nur 105 module i

MUSCULOSKELETAL SYSTEM

MODULE I

NURSING 105: ADULT NURSING

Myrna Williamson, MSN, RN, OCN

In the very young…

• The skeleton is composed of mostly cartilage and is therefore, pliable with a decreased incidence of bone fractures and breakage in childhood

Mature Bone

• Rigid connective tissue consisting of cells;– Collagen– Calcium– Phosphate

SKELETON

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders.

SKELETON

• AXIAL PORTION– Cranium– Vertebrae– Ribs

• APPENDICULAR PORTION– Limbs– Shoulders – Hips

ANATOMY & PHYSIOLOGY REVIEW

• Structure & Function – Skeletal System

• Bone Formation, Maintenance, Healing

– Articular System• Joints – synarthrosis, amphiarthrosis, & diarthrosis

– Skeletal Muscle System• Contraction• Tone• Actions• Exercise, Disuse, & Repair

Bone Cells

Osteogenic CellsOsteoblastsOsteocytesOsteoclasts

Bone Formation & Maintenance

• Ossification• Resorption &

Formation– Local stress– Vit. D– Parathyroid hormone– Calcitonin– Blood supply

TYPES OF BONES


SPONGY BONE

• Located in the ends of long bones and the center of flat and irregular bones

• Can withstand forces applied in many directions

DENSE (COMPACT) BONE

• Covers spongy bone

• Cylinder around a central marrow cavity

• Can withstand force predominantly in one direction

SPONGY BONE AND COMPACT BONE


FUNCTIONS OF BONE

• Framework• Support• Movement• Shape• Maintain Position• Attachment of

Muscles

• Protects Organs• Storage• Hematopoiesis• Remodeling• Reformation• Movable Joints

CHARACTERISTICS OF JOINTS

• Allow the movement between bones

• Formed where two bones join

• Surfaces are covered with cartilage

• Enclosed in a capsule

Classification of Joints

• A-C; Synarthrotic (immovable) & amphiarthrotic (slightly movable) joints.

• D-E: Diarthrodial (freely movable) joints

Types of Diarthrodial Joints

• Hinge• Ball &

Socket• Pivot• Condyloid• Saddle• Gliding

SYNOVIAL JOINT

From Applegate E: The Anatomy and Physiology Learning System, ed. 2, Philadelphia, 2000, W.B. Saunders.

SYNOVIAL JOINT OF THE KNEE


ANTERIOR VIEW OF MAJOR MUSCLES


POSTERIOR VIEW OF MAJOR MUSCLES


SKELETAL MUSCLE


Neuromuscular Junction

CHARACTERISTICS OF MUSCLES

• Made up of bundles of muscle fibers

• Provide the force to move bones

• Assist in maintaining posture

• Assist with heat production

4 Steps of Muscle Contraction

• Excitation

• Coupling

• Contraction

• Relaxation

Body Movements

• Flexion• Extension• Abduction• Adduction• Rotation• Circumduction• Supination

• Pronation• Inversion• Eversion• Protraction• Retraction

Age Related Changes of Musculoskeletal System

• Bones• Muscles• Joints• Ligaments

Nursing Assessment

• Health History– Initial Interview

– Assessment Data• Pain• Altered Sensations

Nursing Assessment

• Physical Assessment– Posture– Gait– Bone Integrity– Joint Function– Muscle Strength & Size– Skin– Neurovascular Status

RISK FACTORS

• Autoimmune disorders

• Calcium deficiency

• Degenerative conditions

• Falls

• Hyperuricemia

• Infection

RISK FACTORS (Continued)

