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 body1. Skeletal Muscles

Voluntary and striated2. Cardiac muscles

Involuntary and striated3. Smooth/Visceral muscles

Involuntary and NON-striated

TENDONSBands of fibrous connective tissue that

tie bones to muscles

LIGAMENTSStrong, 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

JOINTSThe part of the Skeleton where two or

more bones are connected

CARTILAGESA dense connective tissue that consists

of fibers embedded in a strong gel-like substance

BURSAESac 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

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM1. HISTORY2. 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

GaitPostureMuscular palpationJoint palpationRange of motionMuscle strength

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

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY 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

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES3. 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

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM

LABORATORY PROCEDURES4. 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

PAIN3. Administer analgesics as prescribed

Usually NSAIDS Meperidine can be given for severe pain

4. Assess the effectiveness of pain measures

Nursing ManagementIMPAIRED 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 ManagementSELF-CARE DEFICITS1. Assess functional levels of the patient2. 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 DEFICITS3. 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

TractionCast

Nursing Management

TractionA method of fracture immobilization by

applying equipments to align bone fragments

Used for immobilization, bone alignment and relief of muscle spasm

TractionSkin traction

Skeletal traction

TractionPulling 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 principles5. Observe and prevent foot drop

Provide foot plate6. Observe for DVT, skin irritation and

breakdown7. Provide pin care for clients in skeletal

traction- use of hydrogen peroxide

Nursing Management

CAST Immobilizing tool made of plaster of

Paris or fiberglassProvides immobilization of the fracture

Nursing Management

CAST: types

1. Long arm

2. Short arm

3. Spica

Casting MaterialsPlaster of Paris

Drying takes 1-3 days If dry, it is SHINY, WHITE, hard and

resistantFiberglass

Lightweight and dries in 20-30 minutes Water resistant

Nursing Management

CAST: General Nursing Care1. Allow the cast to dry (usually 24-72

hours)2. Handle a wet cast with the

PALMS not the fingertips3. Keep the casted extremity

ELEVATED using a pillow4. Turn the extremity for equal

drying. DO NOT USE DRYER for plaster cast

Nursing Management

CAST: General Nursing Care5. Petal the edges of the cast to

prevent crumbling of the edges6. Examine the skin for

pressure areas and Regularly check the pulses and skin

Nursing Management

CAST: General Nursing Care7. 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

OsteoporosisA disease of the bone characterized by

a decrease in the bone mass and density with a change in bone structure

METABOLIC BONE DISORDERS

Osteoporosis: PathophysiologyNormal 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

METABOLIC BONE DISORDERS

Osteoporosis: TYPES1. Primary Osteoporosis- advanced

age, post-menopausal2. Secondary osteoporosis- Steroid

overuse, Renal failure

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

METABOLIC DISORDER

ASSESSMENT FINDINGS1. Low stature2. Fracture

Femur3. Bone pain

METABOLIC DISORDER

LABORATORY FINDINGS1. 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 DISORDEROsteoporosis Nursing Interventions1. 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

Osteoporosis Nursing InterventionsTake calcium supplements with mealsTake alendronate with an EMPTY

stomach with water Instruct on intake of Hormonal

replacement

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

METABOLIC DISORDER

Osteoporosis Nursing Interventions3. Improve bowel eliminationConstipation is a problem of calcium

supplements and immobilityAdvise intake of HIGH fiber diet and

increased fluids

METABOLIC DISORDER

Osteoporosis Nursing Interventions4. Prevent injury Instruct to use isometric exercise to

strengthen the trunk musclesAVOID sudden jarring, bending and

strenuous liftingProvide a safe environment

Juvenile rheumatoid ArthritisDefinition:

AUTO-IMMUNE inflammatory joint disorder of UNKNOWN cause

SYSTEMIC chronic disorder of connective tissue

Diagnosed BEFORE age 16 years old

Juvenile rheumatoid ArthritisPATHOPHYSIOLOGY : unknown

Affected by stress, climate and genetics

Common in girls 2-5 and 9-12 y.o.

