MUSCULO-SKELETAL SYSTEM  Gait

Review of Anatomy and Physiology  Posture

 The musculo-skeletal system consists of the muscles, tendons, bones and cartilage together  Muscular palpation
with the joints  Joint palpation
 The primary function of which is to produce skeletal movements  Range of motion
 Muscles  Muscle strength
Three types of muscles exist in the body
 1. Skeletal Muscles LABORATORY PROCEDURES
 Voluntary and striated 1. BONE MARROW ASPIRATION
 2. Cardiac muscles  Usually involves aspiration of the marrow to diagnose diseases like leukemia,
 Involuntary and striated aplastic anemia
 3. Smooth/Visceral muscles  Usual site is the sternum and iliac crest
 Involuntary and NON-striated  Pre-test: Consent
TENDONS  Intratest: Needle puncture may be painful
 Bands of fibrous connective tissue that tie bones to muscles  Post-test: maintain pressure dressing and watch out for bleeding
LIGAMENTS 2. Arthroscopy
 Strong, dense and flexible bands of fibrous tissue connecting bones to another bone  A direct visualization of the joint cavity
BONES  Pre-test: consent, explanation of procedure, NPO
 Variously classified according to shape, location and size  Intra-test: Sedative, Anesthesia, incision will be made
 Functions  Post-test: maintain dressing, ambulation as soon as awake, mild soreness of joint
1. Locomotion for 2 days, joint rest for a few days, ice application to relieve discomfort
2. Protection 3. BONE SCAN
3. Support and lever  Imaging study with the use of a contrast radioactive material
4. Blood production  Pre-test: Painless procedure, IV radioisotope is used, no special preparation, pregnancy is
5. Mineral deposition contraindicated
JOINTS  Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed, Supine
 The part of the Skeleton where two or more bones are connected position for scanning
CARTILAGES  Post-test: Increase fluid intake to flush out radioactive material
 A dense connective tissue that consists of fibers embedded in a strong gel-like substance
BURSAE 4. DXA- Dual-energy XRAY absorptiometry
 Sac containing fluid that are located around the joints to prevent friction  Assesses bone density to diagnose osteoporosis
ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM  Uses LOW dose radiation to measure bone density
 The nurse usually evaluates this small part of the over-all assessment and concentrates on  Painless procedure, non-invasive, no special preparation
the patient’s posture, body symmetry, gait and muscle and joint function  Advise to remove jewelry

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM Common musculoskeletal problems

 1. HISTORY  The Nursing Management
 2. Physical Examination  Nursing Management of common musculo-skeletal problems
 Perform a head to toe assessment
 Nurses need to inspect and palpate PAIN
 The special procedure is the assessment of joint and muscle movement  These can be related to joint inflammation, traction, surgical intervention
 Usually, a tape measure and a protractor are the only instruments  1. Assess patient’s perception of pain
 2. Instruct patient alternative pain management like meditation, heat and cold application,
TENS and guided imagery
  3. Administer analgesics as prescribed  5. Observe and prevent foot drop
 Usually NSAIDS  Provide foot plate
 Meperidine can be given for severe pain  6. Observe for DVT, skin irritation and breakdown
 4. Assess the effectiveness of pain measures  7. Provide pin care for clients in skeletal traction- use of hydrogen peroxide

