Published on January 12, 2009
Musculoskeletal System : Musculoskeletal System NUR 105 Adult Health Assessment of Musculoskeletal Function Skeletal System : Skeletal System Bone types Bone structure Bone function Bone growth and metabolism affected by calcium and phosphorous, calcitonin, vitamin D, parathyroid, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin. MusculoskeletalAnatomy and Physiology : MusculoskeletalAnatomy and Physiology Anatomy Flat, Short, Long, Irregular bones Muscles – visceral, cardiac, skeletal Joints – freely & slight moveable, synovial fluid Cartilage,Ligaments, Tendons, Fascia, Bursae Physiology Structure, shape, movement, protection, support, hematopoiesis Joints : Joints Types include synarthrodial, amphiarthrodial, diarthrodial Structure and function of the diarthrodial or synovial joint Subtyped by anatomic structure Ball-and-socket Hinge Condylar Biaxial Pivot A & P of Skeletal : A & P of Skeletal MusculoskeletalAssessment : MusculoskeletalAssessment Health History Subjective Data -Chief Complaints – pain, altered sensation, limited motion Family history, personal history, dietary history, socioeconomic status Medications (steroids); Current health problems - obesity Objective Data - Physical Exam Objective Data - Diagnostic Tests Special Assessment Techniques Ballottement Bulge Sign Phalen Tinel’s Physical Exam : Physical Exam Mental Status General inspection Head and neck: temporomandibular joint; crepitus Height, weight, nutritional status, skin, spine – lordosis, scoliosis, posture, joint function, upper and lower extremities Posture, gait, ROM ex., deep tendon reflexes, bone integrity, muscle strength and tone, neurovascular, MS injuries Scoliosis : Scoliosis Abnormal spinal curvature of various degrees or severity involving shortening of muscles and ligaments. Milwaukee brace, internal fixative devices. Diagnostic Evaluation : Diagnostic Evaluation Imaging Procedures – CT, Bone Scan, MRI Nuclear Studies - radioisotope bone density, Endoscopic Studies –arthrocentesis, arthroscopy Other Studies –biopsy, synovial fluid, Arthrogram, venogram, Electromyography Myelography* Laboratory Studies MusculoskeletalAssessment – Diagnostic Test : MusculoskeletalAssessment – Diagnostic Test Laboratory Urine Tests 24 hour creatine-creatinine ratio Urine Uric acid –24 hr specimen Urine deoxypyridino- line Laboratory Blood Tests Serum muscle enzymes Rheumatoid Factor LE Prep/Antinuclear Antibodies(ANA) Erythrocyte Sedimentation Rate Calcium, Phosphorous, Alkaline phosphatase MuscluloskeletalAssessment – Diagnostic : MuscluloskeletalAssessment – Diagnostic Blood Tests CBC – Hgb, Hct Acid phosphatase Metabolic/Endocrine Enzymes Increase creatine kinase, serum increase glutamin-oxaloacetic due to muscle damage, aldolase, SGOT Musculoskeletal - Radiographic : Musculoskeletal - Radiographic Standard radiography, tomography and xeroradiography, myelography, arthrography and CT Other diagnostic tests: bone and muscle biopsy MS – Diagnostic TestsElectromyography : MS – Diagnostic TestsElectromyography EMG aids in the diagnosis of neuromuscular, lowert motor neuron, and peripheral nerve disorders; usually with nerve conduction studies. Low electrical currents are passed through flat electrodes placed along the nerve. If needles are used, inspect needle sites for hematoma formation. Arthroscopy : Arthroscopy Fiberoptic tube is inserted into a joint for direct visualization. Client must be able to flex the knee; exercises are prescribed for ROM. Evaluate the neurovascular status of the affected limb frequently. Analgesics are prescribed. Monitor for complications. MS – Diagnostic Tests : MS – Diagnostic Tests Bone Scan Gaillum or Thallium scan Magnetic resonance imaging Ultrasonography Metabolic Bone Disorders : Metabolic Bone Disorders Osteoporosis Osteomalcia Paget’s Disease Osteoporosis : Osteoporosis A disease in which loss of bone exceeds rate of bone formation; usually increase in older women, white race, nulliparity. Clinical Manifestations – bone pain, decrease movement. Treatment – Calcium, Vit. D, estrogen replacement, Calcitonin, fluoride, estrogen with progestin, SERM with anti-estrogens, exercise. Pathologic fracture-safety. Classification of Osteoporosis : Classification of Osteoporosis Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s. 