Juvenile rheumatoid Arthritis

Systemic JRA Pauci-articular Polyarticular

FEVER MILD joint pain and swelling

Morning joint stiffness and fever

Salmon-pink rash

IRIDOCYCLITIS Weight Bearing joints

Five or more joints

Less than 4 joints

Five or more joints

Anorexia, anemia, fatigue

Very Good prognosis

Poor prognosis

JRASymptoms may decrease as child

enters adulthoodWith periods of remissions and

exacerbations

JRA

Medical Management

1. ASPIRIN and NSAIDs- mainstay treatment

2. Slow-acting anti-rheumatic drugs

3. Corticosteroids

JRA

Nursing Management

1. Encourage normal performance of daily activities

2. Assist child in ROM exercises

3. Administer medications

4. Encourage social and emotional development

JRA

Nursing Management

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

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITISThe most common form of degenerative

joint disorder

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITISChronic, NON-systemic disorder of

joints

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

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Risk factors1. Increased age2. Obesity3. Repetitive use of joints with previous

joint damage4. Anatomical deformity5. genetic susceptibility

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

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Assessment findings

1. Joint painCaused by

Inflamed synovium Stretching of the joint capsule Irritation of nerve endings

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Assessment findings

2. Stiffness commonly occurs in the morning after commonly occurs in the morning after

awakeningawakening Lasts only for less than 30 minutes DECREASES with movementCrepitation may be elicited

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Diagnostic findings1. X-rayNarrowing of joint spaceLoss of cartilageOsteophytes2. Blood tests will show no evidenceno evidence of

systemic inflammation and are not useful

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

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

DEGENERATIVE JOINT DISEASE

OSTEOARTHRITIS: Nursing Interventions

2. Advise patient to reduce weight Aerobic exercise Walking

3. Administer prescribed medications NSAIDS

Rheumatoid arthritisA type of chronic systemic inflammatory

arthritis and connective tissue disorder affecting more women (ages 35-45) than men

Rheumatoid arthritis

FACTORS:

Genetic

Auto-immune connective tissue disorders

Fatigue, emotional stress, cold, infection

Rheumatoid arthritis

Pathophysiology Immune reaction in the synovium

attracts neutrophils releases enzymes breakdown of collagen irritates the synovial liningcausing synovial inflammation edema and pannus formation and joint erosions and swelling

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

Rheumatoid arthritis

ASSESSMENT FINDINGSJoint involvement is SYMMETRICAL

and BILATERALCharacteristically beginning in the

hands, wrist and feetJoint STIFFNESS occurs early morning,

lasts MORE than 30 minutes, not relieved by movement, diminishes as the day progresses

Rheumatoid arthritis

ASSESSMENT FINDINGSJoints are swollen and warmPainful when movedDeformities are common in the hands

and feet causing misalignment Rheumatoid nodules may be found in

the subcutaneous tissues

Rheumatoid arthritis

Diagnostic test1. X-ray

Shows bony erosion2. 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

Rheumatoid arthritis

MEDICAL MANAGEMENT1. Therapeutic dose of NSAIDS and

Aspirin to reduce inflammation2. Chemotherapy with methotrexate,

antimalarials, gold therapy and steroid3. For advanced cases- arthroplasty,

synovectomy4. Nutritional therapy

Rheumatoid arthritis

MEDICAL MANAGEMENT

GOLD THERAPY: IM or Oral preparationTakes several months (3-6) before

effects can be seenCan damage the kidney and causes

bone marrow depression

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

Rheumatoid arthritis

Nursing MANAGEMENT2. Decrease patient fatigueSchedule activity when pain is

less severeProvide adequate periods of rests3. Promote restorative sleep

Rheumatoid arthritis

Nursing Management4. Increase patient mobilityAdvise proper posture and body

mechanicsSupport joint in functional positionAdvise ACTIVE ROME

Rheumatoid arthritisNursing Management5. Provide Diet therapyPatients experience anorexia, nausea and