Nursing Management CAST

IMPAIRED PHYSICAL MOBILITY  Immobilizing tool made of plaster of Paris or fiberglass
 1. Instruct patient to perform range of motion exercises, either passive or active  Provides immobilization of the fracture
 2. Provide support in ambulation with assistive devices  Nursing Management
 3. Turn and change position every 2 hours CAST: types
 4. Encourage mobility for a short period and provide positive reinforcements for small 1. Long arm
accomplishments 2. Short arm
 Nursing Management 3. Spica
SELF-CARE DEFICITS  Casting Materials
 1. Assess functional levels of the patient  Plaster of Paris
 2. Provide support for feeding problems  Drying takes 1-3 days
 Place patient in Fowler’s position  If dry, it is SHINY, WHITE, hard and resistant
 Provide assistive device and supervise mealtime  Fiberglass
 Offer finger foods that can be handled by patient  Lightweight and dries in 20-30 minutes
 Keep suction equipment ready  Water resistant
 3. Assist patient with difficulty bathing and hygiene
 Assist with bath only when patient has difficulty CAST: General Nursing Care
 Provide ample time for patient to finish activity  1. Allow the cast to dry (usually 24-72 hours)
 2. Handle a wet cast with the PALMS not the fingertips
Musculoskeletal Modalities  3. Keep the casted extremity ELEVATED using a pillow
Traction  4. Turn the extremity for equal drying. DO NOT USE DRYER for plaster cast
Cast  5. Petal the edges of the cast to prevent crumbling of the edges
Nursing Management  6. Examine the skin for pressure areas and Regularly check the pulses and skin
 Nursing Management
Traction  7. Instruct the patient not to place sticks or small objects inside the cast
 A method of fracture immobilization by applying equipments to align bone fragments  8. Monitor for the following: pain, swelling, discoloration, coolness, tingling or lack of
 Used for immobilization, bone alignment and relief of muscle spasm sensation and diminished pulses
 Traction
 Skin traction Fracture
 Skeletal traction  A break in the continuity of the bone and is defined according to its type and extent
 Traction  Fracture
 Pulling force exerted on bones to reduce or immobilize fractures, reduce muscle spasm,  Severe mechanical Stress to bone à bone fracture
correct or prevent deformities  Direct Blows
Traction: General principles  Crushing forces
 1. ALWAYS ensure that the weights hang freely and do not touch the floor  Sudden twisting motion
 2. NEVER remove the weights  Extreme muscle contraction
 3. Maintain proper body alignment
 4. Ensure that the pulleys and ropes are properly functioning and fastened by tying square
knot
TYPES OF FRACTURE  4. Apply sling if forearm fracture is suspected or the suspected fractured arm maybe
 1. Complete fracture bandaged to the chest
 Involves a break across the entire cross-section  5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination
 2. Incomplete fracture  6. DO NOT attempt to reduce the facture
 The break occurs through only a part of the cross-sectio
TYPES OF FRACTURE MEDICAL MANAGEMENT
 1. Closed fracture  1. Reduction of fracture either open or closed, Immobilization and Restoration of function
 The fracture that does not cause a break in the skin  2. Antibiotics, Muscle relaxants and Pain medications
 2. Open fracture
 The fracture that involves a break in the skin General Nursing MANAGEMENT
TYPES OF FRACTURE For CLOSED FRACTURE
 1. Comminuted fracture  1. Assist in reduction and immobilization
 A fracture that involves production of several bone fragments  2. Administer pain medication and muscle relaxants
 2. Simple fracture  3. teach patient to care for the cast
 A fracture that involves break of bone into two parts or one  4. Teach patient about potential complication of fracture and to report infection, poor
alignment and continuous pain
ASSESSMENT FINDINGS
 1. Pain or tenderness over the involved area General Nursing MANAGEMENT
 2. Loss of function For OPEN FRACTURE
 3. Deformity  1. Prevent wound and bone infection
 4. Shortening Administer prescribed antibiotics
 5. Crepitus Administer tetanus prophylaxis
 6. Swelling and discoloration Assist in serial wound debridement
 2. Elevate the extremity to prevent edema formation
ASSESSMENT FINDINGS  3. Administer care of traction and cast
1. Pain
 Continuous and increases in severity  FRACTURE COMPLICATIONS
 Muscles spasm accompanies the fracture is a reaction of the body to immobilize the Early
fractured bone  1. Shock
2. Loss of function  2. Fat embolism
 Abnormal movement and pain can result to this manifestation  3. Compartment syndrome
3. Deformity  4. Infection
 Displacement, angulations or rotation of the fragments Causes deformity  5. DVT

4. Crepitus Late
 A grating sensation produced when the bone fragments rub each other  1. Delayed union
 2. Avascular necrosis
DIAGNOSTIC TEST  3. Delayed reaction to fixation devices
 X-ray  4. Complex regional syndrome