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. Health Promotion/Illness Prevention - Osteoporosis : Health Promotion/Illness Prevention - Osteoporosis Ensure adequate calcium intake. Avoid sedentary life style. Continue program of weight-bearing exercises. Osteoporosis - Assessment : Osteoporosis - Assessment Physical assessment Psychosocial assessment Laboratory assessment Radiographic assessment Slide 29: Os Osteoposrois Osteoporosis Slide 30: Osteoporosis Drug TherapyOsteoporosis : Drug TherapyOsteoporosis Hormone replacement therapy Parathyroid hormone Calcium and vitamin D Bisphosphonates Selective estrogen receptor modulators Calcitonin Other agents used with varying results Diet Therapy - Osteoporosis : Diet Therapy - Osteoporosis Protein Magnesium Vitamin K Trace minerals Calcium and vitamin D Avoid alcohol and caffeine Fall Prevention - Osteoporosis : Fall Prevention - Osteoporosis Hazard-free environment High-risk assessment through programs such as Falling Star protocol Hip protectors that prevent hip fracture in case of a fall Others - Osteoporosis : Others - Osteoporosis Exercise Pain management Orthotic devices Osteomalacia : Osteomalacia Softening of the bone tissue characterized by inadequate mineralization of osteoid Vitamin D deficiency, lack of sunlight exposure Similar, but not the same as osteoporosis Major treatment: vitamin D from exposure to sun and certain foods Paget’s Disease of the Bone : Paget’s Disease of the Bone Metabolic disorder of bone remodeling, or turnover; increased resorption of loss results in bone deposits that are weak, enlarged, and disorganized Nonsurgical management: calcitonin, selected bisphosphonates, mithramycin Surgical management: tibial osteotomy or partial or total joint replacement Paget’s Disease : Paget’s Disease A imbalance of increase osteoblast and osteoclast cells; thickening and hypertrophy. Bone pain most common symptom; bony enlargement and deformities usually bilateral, kyphosis, long bone. Analgesics, meds bisphosphonates and calcitonin, NSAID, assistance devices, and hot/cold treatment. Osteomyelitis : Osteomyelitis A condition caused by the invasion by one or more pathogenic microorganisms that stimulates the inflammatory response in bone tissue Exogenous, endogenous, hematogenous, contiguous Drug therapy Infection control Hyperbaric oxygen therapy Osteomyelitis : Osteomyelitis Infection of bone; causative agent – Staph/Strept Typical signs and symptoms Treatment – IV antibiotic; long term for 4-6 months Surgical Management Osteomyelitis : Surgical Management Osteomyelitis Sequestrectomy Bone grafts Bone segment transfers Muscle flaps Amputation Bone Tumors : Bone Tumors Benign Bone Tumors Malignant Bone Tumors Metastatic Bone Disease Bone Tumors : Bone Tumors Benign bone tumors (noncancerous): Chrondrogenic tumors: osteochondroma, chondroma Osteogenic tumors: osteoid osteoma, osteoblastoma, giant cell tumor Fibrogenic tumors Interventions : Interventions Nondrug pain relief measures Drug therapy: analgesics, NSAIDs Surgical therapy: curettage (simple excision of the tumor tissue), joint replacement, or arthrodesis Osteosarcoma : Osteosarcoma Cancer of the bone – metastasis to the lung is common. Most in long bones. Clinical manifestations – dull pain, swelling, intermittent but increases per time; night pain common. Treatment – radiation, chemotherapy, hormonal therapy, surgical excision with prosthetics, assistance devices, palliative measures. Malignant Bone Tumors : Malignant Bone Tumors Primary tumors, those tumors that originate in the bone Osteosarcoma Ewing’s sarcoma Chondrosarcoma Fibrosarcoma Metastatic bone disease Cancer of BoneAcute Pain; Chronic Pain : Cancer of BoneAcute Pain; Chronic Pain Interventions include: Treatment aimed