weight lossRegular diet with caloric restrictions

because steroids may increase appetite

Supplements of vitamins, iron and PROTEIN

Rheumatoid arthritis

6. Increase Mobility and prevent deformity:Lie FLAT on a firm mattressLie PRONE several times to prevent

HIP FLEXION contractureUse one pillow under the head

because of risk of dorsal kyphosisNO Pillow under the joints because

this promotes flexion contractures

Hot versus Cold

HOT Cold

Use to RELIEVE joint stiffness, pain and muscle spasm

Use to control inflammation and pain

After acute attack ACUTE ATTACK

Gouty arthritisA systemic disease caused by

deposition of uric acid crystals in the joint and body tissues

CAUSES:1. Primary gout- disorder of Purine

metabolism2. Secondary gout- excessive uric

acid in the blood like leukemia

Gouty arthritisASSESSMENT FINDINGS1. Severe pain in the involved joints,

initially the big toe2. Swelling and inflammation of the joint3. TOPHI- yellowish-whitish,

irregular deposits in the skin that break open and reveal a gritty appearance

4. PODAGRA

Gouty arthritis

ASSESSMENT FINDINGS5. Fever, malaise6. Body weakness and headache7. Renal stones

Gouty arthritis

DIAGNOSTIC TESTElevated levels of uric acid in the bloodUric acid stones in the kidney

Gouty arthritisMedical management1. Allupurinol- take it WITH FOOD

Rash signifies allergic reaction

2. Colchicine For acute attack

Gouty arthritisNursing 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

FractureA break in the continuity of the bone

and is defined according to its type and extent

FractureSevere mechanical Stress to bone

bone fractureDirect BlowsCrushing forcesSudden twisting motionExtreme muscle contraction

Fracture

TYPES OF FRACTURE1. 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 FRACTURE1. 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 FRACTURE1. 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. PainContinuous 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 functionAbnormal movement and pain can

result to this manifestation

Fracture

ASSESSMENT FINDINGS

3. DeformityDisplacement, angulations or rotation of

the fragments Causes deformity

Fracture

ASSESSMENT FINDINGS

4. CrepitusA grating sensation produced when the

bone fragments rub each other

FractureDIAGNOSTIC TESTX-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

FractureGeneral 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

FractureGeneral Nursing MANAGEMENT For OPEN FRACTURE1. Prevent wound and bone infectionAdminister prescribed antibioticsAdminister tetanus prophylaxisAssist in serial wound debridement2. Elevate the extremity to prevent edema

formation3. Administer care of traction and cast

FractureFRACTURE COMPLICATIONSEarly1. Shock2. Fat embolism3. Compartment syndrome4. Infection 5. DVT

FractureFRACTURE COMPLICATIONSLate1. Delayed union2. Avascular necrosis3. Delayed reaction to fixation devices4. Complex regional syndrome

FractureFRACTURE COMPLICATIONS: Fat

EmbolismOccurs usually in fractures of the long

bonesFat 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

FractureFRACTURE COMPLICATIONS: Fat

EmbolismOnset is rapid, within 24-72 hoursASSESSMENT FINDINGS1. Sudden dyspnea and respiratory

distress2. tachycardia3. Chest pain4. Crackles, wheezes and cough5. Petechial rashes over the chest, axilla

and hard palate

FractureFRACTURE COMPLICATIONS: Fat

EmbolismNursing Management1. Support the respiratory functionRespiratory failure is the most common

cause of deathAdminister O2 in high concentrationPrepare for possible intubation and

ventilator support

FractureFRACTURE COMPLICATIONS: Fat

EmbolismNursing Management2. Administer drugsCorticosteroidsDopamineMorphine

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

FractureEarly complication: Compartment

syndromeA complication that develops when

tissue perfusion in the muscles is less than required for tissue viability

FractureEarly complication: Compartment syndromeASSESSMENT FINDINGS1. Pain- Deep, throbbing and UNRELIEVED

pain by opiodsPain is due to reduction in the size of the

muscle compartment by tight castPain is due to increased mass in the

compartment by edema, swelling or hemorrhage

FractureEarly complication: Compartment syndromeASSESSMENT FINDINGS2. Paresthesia- burning or tingling sensation3. Numbness 4. Motor weakness5. Pulselessness, impaired capillary refill

time and cyanotic skin

FractureEarly complication: Compartment

syndromeMedical and Nursing management1. Assess frequently the neurovascular

status of the casted extremity2. Elevate the extremity above the

level of the heart3. 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