NCM 104 Handouts By gudecena MUSCULO-SKELETAL NURSING ***Review of Anatomy and Physiology ASSESMENT OF THE MUSCULOSKELETAL SYSTEM Nursing

ASSESSMENT Health History - Pain - Paresthesia - Diet - Family History - Allergy Physical Exam Posture - Kyphosis - Lordosis - Scoliosis Gait - Smoothness and rhythm - Shuffling gait - Ataxic gait Antalgic gait Bone integrity Joint function - Range of motion - Effusion - Crepitus Muscle strength Neurovascular Function Neurovascular Function Diagnostic Evaluation Imaging Procedures - Xray studies - Computed Tomography - MRI - Arthrography Arthrography Intratest: radiopaque substance or air is injected into the joint cavity - If a tear is present, the contrast agent leaks out of the joint and is evident on the x-ray image. Post-procedure
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The joint is usually rested for 12 hours, and a compression elastic bandage is applied as prescribed. Provide comfort measures (mild analgesia, ice) as appropriate. Explain to the patient that it is normal to experience clicking or crackling in the joint for a day or wo after the procedure, until the contrast agent or air is absorbed.

DEXA (Dual-energy XRAY absorptiometry) BONE SCAN - 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 Arthroscopy 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

BONE MARROW ASPIRATION - Pre-test: Consent - Intratest: Needle puncture may be painful - Post-test: maintain pressure dressing and watch out for bleeding Arthrocentesis

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Intra-test: Using aseptic technique, the physician inserts a needle into the joint and aspirates fluid. Anti-inflammatory medications may be injected into the joint. Post-procedure: A sterile dressing is applied after aspiration. Monitor for signs of infection after the procedure

Electromyography (EMG) - Intra-test: Needle electrodes are inserted into selected muscles, and responses to electrical stimuli are recorded on an oscilloscope. - Post-test: Warm compress apllication to relieve residual discomfort after the study. Biopsy - Post-test: - monitor the biopsy site for edema, bleeding, pain, and infection. - Ice application to control bleeding and edema. - Analgesic administration Laboratory Studies - Examination of the patients blood and urine - Complete blood count includes the hemoglobin level and the white blood cell count - Before surgery, coagulation studies - Serum calcium levels - Serum phosphorus levels - Alkaline phosphatase - Thyroid studies and determination of calcitonin, parathyroid hormone, and vitamin D levels. - Serum enzyme levels of creatine kinase and aspartate aminotransferase
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Nursing Management of common musculo-skeletal problems PAIN 1. Assess patients perception of pain 2. Instruct patient alternative pain management like meditation, heat and cold application, TENS and guided imagery 3. Administer analgesics as prescribed 4. Assess the effectiveness of pain measures 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 SELF-CARE DEFICITS 1. Assess functional levels of the patient 2. Provide support for feeding problems Common Musculoskeletal Conditions Common Upper Extremity Problems BURSITIS AND TENDINITIS S/S : pain LOOSE BODIES Tx: Loose bodies removal by arthroscopic surgery. IMPINGEMENT SYNDROME S/s: pain, shoulder tenderness, limited

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movement, muscle spasm, and atrophy. Tx: rest, NSAIDs, joint injections, and physical therapy, Arthroscopic dbridement CARPAL TUNNEL SYNDROME

TREATMENT - Aspiration - corticosteroid injection, or surgical excision. - After treatment, a compression dressing and immobilization splint are used DUPUYTRENS DISEASE

Signs and Symptoms - Pain - Numbness - Paresthesia - possibly weakness along the median nerve (thumb and first two fingers). - Night pain is common. - Tinels sign Treatment - Rest splints to prevent hyperextension and prolonged flexion of the wrist, avoidance of repetitive flexion of the wrist (eg, use of ergonomic changes at work to reduce wrist strain) - NSAIDs, and carpal canal cortisone injections - Specific yoga postures, relaxation, and acupuncture - Traditional or endoscopic laser surgical release of the transverse carpal ligament - The patient wears a hand splint after surgery and limits hand use during healing. - The patient may need assistance with personal care and ADLs. - Full recovery of motor and sensory function after nerve release surgery may take several weeks or months. GANGLION S/S: local tenderness and may cause an aching pain, weakness of the finger occurs (When a tendon sheath is involved).
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Signs/ Symptoms - dull aching discomfort - morning numbness, cramping, and stiffness in the affected fingers. - This condition starts in one hand, but eventually both hands are affected symmetrically. TREATMENT - Initially, finger stretching exercises may prevent contractures. - With contracture development, palmar and digital fasciectomies to improve function. - Finger exercises are begun on postoperative day 1 or 2. COMMON FOOT PROBLEMS Plantar fasciitis Management - stretching exercises - wearing shoes with support and cushioning to relieve pain - orthotic devices (eg, heel cups, arch supports) - NSAIDs CORN Causes - Internal pressure (the underlying bone is prominent because of congenital or acquired abnormality commonly arthritis) - external pressure (ill-fitting shoes)