at reducing the size or removing the tumor Drug therapy; chemotherapy Radiation therapy Surgical management Promotion of physical mobility with ROM exercises Cancer of Bone Anticipatory Grieving : Cancer of Bone Anticipatory Grieving Interventions include: Active listening Encouraging client and family to verbalize feelings Making appropriate referrals Helping client and others to cope with the loss and grieving Promoting the physician-client relationship Disturbed Body Image – Cancer of Bone : Disturbed Body Image – Cancer of Bone Interventions include: Recognize and accept the client’s view of body image alteration. Establish and maintain a trusting nurse-client relationship. Emphasize the client’s strengths and remaining capabilities. Establish realistic mutual goals. Potential for FracturesBone Cancer : Potential for FracturesBone Cancer Interventions Nonsurgical management: radiation therapy and strengthening exercises. Surgical management: replace as much of the defective bone as possible, avoid a second procedure, and return client to a functioning state with a minimum of hospitalization and immobilization. Carpal Tunnel Syndrome : Carpal Tunnel Syndrome Common condition; the median nerve in the wrist becomes compressed, causing pain and numbness Common repetitive strain injury via occupational or sports motions Nonsurgical management: drug therapy and immobilization Possible surgical management Hand Disorders : Hand Disorders Dupuytren's contracture—slowly progressive contracture of the palmar fascia resulting in flexion of the fourth or fifth digit of the hand Ganglion—a round, cystlike lesion, often overlying a wrist joint or tendon Disorders of the Foot : Disorders of the Foot Hallux valgus Hammertoe Morton’s neuroma Tarsal tunnel syndrome Plantar fasciitis Other problems of the foot Scoliosis : Scoliosis Changes in muscles and ligaments on the concave side of the spinal column Congenital, neuromuscular, or idiopathic in type Assessment: complete history, pain assessment, observation of posture Interventions: exercise, weight reduction, bracing, casting, surgery Osteogenesis Imperfecta : Osteogenesis Imperfecta Rare genetic disorder in which the bones are fragile and fracture easily, resulting in bone deformity Clinical manifestations: poor skeletal development Treatment: palliative; client’s life span is often shortened Steroids, calcium, vitamin C, and possibly sodium fluoride Progressive Muscular Dystrophies : Progressive Muscular Dystrophies At least nine types of muscular dystrophies identified; categorized as slowly or rapidly progressive Diagnosis often difficult Management Supportive, making client as comfortable as possible Prednisone, immunosuppressive agents, anabolic steroids Chapter 55 : Chapter 55 Interventions for Clients with Musculoskeletal Trauma Classification of Fractures : Classification of Fractures A fracture is a break or disruption in the continuity of a bone. Types of fractures include: Complete Incomplete Open or compound Closed or simple Pathologic (spontaneous) Fatigue or stress Compression Stages of Bone Healing : Stages of Bone Healing Hematoma formation within 48 to 72 hr after injury Hematoma to granulation tissue Callus formation Osteoblastic proliferation Bone remodeling Bone healing completed within about 6 weeks; up to 6 months in the older person Acute Compartment Syndrome : Acute Compartment Syndrome Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area Prevention of pressure buildup of blood or fluid accumulation Pathophysiologic changes sometimes referred to as ischemia-edema cycle Emergency Care - Acute Compartment Syndrome : Emergency Care - Acute Compartment Syndrome Within 4 to 6 hr after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 to 48 hr. Monitor compartment pressures. (Continued) Emergency Care (Continued) : Emergency Care (Continued) Fasciotomy may be performed to relieve pressure. Pack and dress the wound after fasciotomy. Possible Results of Acute Compartment Syndrome : Possible Results of Acute Compartment Syndrome