EMERGENCY MANAGEMENT OF FRACTURE  FRACTURE COMPLICATIONS: Fat Embolism

 1. Immobilize any suspected fracture  Occurs usually in fractures of the long bones
 2. Support the extremity above and below when moving the affected part from a vehicle  Fat globules may move into the blood stream because the marrow pressure is greater than
 3. Suggested temporary splints- hard board, stick, rolled sheets capillary pressure
  Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs Strains
 Onset is rapid, within 24-72 hours  Excessive stretching of a muscle or tendon
Nursing management
ASSESSMENT FINDINGS  1. Immobilize affected part
 1. Sudden dyspnea and respiratory distress  2. Apply cold packs initially, then heat packs
 2. tachycardia  3. Limit joint activity
 3. Chest pain  4. Administer NSAIDs and muscle relaxants
 4. Crackles, wheezes and cough
 5. Petechial rashes over the chest, axilla and hard palate Common Musculoskeletal conditions
METABOLIC BONE DISORDERS
 Nursing Management Osteoporosis
 1. Support the respiratory function  A disease of the bone characterized by a decrease in the bone mass and density with a
- Respiratory failure is the most common cause of death change in bone structure
- Administer O2 in high concentration Osteoporosis: Pathophysiology
- Prepare for possible intubation and ventilator support  Normal homeostatic bone turnover is alteredà rate of bone RESORPTION is greater than
 2. Administer drugs bone FORMATIONà reduction in total bone massà reduction in bone mineral densityà prone
- Corticosteroids to FRACTURE
- Dopamine Osteoporosis: TYPES
- Morphine  1. Primary Osteoporosis- advanced age, post-menopausal
 3. Institute preventive measures  2. Secondary osteoporosis- Steroid overuse, Renal failure
- Immediate immobilization of fracture RISK factors for the development of Osteoporosis
- Minimal fracture manipulation  1. Sedentary lifestyle
- Adequate support for fractured bone during turning and positioning  2. Age
- Maintain adequate hydration and electrolyte balance  3. Diet- caffeine, alcohol, low Ca and Vit D
 4. Post-menopausal
Early complication: Compartment syndrome  5. Genetics- caucasian and asian
 A complication that develops when tissue perfusion in the muscles is less than required for  6. Immobility
tissue viability ASSESSMENT FINDINGS
 1. Low stature
ASSESSMENT FINDINGS  2. Fracture
 1. Pain- Deep, throbbing and UNRELIEVED pain by opiods  Femur
- Pain is due to reduction in the size of the muscle compartment by tight  3. Bone pain
cast LABORATORY FINDINGS
- Pain is due to increased mass in the compartment by edema, swelling or  1. DEXA-scan
hemorrhage  Provides information about bone mineral density
 2. Paresthesia- burning or tingling sensation  T-score is at least 2.5 SD below the young adult mean value
 3. Numbness  2. X-ray studies
 4. Motor weakness Medical management of Osteoporosis
 5. Pulselessness, impaired capillary refill time and cyanotic skin  1. Diet therapy with calcium and Vitamin D
  2. Hormone replacement therapy
Medical and Nursing management  3. Biphosphonates- Alendronate, risedronate produce increased bone mass by inhibiting
 1. Assess frequently the neurovascular status of the casted extremity the OSTEOCLAST
 2. Elevate the extremity above the level of the heart  4. Moderate weight bearing exercises
 3. Assist in cast removal and FASCIOTOMY  5. Management of fractures
 Osteoporosis Nursing Interventions - Encourage social and emotional development
1. Promote understanding of osteoporosis and the treatment regimen Nursing Management
- Provide adequate dietary supplement of calcium and vitamin D  During acute attack:
- Instruct to employ a regular program of moderate exercises and physical - SPLINT the joints
activity - NEUTRAL positioning
- Manage the constipating side-effect of calcium supplements - Warm or cold packs
- Take calcium supplements with meals
- Take alendronate with an EMPTY stomach with water DEGENERATIVE JOINT DISEASE
- Instruct on intake of Hormonal replacement OSTEOARTHRITIS
- Osteoporosis Nursing Interventions  The most common form of degenerative joint disorder
2. Relieve the pain  Chronic, NON-systemic disorder of joints
 Instruct the patient to rest on a firm mattres  DEGENERATIVE JOINT DISEASE
 Suggest that knee flexion will cause relaxation of back muscles  OSTEOARTHRITIS: Pathophysiology
 Heat application may provide comfort  Injury, genetic, Previous joint damage, Obesity, Advanced age à Stimulate the
 Encourage good posture and body mechanics chondrocytes to release chemicalsà chemicals will cause cartilage degeneration, reactive
 Instruct to avoid twisting and heavy lifting inflammation of the synovial lining and bone stiffening
3. Improve bowel elimination
- Constipation is a problem of calcium supplements and immobility OSTEOARTHRITIS: Risk factors
- Advise intake of HIGH fiber diet and increased fluids  1. Increased age
4. Prevent injury  2. Obesity
- Instruct to use isometric exercise to strengthen the trunk muscles  3. Repetitive use of joints with previous joint damage
- AVOID sudden jarring, bending and strenuous lifting  4. Anatomical deformity
- Provide a safe environment  5. genetic susceptibility