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Treatment - soaking and scraping off the horny layer by a podiatrist - application of a protective shield or pad - surgical modification of the underlying offending osseous structure. CALLUS Treatment : eliminating the underlying causes and having the callus treated by a podiatrist if it is painful. - keratolytic ointment application - Felt padding with adhesive backing is also used to prevent and relieve pressure. - Orthotic devices can be made to remove the pressure from bony protuberances - protuberance excision. INGROWN TOENAIL Prevention - Trimming the nails properly (clipping them straight across and filing the corners consistent with the contour of the toe) can prevent this problem. Treatment - Washing the foot twice a day, followed by the application of a local antibiotic ointment - decreasing the pressure of the nail plate on the surrounding soft tissue. - Warm, wet soaks help to drain an infection. - A toenail may need to be excised by the podiatrist if there is severe infection HAMMER TOE Treatment - Wearing open-toed sandals or shoes that conform to the shape of the foot
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carrying out manipulative exercises, and protecting the protruding joints with pads. Surgical correction (osteotomy)

HALLUX VALGUS Causes - Heredity - ill-fitting shoes - gradual lengthening and widening of the foot associated with aging. - Osteoarthritis TREATMENT - wearing a shoe that conforms to the shape of the foot or that is molded to the foot to prevent pressure on the protruding portions - Corticosteroid injections control acute inflammation. - Surgical removal of the bunion (exostosis) - Osteotomies to realign the toe may be required to improve function and appearance. Postoperative Mgt - analgesic adm. - foot elevation to the level of the heart to decrease edema and pain. - Neurovascular status of the toes assessment. - Toe flexion and extension exercises to facilitate walking. - Shoes that fit the shape and size of the foot are recommended. PES CAVUS Common Causes: CharcotMarie-Tooth disease (a peripheral neuromuscular disease associated with a familial degenerative disorder), diabetes mellitus, and tertiary syphilis

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Management: Exercises are prescribed to manipulate the forefoot into dorsiflexion and relax the toes. Bracing to protect the foot In severe cases, arthrodesis (fusion) is performed to reshape and stabilize the foot.

2. Age 3. Diet- caffeine, alcohol, low Ca and Vit D 4. Post-menopausal 5. Genetics- caucasian and asian 6. Immobility ASSESSMENT FINDINGS 1. Low stature 2. Fracture 3. Bone pain LABORATORY FINDINGS 1. DEXA-scan 2. X-ray studies Medical management 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 Nursing Interventions - 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 sideeffect of calcium supplements Nursing Interventions Take calcium supplements with meals Take alendronate with an EMPTY stomach with water Instruct on intake of Hormonal replacement Relieve the pain

MORTONS NEUROMA S/S: throbbing, burning pain in the foot that is usually relieved when the patient rests. Treatment - inserting innersoles and metatarsal pads designed to spread the metatarsal heads and balance the foot posture. - Local injections of hydrocortisone and a local anesthetic - Surgical excision of the neuroma is necessary. FLATFOOT Symptoms: burning sensation, fatigue, clumsy gait, edema, and pain. TREATMENT - Exercises to strengthen the muscles and to improve posture and walking habits. - foot orthoses to give the foot additional support. Metabolic Bone Disorders Osteoporosis TYPES 1. Primary Osteoporosisadvanced age, post-menopausal 2. Secondary osteoporosisSteroid overuse, lactose intolerance, alcohol abuse, Renal failure, liver failure, cushings syndrome, hyperthyroidism, hyperparathyroidism RISK factors 1. Sedentary lifestyle
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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 Improve bowel elimination - Constipation is a problem of calcium supplements and immobility - Advise intake of HIGH fiber diet and increased fluids Prevent injury - Instruct to use isometric exercise to strengthen the trunk muscles - AVOID sudden jarring, bending and strenuous lifting - Provide a safe environment Osteomalacia Signs and Symptoms - Pain - tenderness to touch - bowing of the bones, and pathologic fractures. - On physical examination, skeletal deformities (spinal kyphosis and bowed legs) - Waddling or limping gait. - Muscle weakness, and unsteadiness

liver and kidney diseases Hyperparathyroidism Prolonged use of antiseizure medication (eg, phenytoin, phenobarbital)