Infection Motor weakness Volkmann’s contractures Myoglobinuric renal failure, known as rhabdomyolysis Other Complications of Fractures : Other Complications of Fractures Shock Fat embolism syndrome: serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream Venous thromboembolism (Continued) Other Complications of Fractures (Continued) : Other Complications of Fractures (Continued) Infection Ischemic necrosis Fracture blisters, delayed union, nonunion, and malunion MusculoskeletalComplications (continued) : MusculoskeletalComplications (continued) Muscle Atrophy, loss of muscle strength range of motion, pressure ulcers, and other problems associated with immobility Embolism/Pneumonia/ARDS TREATMENT – hydration, albumin, corticosteroids Constipation/Anorexia UTI DVT Fractures (cont’d) : Fractures (cont’d) avascular necrosis reaction to internal fixation devices complex regional pain heterotrophic ossification Musculoskeletal Assessment - Fracture : Musculoskeletal Assessment - Fracture Change in bone alignment Alteration in length of extremity Change in shape of bone Pain upon movement Decreased ROM Crepitation Ecchymotic skin (Continued) Musculoskeletal Assessment – Fracture (Continued) : Musculoskeletal Assessment – Fracture (Continued) Subcutaneous emphysema with bubbles under the skin Swelling at the fracture site Special Assessment Considerations : Special Assessment Considerations For fractures of the shoulder and upper arm, assess client in sitting or standing position. Support the affected arm to promote comfort. For distal areas of the arm, assess client in a supine position. For fracture of lower extremities and pelvis, client is in supine position. Risk for Peripheral Neurovascular Dysfunction : Risk for Peripheral Neurovascular Dysfunction Interventions include: Emergency care: assess for respiratory distress, bleeding and head injury Nonsurgical management: closed reduction and immobilization with a bandage, splint, cast, or traction Casts : Casts Rigid device that immobilizes the affected body part while allowing other body parts to move Cast materials: plaster, fiberglass, polyester-cotton Types of casts for various parts of the body: arm, leg, brace, body (Continued) Casts (Continued) : Casts (Continued) Cast care and client education Cast complications: infection, circulation impairment, peripheral nerve damage, complications of immobility Managing Care of the Patient in a Cast : Managing Care of the Patient in a Cast Casting Materials Relieving Pain Improving Mobility Promoting Healing Neurovascular Function Potential Complications Cast, Splint, Braces, and Traction Management Considerations : Cast, Splint, Braces, and Traction Management Considerations Arm Casts Leg Casts Body or Spica Casts Splints and Braces External Fixator Traction MusculoskeletalNursing Care - Casts : MusculoskeletalNursing Care - Casts Cast (Leg, arm, body) Different materials-fiberglass, plastic, plaster, stockinette Neurovascular Check color/capillary refill Temperature Pulse Movement Sensation Traction Buck’s Russell’s Skeletal Traction Nursing Care Weighs hang free Pin Site care Skin and neurovascular check Cast Care (continued) : Cast Care (continued) Elevate Extremity Exercises – to unaffected side; isometric exercises to affected extremity Keep heel off mattress Handle with palms of hands if cast wet Turn every two hours till dry Notify MD at once of wound drainage Do not place items under cast. Traction : Traction Application of a pulling force to the body to provide reduction, alignment, and rest at that site Types of traction: skin, skeletal, plaster, brace, circumferential (Continued) Traction (Continued) : Traction (Continued) Traction care: Maintain correct balance between traction pull and countertraction force Care of weights Skin inspection Pin care Assessment of neurovascular status Musculoskeletal – FracturesTreatment : Musculoskeletal – FracturesTreatment Primary Goal – reduce fracture- Realign and immobilize Medications Analgesics, antibiotics, tetanus toxoid Closed Reduction – Manual