals spongy tissue  6. Hesitancy in joint movement

Slide 73: Rheumatoid arthritis ASSESSMENT FINDINGS  Joint involvement is SYMMETRICAL and BILATERAL  Characteristically beginning in the hands, wrist and feet  Joint STIFFNESS occurs early morning, lasts MORE than 30 minutes, not relieved by movement, diminishes as the day progresses

Slide 74: Rheumatoid arthritis ASSESSMENT FINDINGS  Joints are swollen and warm  Painful when moved  Deformities are common in the hands and feet causing misalignment  Rheumatoid nodules may be found in the subcutaneous tissues

Slide 75: Rheumatoid arthritis Diagnostic test  1. X-ray  Shows bony erosion  2. Blood studies reveal (+) rheumatoid factor, elevated ESR and CRP and ANTI-nuclear antibody  3. Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing numerous WBC and inflammatory proteins

Slide 76: Rheumatoid arthritis MEDICAL MANAGEMENT  1. Therapeutic dose of NSAIDS and Aspirin to reduce inflammation  2. Chemotherapy with methotrexate, antimalarials, gold therapy and steroid  3. For advanced cases- arthroplasty, synovectomy  4. Nutritional therapy

Slide 77: Rheumatoid arthritis MEDICAL MANAGEMENT GOLD THERAPY:  IM or Oral preparation  Takes several months (3-6) before effects can be seen  Can damage the kidney and causes bone marrow depression

Slide 78: Rheumatoid arthritis Nursing MANAGEMENT 1. Relieve pain and discomfort  USE splints to immobilize the affected extremity during acute stage of the disease and inflammation to REDUCE DEFORMITY  Administer prescribed medications  Suggest application of COLD packs during the acute phase of pain, then HEAT application as the inflammation subsides

Slide 79: Rheumatoid arthritis Nursing MANAGEMENT 2. Decrease patient fatigue Schedule activity when pain is less severe Provide adequate periods of rests 3. Promote restorative sleep

Slide 80: Rheumatoid arthritis Nursing Management 4. Increase patient mobility  Advise proper posture and body mechanics  Support joint in functional position  Advise ACTIVE ROME

Slide 81: Rheumatoid arthritis Nursing Management 5. Provide Diet therapy  Patients experience anorexia, nausea and weight loss  Regular diet with caloric restrictions because steroids may increase appetite  Supplements of vitamins, iron and PROTEIN

Slide 82: Rheumatoid arthritis 6. Increase Mobility and prevent deformity:  Lie FLAT on a firm mattress  Lie PRONE several times to prevent HIP FLEXION contracture  Use one pillow under the head because of risk of dorsal kyphosis  NO Pillow under the joints because this promotes flexion contractures

Slide 83: Hot versus Cold HOT Cold Use to RELIEVE joint Use to control stiffness, pain and inflammation and pain muscle spasm After acute attack ACUTE ATTACK

Slide 84: Gouty arthritis A systemic disease caused by deposition of uric acid crystals in the joint and body tissues  CAUSES:  1. Primary gout- disorder of Purine metabolism  2. Secondary gout- excessive uric acid in the blood like leukemia

Slide 87: Gouty arthritis  ASSESSMENT FINDINGS  1. Severe pain in the involved joints, initially the big toe  2. Swelling and inflammation of the joint  3. TOPHI- yellowish-whitish, irregular deposits in the skin that break open and reveal a gritty appearance  4. PODAGRA

Slide 88: Gouty arthritis ASSESSMENT FINDINGS  5. Fever, malaise  6. Body weakness and headache  7. Renal stones

Slide 89: Gouty arthritis DIAGNOSTIC TEST  Elevated levels of uric acid in the blood  Uric acid stones in the kidney

Slide 90: Gouty arthritis  Medical management  1. Allupurinol- take it WITH FOOD Rash signifies allergic reaction   2. Colchicine For acute attack 

Slide 91: Gouty arthritis Nursing Intervention 1. Provide a diet with LOW purine  Avoid Organ meats, aged and processed foods  STRICT dietary restriction is NOT necessary 2. Encourage an increased fluid intake (2- 3L/day) to prevent stone formation 3. Instruct the patient to avoid alcohol 4. Provide alkaline ash diet to increase urinary pH 5. Provide bed rest during early attack of gout

Slide 92: Gouty arthritis Nursing Intervention 6. Position the affected extremity in mild flexion 7. Administer anti-gout medication and analgesics

Slide 93: Fracture A break in the continuity of the bone and is defined according to its type and extent

Slide 94: Fracture mechanical Stress to bone   Severe bone fracture  Direct Blows  Crushing forces  Sudden twisting motion  Extreme muscle contraction

Slide 95: Fracture TYPES OF FRACTURE  1. Complete fracture  Involves a break across the entire cross- section  2. Incomplete fracture  The break occurs through only a part of the cross-section

Slide 97: Fracture TYPES OF FRACTURE  1. Closed fracture  The fracture that does not cause a break in the skin  2. Open fracture  The fracture that involves a break in the skin

Slide 99: Fracture TYPES OF FRACTURE  1. Comminuted fracture A fracture that involves production of several bone fragments  2. Simple fracture A fracture that involves break of bone into two parts or one