Clinical Assessment - On x-ray, generalized demineralization of bone is evident. - Studies of the vertebrae may show a compression fracture - Laboratory studies show low serum calcium and phosphorus levels and a moderately elevated alkaline phosphatase concentration. - Urine excretion of calcium and creatinine is low. - Bone biopsy demonstrates an increased amount of osteoid. Medical Management increased doses of vitamin D, along with supplemental calcium Exposure to sunlight for ultraviolet radiation to transform a cholesterol substance (7dehydrocholesterol) present in the skin into vitamin D Diet with adequate protein and increased calcium and vitamin D. Instruct about dietary sources of calcium and vitamin D (eg, fortified milk and cereals, eggs, chicken livers). Monitor serum calcium levels Assist patient to change positions and handle the patient gently, Pillows to support the body. Some persistent orthopedic deformities may need to be treated with braces or surgery (eg, osteotomy may be

Causes - failed calcium absorption (eg, malabsorption syndrome) - excessive loss of calcium from the body. - Gastrointestinal disorders (eg, celiac disease, chronic biliary tract obstruction, chronic pancreatitis, small bowel resection)
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performed to correct long bone deformity). PAGETS DISEASE S/S: pain and deformity Assessment and Diagnostic Findings Elevated serum alkaline phosphatase concentration a urinary hydroxyproline excretion reflect increased osteoblastic activity. normal blood calcium levels. X-rays confirm the diagnosis of Pagets disease.. Bone scans demonstrate the extent of the disease. Bone biopsy may aid in the differential diagnosis.

Direct bone contamination from bone surgery, open fracture, or traumatic injury (eg, gunshot wound) Hematogenous (bloodborne) spread from other sites of infection (eg, infected tonsils, boils, infected teeth, upper respiratory infections).

high risk for osteomyelitis - poorly nourished - Elderly - Obese - impaired immune systems - those with chronic illness (eg, diabetes, rheumatoid arthritis) - those receiving long term corticosteroid therapy. Common Etiologic Agents - Staphylococcus aureus - 70% to 80% of bone infections. - Proteus and Pseudomonas species - Escherichia coli. Clinical Manifestations Manifestations of septicemia (eg, chills, high fever, rapid pulse, general malaise). The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting pus.

Medical Management Administration of NSAIDs Gait problems from bowing of the legs are managed with walking aids, shoe lifts, and physical therapy. Weight control to reduce stress on weakened bones and malaligned joints. Diet adequate in calcium and vitamin D and periodic monitoring.

PHARMACOLOGIC THERAPY 1. Calcitonin 2. Bisphosphonates 3. Plicamycin (Mithracin Musculoskeletal Infections Osteomyelitis The bone becomes infected by one of three modes - Extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional infection)
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Assessment and Diagnostic Findings Early x-ray findings demonstrate soft tissue swelling. In about 2 weeks, areas of irregular decalcification, bone

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necrosis, periosteal elevation, and new bone formation are evident. Elevated leukocyte levels Elevated sedimentation rate. Wound culture will reveal presence of microorganism

4. Anatomical deformity 5. genetic susceptibility Assessment findings 1. Joint pain 2. Stiffness Diagnostic findings 1. X-ray 2. Blood tests will show no evidence of systemic inflammation and are not useful Medical management 1. Weight reduction 2. Use of splinting devices to support joints 3. Occupational and physical therapy 4. Pharmacologic management Nursing Interventions - Provide relief of PAIN - Advise patient to reduce weight - Administer prescribed medications - Position the client to prevent flexion deformity Rheumatoid arthritis FACTORS: - Genetic - Auto-immune connective tissue disorders - Fatigue, emotional stress, cold, infection - Rheumatoid arthritis ASSESSMENT FINDINGS 1. PAIN 2. Joint swelling and stiffnessSYMMETRICAL, Bilateral 3. Warmth, erythema and lack of function 4. Fever, weight loss, anemia, fatigue 5. Palpation of joint reveals spongy tissue 6. Hesitancy in joint movement Diagnostic test 1. X-ray

Medical Management Antibiotic therapy General supportive measures (eg, hydration, diet high in vitamins and protein, correction of anemia) Immobilization of affected area Warm wet soaks for 20 minutes several times a day Infected bone is surgically exposed, the purulent and necrotic material is removed, and the area is irrigated with sterile saline solution Sequestrectomy (removal of enough involucrum to enable the surgeon to remove the sequestrum)

Nursing Interventions - Relieve Pain - IMPROVE PHYSICAL MOBILITY - CONTROL THE INFECTIOUS PROCESS DEGENERATIVE JOINT DISEASE OSTEOARTHRITIS Classification - Primary (idiopathic) - with no prior event or disease related to the OA - Secondary - resulting from previous joint injury or inflammatory disease Risk factors 1. Increased age 2. Obesity 3. Repetitive use of joints with previous joint damage
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2. Blood studies reveal (+) rheumatoid factor, elevated ESR and C-Reactive Protein 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 2. Chemotherapy with methotrexate, antimalarials, gold therapy and steroid 3. For advanced cases- arthroplasty, synovectomy 4. Nutritional therapy