Juvenile rheumatoid Arthritis OSTEOARTHRITIS: Assessment findings

- AUTO-IMMUNE inflammatory joint disorder of UNKNOWN cause  1. Joint pain
- SYSTEMIC chronic disorder of connective tissue  2. Joint stiffness
- Diagnosed BEFORE age 16 years old  3. Functional joint impairment limitation
- Juvenile rheumatoid Arthritis  The joint involvement is ASYMMETRICAL
 PATHOPHYSIOLOGY : unknown  This is not systemic, there is no FEVER, no severe swelling
- Affected by stress, climate and genetics  Atrophy of unused muscles
- Common in girls 2-5 and 9-12 y.o.  Usual joint are the WEIGHT bearing joints
- Symptoms may decrease as child enters adulthood
- With periods of remissions and exacerbations OSTEOARTHRITIS: Assessment findings
 1. Joint pain Caused by
 Medical Management - Inflamed synovium
- ASPIRIN and NSAIDs- mainstay treatment - Stretching of the joint capsule
- Slow-acting anti-rheumatic drugs - Irritation of nerve endings
- Corticosteroids  2. Stiffness
 commonly occurs in the morning after awakening
Nursing Management  Lasts only for less than 30 minutes
- -Encourage normal performance of daily activities  DECREASES with movement
- Assist child in ROM exercises  Crepitation may be elicited
- Administer medications
OSTEOARTHRITIS: Diagnostic findings ASSESSMENT FINDINGS
 1. X-ray  1. PAIN
 Narrowing of joint space  2. Joint swelling and stiffness-SYMMETRICAL, Bilateral
 Loss of cartilage  3. Warmth, erythema and lack of function
 Osteophytes  4. Fever, weight loss, anemia, fatigue
 2. Blood tests will show no evidence of systemic inflammation and are not useful  5. Palpation of join reveals spongy tissue
 6. Hesitancy in joint movement
OSTEOARTHRITIS: Medical management - Joint involvement is SYMMETRICAL and BILATERAL
 1. Weight reduction - Characteristically beginning in the hands, wrist and feet
 2. Use of splinting devices to support joints - Joint STIFFNESS occurs early morning, lasts MORE than 30 minutes, not relieved by
 3. Occupational and physical therapy movement, diminishes as the day progresses
 4. Pharmacologic management - Joints are swollen and warm
- Use of PARACETAMOL, NSAIDS - Painful when move
- Use of Glucosamine and chondroitin - Deformities are common in the hands and feet causing misalignment
- Topical analgesics  Rheumatoid nodules may be found in the subcutaneous tissues
- Intra-articular steroids to decrease inflammation
 Diagnostic test
OSTEOARTHRITIS: Nursing Interventions  1. X-ray
 1. Provide relief of PAIN  Shows bony erosion
- Administer prescribed analgesics  2. Blood studies reveal (+) rheumatoid factor, elevated ESR and CRP and ANTI-nuclear
- Application of heat modalities. ICE PACKS may be used in the early acute stage!!! antibody
- Plan daily activities when pain is less severe  3. Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing
- Pain meds before exercising numerous WBC and inflammatory proteins
 2. Advise patient to reduce weight
- Aerobic exercise  MEDICAL MANAGEMENT
- Walking  1. Therapeutic dose of NSAIDS and Aspirin to reduce inflammation
 3. Administer prescribed medications  2. Chemotherapy with methotrexate, antimalarials, gold therapy and steroid
- NSAIDS  3. For advanced cases- arthroplasty, synovectomy
 4. Nutritional therapy
Rheumatoid arthritis
 A type of chronic systemic inflammatory arthritis and connective tissue disorder affecting GOLD THERAPY:
more women (ages 35-45) than men  IM or Oral preparation
 Rheumatoid arthritis  Takes several months (3-6) before effects can be seen
FACTORS:  Can damage the kidney and causes bone marrow depression
