NurseReview.Org Musculoskeletal System

MUSCULO-SKELETAL SYSTEM Nurse Licensure Examination Review

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

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

TENDONS
Bands of fibrous connective tissue that tie bones to muscles

LIGAMENTS
Strong, dense and flexible bands of fibrous tissue connecting bones to another bone

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

JOINTS
The part of the Skeleton where two or more bones are connected

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

BURSAE
Sac containing fluid that are located around the joints to prevent friction

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

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

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

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

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

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

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

Common musculoskeletal problems The Nursing Management

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

Nursing Management
PAIN
3. Administer analgesics as prescribed
Usually NSAIDS
Meperidine can be given for severe pain
4. Assess the effectiveness of pain measures

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

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

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

Musculoskeletal Modalities
Traction
Cast

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

Traction
Skin traction
Skeletal traction

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

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

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

Nursing Management
CAST
Immobilizing tool made of plaster of Paris or fiberglass
Provides immobilization of the fracture

Nursing Management
CAST: types
Long arm
Short arm
Spica

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

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

Nursing Management
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

Nursing Management
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

Common Musculoskeletal conditions Nursing management

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

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

Osteoporosis: TYPES
1. Primary Osteoporosis- advanced age, post-menopausal
2. Secondary osteoporosis- Steroid overuse, Renal failure

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

METABOLIC DISORDER
ASSESSMENT FINDINGS
1. Low stature
2. Fracture
Femur
3. Bone pain

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

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

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

METABOLIC DISORDER
Take calcium supplements with meals
Take alendronate with an EMPTY stomach with water
Instruct on intake of Hormonal replacement

METABOLIC DISORDER
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

METABOLIC DISORDER
3. Improve bowel elimination
Constipation is a problem of calcium supplements and immobility
Advise intake of HIGH fiber diet and increased fluids

METABOLIC DISORDER
4. Prevent injury
Instruct to use isometric exercise to strengthen the trunk muscles
AVOID sudden jarring, bending and strenuous lifting
Provide a safe environment

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

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

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

JRA
Symptoms may decrease as child enters adulthood
With periods of remissions and exacerbations

JRA
Medical Management
ASPIRIN and NSAIDs- mainstay treatment
Slow-acting anti-rheumatic drugs
Corticosteroids

JRA
Nursing Management
Encourage normal performance of daily activities
Assist child in ROM exercises
Administer medications
Encourage social and emotional development

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

DEGENERATIVE JOINT DISEASE
OSTEOARTHRITIS
The most common form of degenerative joint disorder

OSTEOARTHRITIS
Chronic, NON-systemic disorder of joints

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

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

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

1. Joint pain
Caused by
Inflamed synovium
Stretching of the joint capsule
Irritation of nerve endings

2. Stiffness
commonly occurs in the morning after awakening
Lasts only for less than 30 minutes
DECREASES with movement
Crepitation may be elicited

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

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

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

OSTEOARTHRITIS: Nursing Interventions
2. Advise patient to reduce weight
Aerobic exercise
Walking
3. Administer prescribed medications
NSAIDS

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

FACTORS:
Genetic
Auto-immune connective tissue disorders
Fatigue, emotional stress, cold, infection

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

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

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

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

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

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

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

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

Nursing MANAGEMENT
2. Decrease patient fatigue
Schedule activity when pain is less severe
Provide adequate periods of rests
3. Promote restorative sleep

Nursing Management
4. Increase patient mobility
Advise proper posture and body mechanics
Support joint in functional position
Advise ACTIVE ROME

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

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

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

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

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

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

Gouty arthritis
DIAGNOSTIC TEST
Elevated levels of uric acid in the blood
Uric acid stones in the kidney

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

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

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

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

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

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

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

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

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

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

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

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

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

Fracture
DIAGNOSTIC TEST
X-ray

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

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

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

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

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

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

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

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

Fracture
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

Fracture
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

Fracture
Nursing Management
2. Administer drugs
Corticosteroids
Dopamine
Morphine

Fracture
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

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

Fracture
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

Fracture
ASSESSMENT FINDINGS
2. Paresthesia- burning or tingling sensation
3. Numbness
4. Motor weakness
5. Pulselessness, impaired capillary refill time and cyanotic skin

Fracture
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

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

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

End of Musculoskeletal

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NurseReview.Org Musculoskeletal System

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NurseReview.Org Musculoskeletal System — Presentation Transcript