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Nur105Musculoskeletal System 2006 Website

Nur105Musculoskeletal System 2006 Website

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Musculoskeletal System

NUR 105 Adult Health Assessment of Musculoskeletal Function

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.

Musculoskeletal Anatomy 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

amphiarthrodial. diarthrodial  Structure and function of the diarthrodial or synovial joint  Subtyped by anatomic structure      Ball-and-socket Hinge Condylar Biaxial Pivot .Joints Types include synarthrodial.

A & P of Skeletal .



dietary history. limited motion  Family history. Current health problems . altered sensation.Diagnostic Tests  Special Assessment Techniques     Ballottement Bulge Sign Phalen Tinel¶s .Musculoskeletal Assessment  Health History Subjective Data -Chief Complaints ± pain. personal history. socioeconomic status  Medications (steroids).obesity   Objective Data .Physical Exam  Objective Data .

gait. neurovascular. deep tendon reflexes. MS injuries . skin. spine ± lordosis. bone integrity. upper and lower extremities Posture.. ROM ex. nutritional status. scoliosis. weight. joint function. muscle strength and tone.Physical Exam      Mental Status General inspection Head and neck: temporomandibular joint. crepitus Height. posture.




Scoliosis  Abnormal spinal curvature of various degrees or severity involving shortening of muscles and ligaments. internal fixative devices. .  Milwaukee brace.


 Electromyography  Myelography*  Laboratory Studies ± .radioisotope bone density. Bone Scan. synovial fluid. MRI ±arthrocentesis. arthroscopy  Nuclear Studies . Arthrogram. venogram.Diagnostic Evaluation  Imaging Procedures ± CT.  Endoscopic Studies  Other Studies biopsy.

Phosphorous.Musculoskeletal Assessment ± Diagnostic Test  Laboratory  Urine Tests ‡ 24 hour creatinecreatinine ratio ‡ Urine Uric acid ±24 hr specimen ‡ Urine deoxypyridinoline  Laboratory  Blood Tests      Serum muscle enzymes Rheumatoid Factor LE Prep/Antinuclear Antibodies(ANA) Erythrocyte Sedimentation Rate Calcium. Alkaline phosphatase .

Muscluloskeletal Assessment ± Diagnostic  Blood Tests  CBC ± Hgb. aldolase. serum increase glutaminoxaloacetic due to muscle damage. SGOT . Hct  Acid phosphatase  Metabolic/Endocrine  Enzymes Increase creatine kinase.

Musculoskeletal . tomography and xeroradiography.Radiographic  Standard radiography. arthrography and CT  Other diagnostic tests: bone and muscle biopsy . myelography.

inspect needle sites for hematoma formation. lowert motor neuron.  Low electrical currents are passed through flat electrodes placed along the nerve.MS ± Diagnostic Tests Electromyography  EMG aids in the diagnosis of neuromuscular. . and peripheral nerve disorders. usually with nerve conduction studies.  If needles are used.

 Monitor for complications.  Evaluate the neurovascular status of the affected limb frequently.  Client must be able to flex the knee.  Analgesics are prescribed. .Arthroscopy  Fiberoptic tube is inserted into a joint for direct visualization. exercises are prescribed for ROM.


MS ± Diagnostic Tests  Bone Scan  Gaillum or Thallium scan  Magnetic resonance imaging  Ultrasonography .

Metabolic Bone Disorders Osteoporosis Osteomalcia Paget¶s Disease .

estrogen with progestin.  Clinical Manifestations ± bone pain. SERM with anti-estrogens. D.  Pathologic fracture-safety.  Treatment ± Calcium. usually increase in older women. nulliparity. decrease movement. white race. . fluoride. exercise. estrogen replacement. Calcitonin. Vit.Osteoporosis  A disease in which loss of bone exceeds rate of bone formation.

Classification of Osteoporosis  Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s.  Regional osteoporosis occurs when a limb is immobilized. . long-term immobility. long-term drug therapy.  Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism.

 Continue program of weight-bearing exercises.Osteoporosis  Ensure adequate calcium intake.  Avoid sedentary life style. .Health Promotion/Illness Prevention .

Osteoporosis .Assessment  Physical assessment  Psychosocial assessment  Laboratory assessment  Radiographic assessment .


O Os s t e o p o s r o i Osteoporosis .

Osteoporosis .

