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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