3. TOPHI- yellowish-whitish, irregular deposits in the skin that break open and reveal a gritty appearance 4. Fever, malaise 5. Body weakness and headache 6. Renal stones DIAGNOSTIC TEST - Elevated levels of uric acid in the blood - Uric acid stones in the kidney - (+) urate crystals in the synovial fluid Medical management 1. Allopurinol 2. Colchicine 3. Probenecid Nursing Intervention 1. Provide a diet with LOW purine 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 6. Position the affected extremity in mild flexion 7. Administer anti-gout medication and analgesics Fracture TYPES OF FRACTURE 1. Complete fracture 2. Incomplete fracture 3. Comminuted fracture 4. Simple fracture ASSESSMENT FINDINGS 1. Pain or tenderness over the involved area 2. Loss of function 3. Deformity 4. Shortening 5. Crepitus

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 2. Decrease patient fatigue 3. Promote restorative sleep 4. Increase patient mobility 5. Provide Diet therapy 6. Increase Mobility and prevent deformity Gouty arthritis CAUSES: 1. Primary gout- disorder of Purine metabolism 2. Secondary gout- excessive uric acid in the blood like leukemia ASSESSMENT FINDINGS 1. Severe pain in the involved joints, initially the big toe 2. Swelling and inflammation of the joint
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6. Swelling and discoloration 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 5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination 6. DO NOT attempt to reduce the facture

4. Administer care of traction and cast FRACTURE COMPLICATIONS Early 1. Shock 2. Fat embolism 3. Compartment syndrome 4. Infection 5. DVT Late 1. Delayed union 2. Avascular necrosis 3. Delayed reaction to fixation devices 4. Complex regional pain syndrome Fat Embolism Onset is rapid, within 24-72 hours 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 Nursing Management 1. Support the respiratory function 2. Administer drugs 3. Institute preventive measures Early complication: Compartment syndrome ASSESSMENT FINDINGS 1. Pain- Deep, throbbing and UNRELIEVED pain by opiods 2. Paresthesia- burning or tingling sensation 3. Numbness 4. Motor weakness 5. Pulselessness, impaired capillary refill time and cyanotic skin Medical and Nursing management 1. Assess frequently the neurovascular status of the casted extremity 2. Elevate the extremity above the level of the heart

MEDICAL MANAGEMENT 1. Reduction of fracture either open or closed, Immobilization and Restoration of function 2. Antibiotics, Muscle relaxants and Pain medications 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 For OPEN FRACTURE 1. Prevent wound and bone infection 2. Administer prescribed antibiotics 3. Elevate the extremity to prevent edema formation
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3. Assist in cast removal and FASCIOTOMY Musculoskeletal Modalities Traction PURPOSE - To decrease muscle spasms - To reduce, align and immobilize fractures - To correct 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 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 8. Promote skin integrity CAST CAST: types - Long arm - Short arm - Short leg - Long leg - Spica - Body cast Casting Materials Plaster of Paris - Drying takes 1-3 days Sprains Nursing management 1. Immobilize extremity and advise rest 2. Apply cold packs initially then heat packs
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If dry, it is SHINY, WHITE, hard and resistant Fiberglass - Lightweight and dries in 20-30 minutes - Water resistant Cast application - TO immobilize a body part in a specific position - TO exert uniform compression to the tissue - TO provide early mobilization of UNAFFECTED body part - TO correct deformities - TO stabilize and support unstable joints Nursing Management CAST: General Nursing Care 1. Allow the cast to air dry (usually 2472 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 5. Trim 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 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

3. Compression bandage may be applied to relieve edema 4. Assist in cast application 5. Administer NSAIDS Strains

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Nursing management 1. Immobilize affected part 2. Apply cold packs initially, then heat packs 3. Limit joint activity 4. Administer NSAIDs and muscle relaxants Amputation Removal of body part Peripheral vascular dse, fulminating gas gangrene, trauma, congenital deformities, chronic osteomyelitis, malignant tumor Purpose is to relieve symptom and improve function Staged amputation- gangrene and infection Complication are hemorrhage, infection, skin breakdown, phantom limb pain, joint contracture

Neurovascular evaluation Functional status of the extremity Diet- balance with adequate protein and vitamins Psychological status Grief response

Nursing diagnosis - Acute pain - Disturbed body image - Infection, risk - Ineffective coping - Risk for disturbed sensory perception - Self care deficit Goals Relief of pain Absence of altered sensory perception Acceptance of body image Restoration of physical mobility Absence of complication

Assessment

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