 Hormone replacement therapy  Parathyroid hormone  Calcium and vitamin D  Bisphosphonates  Selective estrogen receptor Drug Therapy Osteoporosis modulators  Calcitonin  Other agents used with varying results .

Osteoporosis  Protein  Magnesium  Vitamin K  Trace minerals  Calcium and vitamin D  Avoid alcohol and caffeine .Diet Therapy .

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 .Fall Prevention .

Osteoporosis  Exercise  Pain management  Orthotic devices .Others .

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  Metabolic disorder of bone remodeling. or turnover. selected bisphosphonates. and disorganized  Nonsurgical management: calcitonin. mithramycin  Surgical management: tibial osteotomy or partial or total joint replacement . increased resorption of loss results in bone deposits that are weak. enlarged.

kyphosis.Paget¶s Disease  A imbalance of increase osteoblast and osteoclast cells. and hot/cold treatment. .  Bone pain most common symptom. bony enlargement and deformities usually bilateral. thickening and hypertrophy. NSAID. meds bisphosphonates and calcitonin. long bone. assistance devices.  Analgesics.

hematogenous. endogenous. contiguous  Drug therapy  Infection control  Hyperbaric oxygen therapy .Osteomyelitis  A condition caused by the invasion by one or more pathogenic microorganisms that stimulates the inflammatory response in bone tissue  Exogenous.

Osteomyelitis  Infection of bone. causative agent ± Staph/Strept  Typical signs and symptoms  Treatment ± IV antibiotic. long term for 4-6 months .

Surgical Management Osteomyelitis  Sequestrectomy  Bone grafts  Bone segment transfers  Muscle flaps  Amputation .

Bone Tumors Benign Bone Tumors Malignant Bone Tumors Metastatic Bone Disease .

Bone Tumors 
Benign bone tumors (noncancerous): 

tumors: osteochondroma, chondroma  Osteogenic tumors: osteoid osteoma, osteoblastoma, giant cell tumor  Fibrogenic tumors

Nondrug pain relief measures  Drug therapy: analgesics, NSAIDs  Surgical therapy: curettage (simple

excision of the tumor tissue), joint replacement, or arthrodesis

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.

those tumors that originate in the bone  Osteosarcoma  Ewing¶s sarcoma  Chondrosarcoma  Fibrosarcoma  Metastatic bone disease .Malignant Bone Tumors  Primary tumors.

chemotherapy  Radiation therapy  Surgical management  Promotion of physical mobility with ROM exercises . Chronic Pain  Interventions include:  Treatment aimed at reducing the size or removing the tumor  Drug therapy.Cancer of Bone Acute Pain.

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 .

 Establish realistic mutual goals. .  Emphasize the client¶s strengths and remaining capabilities.Disturbed Body Image ± Cancer of Bone  Interventions include:  Recognize and accept the client¶s view of body image alteration.  Establish and maintain a trusting nurseclient relationship.

 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. Interventions  Nonsurgical Potential for Fractures Bone Cancer management: radiation therapy and strengthening exercises. .

causing pain and numbness  Common repetitive strain injury via occupational or sports motions  Nonsurgical management: drug therapy and immobilization  Possible surgical management .Carpal Tunnel Syndrome  Common condition. the median nerve in the wrist becomes compressed.

often overlying a wrist joint or tendon . cystlike lesion.Hand Disorders  Dupuytren's contracture²slowly progressive contracture of the palmar fascia resulting in flexion of the fourth or fifth digit of the hand  Ganglion²a round.

Disorders of the Foot  Hallux valgus  Hammertoe  Morton¶s neuroma  Tarsal tunnel syndrome  Plantar fasciitis  Other problems of the foot .


casting. weight reduction. pain assessment. observation of posture  Interventions: exercise. or idiopathic in type  Assessment: complete history. neuromuscular.Scoliosis  Changes in muscles and ligaments on the concave side of the spinal column  Congenital. surgery . bracing.

resulting in bone deformity  Clinical manifestations: poor skeletal development  Treatment: palliative. vitamin C.Osteogenesis Imperfecta  Rare genetic disorder in which the bones are fragile and fracture easily. calcium. and possibly sodium fluoride . client¶s life span is often shortened  Steroids.

Progressive Muscular Dystrophies  At least nine types of muscular dystrophies identified. anabolic steroids . immunosuppressive agents. categorized as slowly or rapidly progressive  Diagnosis often difficult  Management  Supportive. making client as comfortable as possible  Prednisone.

