Musculoskeletal System

Day 1

What is the first step of the nursing process?

A. Nursing DiagnosisB. AssessmentC. Building a relationship of trustD. EmpathyE. Teaching

Highly integrated system

BONE JOINT

LIGAMENTBURSAE

MUSCLETENDON

What is the leading cause of disability in the US?

A. Motor Vehicle accidentsB. Sports injuriesC. ArthritisD. DiabetesE. Cardio-vascular impairment

Musculoskeletal SystemFUNCTION!

• Protection

Musculoskeletal SystemFUNCTION!

• Protection• Framework• Mobility– Move– Heat– Facilitates blood return

Musculoskeletal SystemFUNCTION!

• Protection• Framework• Mobility• Reservoir – Blood cells– Essential minerals

• Ca• Ph

Anatomy & PhysiologySKELETAL SYSTEM

How many bones are in the human body?A. 206B. 1,245C. 847D. 145E. 666

Bone Types

• Long bones• Short bones• Flat bones• Irregular bones

Bone components

Compact Bone• Dense

Spongy bone• Porous

• Diaphysis– Shaft

• Epiphyses– End

• Epiphyseal plate– growth

Periosteum

• Covering• Contains– Nerves– Blood vessels– Lymph tissue

• Function– Nourishment– Attachment

Which of the following are formed in the bone marrow?

A. Red blood cellsB. White blood cellsC. PlateletsD. HemoglobinE. All of the above

Bone Marrow

Red

• Locations– Flat bones

• Function– RBC– WBC – Platelets– Hgb

Yellow• Location– Long bones

• Fatty

Bone Cells

• Osteoblasts– Form matrix

• Osteocytes– Maintenance

• Osteoclasts– Dissolving & resorbing

Bone Maintenance

• Modeling– Childhood– Bones grow & form

• Remodeling– Adulthood– Resorption– Osteogenesis

Cool Fact!

Complete skeletal turnover occurs every 10

years

Resorption / OsteogenesisHomeostasis

a. Physical activityb. Nutritionc. Hormones

Physical Activity

• Weight-bearing stimulates bone formation & remodeling

What happens if…

• A person is on prolonged bed rest or physically disabled and they don't engage in regular weight bearing activities?– h bone resorption – Calcium loss – Osteopenic bones – fractures

Nutrition

• Calcium–1000 – 1200 mg / day–16 – 24 oz. milk

What two endocrine hormones work in harmony to maintain

normal serum Calcium levels? • What? I need to give you multiple choice

answers! NO way! Turn to your neighbor and tell them the answer to this question

• PTH• Calcitonin

Hormones

PTH• Secreted by

– Parathyroid• Effect

– h Serum Ca+ levels• Action

– Promotes movement of Ca+ from bone to blood

Calcitonin• Secreted by

– Thyroid• Effect

– i Serum Ca+ levels• Action

– Inhibits bone resorption & h deposits of Ca+ in the bone

Hormones

• Hyperthyroidism – h bone resorption– i bone formation

• Cushing’s syndrome – h bone resorption– i bone formation

What is the name of the most common form of hyperthyroidism in the U.S.A?

A. Hashimoto’s thyroiditisB. Graves diseaseC. Addison’s diseaseD. CretinismE. Pheochromocytoma

Cushing’s Disease is caused by what hormonal imbalance?

A. Steroid excessB. Steroid deficitC. Thyroid hormone excessD. Thyroid hormone deficitE. Excess ADH

Small Group Questions

1. What are the 4 main functions of the M/S system?

2. What & where is the periosteum?3. What types of bone marrow are there?

(location & function)4. What are the 3 main types of bone cells and

their main function?5. Describe resorption and osteogenesis.

Articular System

• Joint– Junction of 2 or more

bones

Joints

• Synarthrosis– immovable

• Amphiarthrosis– Limited motion– Joined by cartilage

• Diarthrosis– Freely movable

Types of diarthrosis joints

• Ball & Socket• Hinge• Saddle• Pivot• Gliding

Synovial Joints

• Bones covered with hyaline cartilage

• Form capsule• Lined with synovium

membrane• Secretes lubricant

Do the bone surfaces of a normal functioning synovial joint come in

direct contact with each other?