and Cast; External Fixation Device Traction; Splints; Braces Surgery Open reduction with internal fixation Reconstructive surgery Endoprosthetic replacement Nursing Management : Nursing Management Positioning Strengthening Exercises Potential Complications MusculoskeletalNursing Care : MusculoskeletalNursing Care Other External Immobilizations Halo Vest External Fixation with lag screws at tibia, pelvic, ankle/foot Musculoskeletal Nursing Care -2 : Musculoskeletal Nursing Care -2 Promote comfort Assess infection Promote mobility Teach safety Vital Signs Flotation, sheep skin Nutrition Vital Signs Monitor elimination Elevate extremity to decrease swelling/ ice pack Teach skin care, cast care, diet, complications Operative Procedures : Operative Procedures Open reduction with internal fixation External fixation Postoperative care: similar to that for any surgery; certain complications specific to fractures and musculoskeletal surgery include fat embolism and venous thromboembolism Procedures for Nonunion : Procedures for Nonunion Electrical bone stimulation Bone grafting Bone banking Managing the Patient Undergoing Orthopedic Surgery : Managing the Patient Undergoing Orthopedic Surgery Joint Replacement Total Hip Replacement Total Knee Replacement Acute Pain - Orthopedic Surgery : Acute Pain - Orthopedic Surgery Interventions include: Reduction and immobilization of fracture Assessment of pain Drug therapy: opioid and nonopioid drugs (Continued) Acute Pain (Continued) Orthopedic Surgery : Acute Pain (Continued) Orthopedic Surgery Complementary and alternative therapies: ice, heat, elevation of body part, massage, baths, back rub, therapeutic touch, distraction, imagery, music therapy, relaxation techniques Risk for Infection : Risk for Infection Interventions include: Apply strict aseptic technique for dressing changes and wound irrigations. Assess for local inflammation Report purulent drainage immediately to health care provider. (Continued) Risk for Infection (Continued) : Risk for Infection (Continued) Assess for pneumonia and urinary tract infection. Administer broad-spectrum antibiotics prophylactically. Impaired Physical Mobility : Impaired Physical Mobility Interventions include: Use of crutches to promote mobility Use of walkers and canes to promote mobility Imbalanced Nutrition: Less Than Body Requirements : Imbalanced Nutrition: Less Than Body Requirements Interventions include: Diet high in protein, calories, and calcium, supplemental vitamins B and C Frequent small feedings and supplements of high-protein liquids Intake of foods high in iron Upper Extremity Fractures : Upper Extremity Fractures Fractures include those of the: Clavicle Scapula Humerus Olecranon Radius and ulna Wrist and hand Lower Extremity Fractures : Lower Extremity Fractures Fractures include those of the: Femur Patella Tibia and fibula Ankle and foot Fractures of the Hip : Fractures of the Hip Intracapsular or extracapsular Treatment of choice: surgical repair, when possible, to allow the older client to get out of bed Open reduction with internal fixation Intramedullary rod, pins, a prosthesis, or a fixed sliding plate Prosthetic device Fractures of the Pelvis : Fractures of the Pelvis Associated internal damage the chief concern in fracture management of pelvic fractures Non–weight-bearing fracture of the pelvis Weight-bearing fracture of the pelvis Compression Fractures of the Spine : Compression Fractures of the Spine Most are associated with osteoporosis rather than acute spinal injury. Multiple hairline fractures result when bone mass diminishes. (Continued) Compression Fractures of the Spine (Continued) : Compression Fractures of the Spine (Continued) Nonsurgical management includes bedrest, analgesics, and physical therapy. Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected. (Continued) Amputation : Amputation Levels Complications Rehabilitation Nursing Management relieving pain minimizing altered sensory perception promoting wound healing enhancing body image self-care Amputations : Amputations Surgical amputation Traumatic amputation Levels of amputation Complications of amputations: hemorrhage, infection, phantom limb pain, problems associated with immobility, neuroma, flexion contracture Phantom Limb Pain : Phantom Limb Pain Phantom limb pain is a frequent complication of amputation. Client complains of pain at the site of the removed body part, most often shortly after surgery. Pain is intense burning feeling, crushing sensation or cramping. Some clients feel that the removed body part is in a distorted position. Management of Phantom Pain : Management of Phantom Pain Phantom limb pain must be distinguished from stump pain because they are managed differently. Recognize that this pain is real and interferes with the amputee’s activities of daily living. (Continued) Management of Phantom Pain (Continued) : Management of Phantom Pain (Continued) Some studies have shown that opioids are not as effective for phantom limb pain as they are for residual limb pain. Other drugs include intravenous infusion calcitonin, beta blockers, anticonvulsants, and antispasmodics. Exercise After Amputation : Exercise After Amputation ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial Prostheses : Prostheses Devices to help shape and shrink the residual limb and help client readapt Wrapping of elastic bandages Individual fitting of the prosthesis; special care Crush Syndrome : Crush Syndrome Can occur when leg or arm injury includes multiple compartments Characterized by acute compartment syndrome, hypovolemia, hyperkalemia, rhabdomyolysis, and acute tubular necrosis Treatment: adequate intravenous fluids, low-dose dopamine, sodium bicarbonate, kayexalate, and hemodialysis Complex Regional Pain Syndrome : Complex Regional Pain Syndrome A poorly understood complex disorder that includes debilitating pain, atrophy, autonomic dysfunction, and motor impairment Collaborative management: pain relief, maintaining ROM, endoscopic thoracic sympathectomy, and psychotherapy. Sports-Related Injuries : Sports-Related Injuries Rotator Cuff Tears Epicondylitis (Tennis Elbow) Lateral and Medial Collateral Ligament Injury Anterior and Posterior Cruciate Ligament Injury Meniscal Injuries Rupture of the Achilles Tendon Contusions, Strains, and Sprains : Contusions, Strains, and Sprains Contusion is a soft tissue injury Strain is a pulled muscle from overuse, overstretching, or excessive stress Sprain is an injury to ligaments surrounding a joint RICE Strains : Strains Excessive stretching of a muscle or tendon when it is weak or unstable Classified according to severity: first-, second-, and third-degree strain Management: cold and heat applications, exercise and activity limitations, anti-inflammatory drugs, muscle relaxants, and possible surgery Sprains : Sprains Excessive stretching of a ligament Treatment of sprains: first-degree: rest, ice for 24 to 48 hr, compression bandage, and elevation second-degree: immobilization, partial weight bearing as tear heals third-degree: immobilization for 4 to 6 weeks, possible surgery Rotator Cuff Injuries : Rotator Cuff Injuries Shoulder pain; cannot initiate or maintain abduction of the arm at the shoulder Drop arm test Conservative treatment: nonsteroidal anti-inflammatory drugs, physical therapy, sling support, ice or heat applications during healing Surgical repair for a complete tear Musculoskeletal DisordersSummary : Musculoskeletal DisordersSummary Many diseases are systemic, progressive inflammatory disorders. No cure; treat symptom. Promote optimum mobility- therapy, rest, hot/cold treatments, steroids, NSAID, immunosuppressants, assistance device, Calcitonin. Diet – lo purine diet, Calcium, Vit. D. MusculoskeletalSummary - 2 : MusculoskeletalSummary - 2 Prevention- infections, stress, no rest. Surgical intervention – removal of in case of cancer, internal fixative device for Scolosis, or hip or knee replacement with prothesis for degenerative joint disease, rheumatoid arthritis. Key – prevent complications, patient teaching and achieve optimum level of mobility.