Chapter 55 Interventions for Clients with Musculoskeletal Trauma .

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 .

up to 6 months in the older person .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.


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 ischemiaedema cycle .

Acute Compartment Syndrome  Within 4 to 6 hr after the onset of acute compartment syndrome.Emergency Care . neuromuscular damage is irreversible. (Continued) .  Monitor compartment pressures. the limb can become useless within 24 to 48 hr.

 Pack and dress the wound after fasciotomy. .Emergency Care (Continued)  Fasciotomy may be performed to relieve pressure.

known as rhabdomyolysis .Possible Results of Acute Compartment Syndrome  Infection  Motor weakness  Volkmann¶s contractures  Myoglobinuric renal failure.

fat globules are released from yellow bone marrow into bloodstream  Venous thromboembolism (Continued) .Other Complications of Fractures  Shock  Fat embolism syndrome: serious complication resulting from a fracture.

and malunion . delayed union.Other Complications of Fractures (Continued)  Infection  Ischemic necrosis  Fracture blisters. nonunion.

and other problems associated with immobility  Embolism/Pneumonia/ARDS  TREATMENT ± hydration. albumin. pressure ulcers. corticosteroids  Constipation/Anorexia  UTI  DVT . loss of muscle strength range of motion.Musculoskeletal Complications (continued)  Muscle Atrophy.

Fractures (cont¶d)    avascular necrosis reaction to internal fixation devices complex regional pain heterotrophic ossification .

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)  Subcutaneous emphysema with bubbles under the skin  Swelling at the fracture site .

 Support the affected arm to promote comfort. .  For distal areas of the arm. client is in supine position. assess client in a supine position.Special Assessment Considerations  For fractures of the shoulder and upper arm.  For fracture of lower extremities and pelvis. assess client in sitting or standing position.

splint. cast. bleeding and head injury  Nonsurgical management: closed reduction and immobilization with a bandage. or traction .Risk for Peripheral Neurovascular Dysfunction  Interventions include:  Emergency care: assess for respiratory distress.

brace. body (Continued) . polyester-cotton  Types of casts for various parts of the body: arm. fiberglass.Casts  Rigid device that immobilizes the affected body part while allowing other body parts to move  Cast materials: plaster. leg.

peripheral nerve damage.Casts (Continued)  Cast care and client education  Cast complications: infection. circulation impairment. complications of immobility .

Managing Care of the Patient in a Cast Casting Materials Relieving Pain Improving Mobility Promoting Healing Neurovascular Function Potential Complications .

Cast. and Traction Management Considerations Arm Casts Leg Casts Body or Spica Casts Splints and Braces External Fixator Traction . Braces. Splint.


body)  Different materialsfiberglass. arm.Casts  Cast (Leg. plastic. plaster.Musculoskeletal Nursing Care . stockinette  Neurovascular   Traction  Buck¶s  Russell¶s  Skeletal  Traction Nursing Care  Weighs hang free  Pin Site care  Skin and neurovascular check     Check color/capillary refill Temperature Pulse Movement Sensation .

. 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.Cast Care (continued)  Elevate Extremity  Exercises ± to unaffected side.

Traction  Application of a pulling force to the body to provide reduction. brace. circumferential (Continued) . plaster. alignment. and rest at that site  Types of traction: skin. skeletal.

Traction (Continued)  Traction care:  Maintain correct balance between traction pull and countertraction force  Care of weights  Skin inspection  Pin care  Assessment of neurovascular status .



External Fixation Device  Traction. Splints. Braces  Surgery Open reduction with internal fixation  Reconstructive surgery  Endoprosthetic replacement  . tetanus toxoid  Closed Reduction ± Manual and Cast.Musculoskeletal ± Fractures Treatment  Primary Goal ± reduce fracture Realign and immobilize  Medications  Analgesics. antibiotics.



Nursing Management Positioning Strengthening Exercises Potential Complications .

ankle/foot . pelvic.Musculoskeletal Nursing Care  Other External Immobilizations  Halo Vest  External Fixation with lag screws at tibia.

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. diet. cast care. complications .


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  Electrical bone stimulation  Bone grafting  Bone banking .

Managing the Patient Undergoing Orthopedic Surgery Joint Replacement Total Hip Replacement Total Knee Replacement .