A. YesB. NoSynovial fluid acts as a shock absorber

Ligaments, tendons, bursa

• Tendons – Bind muscle to bone

Ligaments, tendons, bursa

• Ligaments – Bind bone to bone

Ligaments, tendons, bursa Bursa– Sac filled with synovial fluid • Elbow• Shoulder• Hip • Knee

Small Group Questions

1. Define synarthrosis, amphiarthrosis & diaarthrosis?

2. What is a synovial joint?3. Define ligament, tendon & bursa.4. What hormones are vital for Ca+ and Ph+

homeostasis?

Types of Muscles

• Skeletal Muscles– Voluntary movement

• Smooth muscles– Internal control– e.g. bladder, GI, bronchi

• Cardiac muscles– Heart

Muscle Cell

• Parallel cells encased – Fascia

• Contains– Myofibrils– Contain• Sarcomeres• Contracting unit

Contraction

• Cell contract in response to electrical stimulation

• Ca+ ion enters sacromeres

• Sacromeres contract • Ca+ rapidly removed • Sacromere relaxes

Ca

Ca

Ca

Energy Source

• ATP– Adenosine triphosphate

– Glucose Metabolism

• Not all ATP is used with muscle contraction excess energy heat

Types of contractions

• Isometric– Length of muscle

remains constant but h force

• Isotonic – Shortening of the muscle

without increase in tension

• Combination

Muscle Tone

• State of readiness• Flaccid:– i tone

• Spastic:– h tone

• Atonic:– No nerve impulse no

tone atrophy

Muscle Action

• Contraction movement!

• Exercise – Function– Strength– Size

• Hypertrophy

• Over exercise – Lactic acid– Fatigue

Gerontologic Considerations

• Aging vs…– i activity – Lifestyle– Pathophysiological

factors

Aging Structural Changes• Bones

– i bone mass– Vertebrae collapse

• Muscles– h collagen– Atrophy– i elasticity

• Joints– Cartilage deteriorates

• Ligaments– Lax

Aging functional Changes

• Bones– Fragile, prone to fracture

• Muscles– i strength, weak, tired,

stumble• Joints– Stiff, pain

• Ligaments– Postural changes

Aging H&P findings

• i height• Kyphosis• Flexion of hips & knees• Fractures• Stiffness• i strength

Assessment: Health History

• Common symptoms– Pain– Alt. sensation

• Past health• Social history• Family history

Small Group Question

• Mrs. Jones comes into the doctor’s office complaining of pain in her left knee. What questions will you ask her to assess her pain?

Did you ask the following questions?

• Characteristics• Location• Rating• Onset• Duration• Manifestations• Precipitating factors

• Effect of ADL’s• Aggravations • Diminishes• Radiating• Associated complaints• Past injuries

Physical Examination

• Posture– What is this?– Kyphosis

• h curve of the thoracic spine

Physical Examination

• Posture– What is this?– Lordosis

• h Curve of the lumbar spine

Physical Examination

• Posture– What is this?– Scoliosis

• Lateral curve of the spine

Physical Examination

• Gait– Smooth– Steady

Physical Assessment

• Bone Integrity– Deformity?– Alignment– Symmetry

Physical Assessment

• Joint Function– ROM

• Range of Motion

ROM

abduction• Move away from midline

adduction• Move towards midline

ROM

extension• Straighten a limb

flexion• Bend a limb

ROM

Dorsiflexion• Bend ankle bringing toe

upwards

Plantar flexion• Straighten ankle to point

toes down

ROM

Pronation• Palm down

Supination• Palm up

ROM

Eversion• Turn out

INversion• Turn in

ROM

• Circumduction– Move in a circle

ROMInternal rotation /Medial rotation

• Move inward on a central axis

External rotation /Lateral rotation

• Move outward on a central axis

Range of Motion

Passive• Total assist

Active• Independent

Range of Motion

• Never attempt to move a joint past its normal range of motion for the client or past the point at

which pain is experienced.