 Genetic
 Auto-immune connective tissue disorders Nursing MANAGEMENT
 Fatigue, emotional stress, cold, infection  1. Relieve pain and discomfort
Pathophysiology - USE splints to immobilize the affected extremity during acute stage of the
 Immune reaction in the synovium à attracts neutrophils à releases enzymes à breakdown of disease and inflammation to REDUCE DEFORMITY
collagen à irritates the synovial liningàcausing synovial inflammation edema and pannus - Administer prescribed medications
formation and joint erosions and swelling - Suggest application of COLD packs during the acute phase of pain, then HEAT
application as the inflammation subsides
  2. Decrease patient fatigue Nursing Intervention
- Schedule activity when pain is less severe  1. Provide a diet with LOW purine
- Provide adequate periods of rests - Avoid Organ meats, aged and processed foods
 3. Promote restorative sleep - STRICT dietary restriction is NOT necessary
 4. Increase patient mobility  2. Encourage an increased fluid intake (2-3L/day) to prevent stone formation
- Advise proper posture and body mechanics  3. Instruct the patient to avoid alcohol
- Support joint in functional position  4. Provide alkaline ash diet to increase urinary pH
- Advise ACTIVE ROME  5. Provide bed rest during early attack of gout
 5. Provide Diet therapy  6. Position the affected extremity in mild flexion
- Patients experience anorexia, nausea and weight loss  7. Administer anti-gout medication and analgesics
- Regular diet with caloric restrictions because steroids may increase appetite
- Supplements of vitamins, iron and PROTEIN Osteomyelitis
 6. Increase Mobility and prevent deformity:  Infection of the bone and surrounding soft tissues most commonly by S. Aureus
- Lie FLAT on a firm mattress  Infection may reach bone through open wound ( compound fracture or surgery), through
- PRONE several times to prevent HIP FLEXION contracture the blood stream, or by direct extension from infected adjacent structure.
- Use one pillow under the head because of risk of dorsal kyphosis  Infection can be acute or chronic, both cause bone destruction.
- NO Pillow under the joints because this promotes flexion contractures Assessments
- Hot versus Cold  Malaise, fever
 Pain and tenderness of bone, redness and swelling over bone. Difficulty with weight
Gouty arthritis bearing: drainage from wound site may be present.
 A systemic disease caused by deposition of uric acid crystals in the joint and body tissues Diagnostic Test
CAUSES:  CBC: WBC elevated
 1. Primary gout- disorder of Purine metabolism  Blood cultures may be positive
 2. Secondary gout- excessive uric acid in the blood like leukemia  ESR may be elevated
ASSESSMENT FINDINGS Nursing Interventions
 1. Severe pain in the involved joints, initially the big toe 1. Administer antibiotics and analgesic as ordered.
 2. Swelling and inflammation of the joint 2. Use sterile techniques during dressing change.
 3. TOPHI- yellowish-whitish, irregular deposits in the skin that break open and reveal a 3. Maintain body alignment and change position frequently to prevent deformities.
gritty appearance 4. Provide immobilization of affected part as ordered.
 5. Fever, malaise 5. Prepare client surgery if indicated.
 6. Body weakness and headache a. Incision and drainage of bone abscess.
 7. Renal stones b. Sequestrectomy: removal of dead, infected bone and cartilage.
c. Bone grafting after repeated infections.
DIAGNOSTIC TEST d. Leg amputation
 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