Slide 100: Fracture ASSESSMENT FINDINGS  1. Pain or tenderness over the involved area  2. Loss of function  3. Deformity  4. Shortening  5. Crepitus  6. Swelling and discoloration

Slide 101: Fracture ASSESSMENT FINDINGS 1. Pain  Continuous and increases in severity  Muscles spasm accompanies the fracture is a reaction of the body to immobilize the fractured bone

Slide 102: Fracture ASSESSMENT FINDINGS 2. Loss of function  Abnormal movement and pain can result to this manifestation

Slide 103: Fracture ASSESSMENT FINDINGS 3. Deformity  Displacement, angulations or rotation of the fragments Causes deformity

Slide 104: Fracture ASSESSMENT FINDINGS 4. Crepitus  A grating sensation produced when the bone fragments rub each other

Slide 105: Fracture  DIAGNOSTIC TEST  X-ray

Slide 106: Fracture EMERGENCY MANAGEMENT OF FRACTURE  1. Immobilize any suspected fracture  2. Support the extremity above and below when moving the affected part from a vehicle  3. Suggested temporary splints- hard board, stick, rolled sheets  4. Apply sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged to the chest

Slide 107: Fracture EMERGENCY MANAGEMENT OF FRACTURE  5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination  6. DO NOT attempt to reduce the facture

Slide 108: Fracture MEDICAL MANAGEMENT  1. Reduction of fracture either open or closed, Immobilization and Restoration of function  2. Antibiotics, Muscle relaxants and Pain medications

Slide 109: Fracture General Nursing MANAGEMENT  For CLOSED FRACTURE  1. Assist in reduction and immobilization  2. Administer pain medication and muscle relaxants  3. teach patient to care for the cast  4. Teach patient about potential complication of fracture and to report infection, poor alignment and continuous pain

Slide 110: Fracture General Nursing MANAGEMENT  For OPEN FRACTURE  1. Prevent wound and bone infection  Administer prescribed antibiotics  Administer tetanus prophylaxis  Assist in serial wound debridement  2. Elevate the extremity to prevent edema formation  3. Administer care of traction and cast

Slide 111: Fracture  FRACTURE COMPLICATIONS  Early  1. Shock  2. Fat embolism  3. Compartment syndrome  4. Infection  5. DVT

Slide 112: Fracture  FRACTURE COMPLICATIONS  Late  1. Delayed union  2. Avascular necrosis  3. Delayed reaction to fixation devices  4. Complex regional syndrome

Slide 113: Fracture  FRACTURE COMPLICATIONS: Fat Embolism  Occurs usually in fractures of the long bones  Fat globules may move into the blood stream because the marrow pressure is greater than capillary pressure  Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs

Slide 114: Fracture  FRACTURE COMPLICATIONS: Fat Embolism  Onset is rapid, within 24-72 hours  ASSESSMENT FINDINGS  1. Sudden dyspnea and respiratory distress  2. tachycardia  3. Chest pain  4. Crackles, wheezes and cough  5. Petechial rashes over the chest, axilla and hard palate

Slide 115: Fracture  FRACTURE COMPLICATIONS: Fat Embolism  Nursing Management  1. Support the respiratory function  Respiratory failure is the most common cause of death  Administer O2 in high concentration  Prepare for possible intubation and ventilator support

Slide 116: Fracture  FRACTURE COMPLICATIONS: Fat Embolism  Nursing Management  2. Administer drugs  Corticosteroids  Dopamine  Morphine

Slide 117: Fracture FRACTURE COMPLICATIONS: Fat Embolism   Nursing Management  3. Institute preventive measures  Immediate immobilization of fracture  Minimal fracture manipulation  Adequate support for fractured bone during turning and positioning  Maintain adequate hydration and electrolyte balance

Slide 118: Fracture  Early complication: Compartment syndrome  A complication that develops when tissue perfusion in the muscles is less than required for tissue viability

Slide 119: Fracture  Early complication: Compartment syndrome  ASSESSMENT FINDINGS  1. Pain- Deep, throbbing and UNRELIEVED pain by opiods  Pain is due to reduction in the size of the muscle compartment by tight cast  Pain is due to increased mass in the compartment by edema, swelling or hemorrhage

Slide 120: Fracture  Early complication: Compartment syndrome  ASSESSMENT FINDINGS  2. Paresthesia- burning or tingling sensation  3. Numbness  4. Motor weakness  5. Pulselessness, impaired capillary refill time and cyanotic skin

Slide 121: Fracture  Early complication: Compartment syndrome  Medical and Nursing management  1. Assess frequently the neurovascular status of the casted extremity  2. Elevate the extremity above the level of the heart  3. Assist in cast removal and FASCIOTOMY

Slide 122: Strains Excessive stretching of a muscle or  tendon  Nursing management  1. Immobilize affected part  2. Apply cold packs initially, then heat packs  3. Limit joint activity  4. Administer NSAIDs and muscle relaxants

Slide 123: Sprains Excessive stretching of the LIGAMENTS   Nursing management  1. Immobilize extremity and advise rest  2. Apply cold packs initially then heat packs  3. Compression bandage may be applied to relieve edema  4. Assist in cast application  5. Administer NSAIDS