Physical Assessment

• Joint Function– ROM– Deformity– Stability– Contracture

• Permanent shortening of the muscle

– Crepitus– Effusion

Bulge Sign

• Position: supine• Milk upward on the

medial side of the knee• Tap the lateral side of

the patella• Observe for a fluid

bulge • = effusion

• http://www.youtube.com/watch?v=LsgutijmX7U

• http://www.youtube.com/watch?v=fNUGyNYVhqE

Ballottement

• Apply downward pressure just above the knee

• Tap the patella • Fluid will cause the

patella to rebound

• http://www.youtube.com/watch?v=PlgSsE8EvXE

Balloon sign

• AKA– Water on the knee

• http://www.youtube.com/watch?v=FfO4Nhu0u3s

Muscle Strength & SizeGrade Description

0 No contraction, paralysis

1 Contraction felt, no movement

2 Passive ROM

3 Full ROM against Gravity

4 Full ROM against some resistance

5 Full ROM against full resistance

Muscle Strength & Size

• Measure Girth– Max circumference– At rest

Skin

• Edema• Temp• Color

Neurovascular status

• CMS– Circulation

• Color• Temp• Cap. refill

– Motion• Weak / paralysis

– Sensation• Paresthesia• Pain

Neurovascular status

• 5 – P’s– Pain– Pallor– Pulselessness– Paresthesia– Paralysis

Small group Questions

1. Define lordosis, scoliosis, kyphosis.2. Differentiate between the different

movement of ROM.3. How are the bulge and ballottement signs

assessed and what do they indicate?4. How do you assess neurovascular status?

Diagnostic Tests

Laboratory tests• Erythrocyte sedimentation

rate (ESR)• C-reactive protein (CRP)• Calcium• Phosphate• Uric Acid

Diagnostic test• X-ray• CT-scan• MRI• Bone scan• Densitometry• Arthrocentesis• Arthroscopy• Electromyelogram

Erythrocyte Sedimentation Rate (ESR)

• What does an elevated ESR indicate?A. Bone cancerB. OsteoporosisC. InflammationD. AnemiaE. Auto-immune disease

C-reactive Protein

• What does an positive CRP indicate?A. Bone cancerB. OsteoporosisC. InflammationD. AnemiaE. Auto-immune disease

Calcium (Ca+)

• Location– Bone & teeth

• Vital for – Nerve impulse– Muscle contraction– Muscle relaxation– Blood clotting

Phosphate (Ph)

• ICF ion• Important for energy

ATP• Ca & Ph have an inverse

relationship

Ca

Ph

Uric Acid

• End product of protein metabolism

• Excreted by kidneys• Elevated levels gout

Antinuclear antibodies (ANA)

• Found in auto-immune disorders

X-ray

• Purpose– Bone density, texture,

erosion, placement• Nrs. Considerations:– No prep– PG?

Computed Tomography (CT scan)

• Purpose– h detail - X-ray– Bone, tumor, soft tissue,

ligaments, tendons• Nrs. Considerations:– No prep– PG?– Contrast?

allergies

• Sagittal CT scan

Magnetic Resonance imaging(MRI)

• Purpose– Non-invasive – Soft Tissue

• Nrs. Considerations– No metal– No transdermal patches

Bone Scan

• Purpose– Bone seeking

radioisotope injected IV– Scan

• Distribution• Concentration

• Nrs considerations– Drink fluidsAllergiesPG

Bone densitometry

• Purpose– Bone mineral density– X-ray or ultrasound

Arthrocentesis

• Purpose– Remove fluid from the

joint– Examination– i Pain d/t effusion

• Procedure– Needle inserted into

joint– Aspirate fluid

• http://www.youtube.com/watch?v=fZ2dcZhoGP8

Arthrocentesis

• Nrs. Considerations– Sterile dressings– Risk of infection

Arthroscopy

• Purpose– Direct visualization of

the joint• Nrs. Considerations– Compression bandage– Ice– Elevate– P S&S of infection

• http://www.youtube.com/watch?v=Yb2YsSbSdck

Electromyelogram (EMG)

• Purpose– Electrical potential of a

muscle – Differentiate muscle &

nerve problem

Small Group Questions

1. What do the following tests measure?– ESR, CRP, Ca+, Ph+, Uric acid and ANA

2. How are the following diagnostic tests performed, what do they diagnose and what are the nursing considerations?– X-ray, Ctscan, MRI, Bone scan, Densitometry,

Arthrocentesis, Arthroscopy, EMG