Acute Pain .Orthopedic Surgery  Interventions include:  Reduction and immobilization of fracture  Assessment of pain  Drug therapy: opioid and nonopioid drugs (Continued) .

imagery. distraction. music therapy. heat.Acute Pain (Continued) Orthopedic Surgery  Complementary and alternative therapies: ice. relaxation techniques . elevation of body part. back rub. massage. baths. therapeutic touch.

 Assess for local inflammation  Report purulent drainage immediately to health care provider. (Continued) .Risk for Infection  Interventions include:  Apply strict aseptic technique for dressing changes and wound irrigations.

.  Administer broad-spectrum antibiotics prophylactically.Risk for Infection (Continued)  Assess for pneumonia and urinary tract infection.

Impaired Physical Mobility  Interventions include:  Use of crutches to promote mobility  Use of walkers and canes to promote mobility .

supplemental vitamins B and C  Frequent small feedings and supplements of high-protein liquids  Intake of foods high in iron  Diet . calories. and calcium.Imbalanced Nutrition: Less Than Body Requirements  Interventions include: high in protein.

Upper Extremity Fractures  Fractures include those of the:  Clavicle  Scapula  Humerus  Olecranon  Radius and ulna  Wrist and hand .

Lower Extremity Fractures  Fractures include those of the:  Femur  Patella  Tibia and fibula  Ankle and foot .

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  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 .

(Continued) .Compression Fractures of the Spine  Most are associated with osteoporosis rather than acute spinal injury.  Multiple hairline fractures result when bone mass diminishes.

analgesics. (Continued) . and physical therapy.Compression Fractures of the Spine (Continued)  Nonsurgical management includes bedrest. in which bone cement is injected.  Minimally invasive surgeries are vertebroplasty and kyphoplasty.

Amputation  Levels  Complications  Rehabilitation  Nursing Management  relieving pain  minimizing altered sensory perception  promoting wound healing  enhancing body image  self-care .

phantom limb pain. problems associated with immobility. flexion contracture .Amputations  Surgical amputation  Traumatic amputation  Levels of amputation  Complications of amputations: hemorrhage. infection. neuroma.

 Some clients feel that the removed body part is in a distorted position. crushing sensation or cramping. most often shortly after surgery.  Client complains of pain at the site of the removed body part.Phantom Limb Pain  Phantom limb pain is a frequent complication of amputation. .  Pain is intense burning feeling.

(Continued) .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.

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.

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 .Exercise After Amputation  ROM to prevent flexion contractures.


special care .Prostheses  Devices to help shape and shrink the residual limb and help client readapt  Wrapping of elastic bandages  Individual fitting of the prosthesis.


and hemodialysis . low-dose dopamine. kayexalate. hyperkalemia. rhabdomyolysis.Crush Syndrome  Can occur when leg or arm injury includes multiple compartments  Characterized by acute compartment syndrome. sodium bicarbonate. and acute tubular necrosis  Treatment: adequate intravenous fluids. hypovolemia.

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 
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 
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


and third-degree strain  Management: cold and heat applications.Strains  Excessive stretching of a muscle or tendon when it is weak or unstable  Classified according to severity: first-. exercise and activity limitations. anti-inflammatory drugs. muscle relaxants. and possible surgery . second-.

ice for 24 to 48 hr. and elevation  second-degree: immobilization. possible surgery . partial weight bearing as tear heals  third-degree: immobilization for 4 to 6 weeks. compression bandage.Sprains  Excessive stretching of a ligament  Treatment of sprains:  first-degree: rest.

cannot initiate or maintain abduction of the arm at the shoulder  Drop arm test  Conservative treatment: nonsteroidal anti-inflammatory drugs.Rotator Cuff Injuries  Shoulder pain. physical therapy. ice or heat applications during healing  Surgical repair for a complete tear . sling support.



immunosuppressants. . D. Calcium.  Diet ± lo purine diet. hot/cold treatments.Musculoskeletal Disorders Summary  Many diseases are systemic.  Promote optimum mobility.therapy. steroids. NSAID. progressive inflammatory disorders. Calcitonin. treat symptom. rest. assistance device.  No cure. Vit.

.Musculoskeletal Summary .  Surgical intervention ± removal of in case of cancer. no rest. internal fixative device for Scolosis. or hip or knee replacement with prothesis for degenerative joint disease. patient teaching and achieve optimum level of mobility. rheumatoid arthritis.infections.  Key ± prevent complications. stress.2  Prevention.

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