• Medications

• Metabolic disorders

• Neoplastic disorders

• Obesity

• Postmenopausal states

• Trauma and injury

Diagnostic Evaluation

• Imaging Procedures– X-ray– Computed Tomography

(CT)– Magnetic Resonance

Imaging (MRI)– Arthrography– Bone Densitometry

Diagnostic Evaluation

• Nuclear Studies– Bone Scan

• Endoscopic Studies– Arthroscopy

• Other Studies– Arthrocentesis– Electromyography– Biopsy

• Laboratory Studies– (CBC)– Urinalysis (Calcium)– Blood Chemistry– Serum Calcium– Serum Phosphate– Uric Acid– Serum Creatinine– LDH, SGOT, CPK

X-RAYS

• DESCRIPTION• IMPLEMENTATION

ARTHROCENTESIS


ARTHROGRAM


Arthrogram of the Knee

ARTHROSCOPY


BONE SCAN


BONE OR MUSCLE BIOPSY


Muscle Biopsy Showing Polymyositis

ELECTROMYOGRAPHY (EMG)

From Mourad LA (1991) Orthopedic disorders. St. Louis: Mosby.

MYELOGRAM

From Herlihy B, Maebius NK: The human body in health and illness, Philadelphia, 2000, W.B. Saunders.

MUSCULOSKELETAL INJURIES

• Skeletal Trauma• Injuries to Support

Structures

Fractures

• Described according to location and type

Types of Fractures

• Complete or Incomplete

• Open (formerly referred to as compound)

• Closed (formerly referred to as simple)

Complete Fractures

• Linear

• Oblique

• Transverse

• Spiral

Complete Fractures

• Comminuted

• Impacted

• Pathologic

• Avulsion

Complete Fractures

• Compression

• Displaced

• Extracapsular

• Intracapsular

Incomplete Fractures

• Greenstick

• Torus

• Bowing fracture

• Transchondral fracture

• Stress Fractures

TYPES OF FRACTURES

From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia: W.B. Saunders.

Types of Fractures

Pathophysiology of a Fracture

• Tissue Disrupted• Bleeding Occurs • Hematoma Forms• Bone Tissue

Healing of a Fracture

• Inflammatory response

• Vascular tissue • Bone-forming cells• Callus formation• Osteoblasts • Remodeling

Speed of Healing

• Hematoma formation – within hours• Procallus – within days• Callus formation – within weeks• Replacement and remodeling – up

to 4 years

Fractures – Clinical Manifestations

• Impaired function• Deformity (unnatural

alignment)• Swelling• Muscle spasm• Tenderness• Pain• Impaired sensation

FRACTURE OF AN EXTREMITY

• ASSESSMENT• INITIAL CARE

INTERVENTIONS FOR A FRACTURE

• Reduction• Fixation• Traction• Casts

Fractures - Treatment

• Reduction– Closed manipulation– Traction (skin or skeletal)– Open reduction and internal fixation (ORIF),

(insertion of prosthesis, screw, plate, nail or wire).

CLOSED REDUCTION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

INTERNAL FIXATION

From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.

Types of Internal Fixation for a Hip Fracture

EXTERNAL FIXATION

From Ignatavicius, D., Workman, M. (2002). Medical-surgical nursing, ed 3, Philadelphia: W.B. Saunders. Courtesy of Smith and Nephew, Inc., Orthopedics Division, Memphis, TN.

TYPES OF HIP FRACTURES

• Intracapsular

• Extracapsular

HIP REPLACEMENTS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.

TOTAL HIP REPLACEMENT

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

HIP FRACTURE

• POSTOPERATIVE CARE

• CLIENT EDUCATION

TOTAL KNEE REPLACEMENT

• DESCRIPTION• POSTOPERATIVE

CARE

KNEE PROSTHESIS


CONTINUOUS PASSIVE MOTION

Cast Care

• Educate• Apply Ice• Instruct• Prevent• Attend

TRACTION


SKELETAL TRACTION


SKIN TRACTION

• DESCRIPTION– Traction applied by the

use of elastic bandages or adhesive

Side Arm

CERVICAL SKIN TRACTION

From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2, Philadelphia: W.B. Saunders.

HEAD HALTER TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BUCK’S SKIN TRACTION


PELVIC SKIN TRACTION


BALANCED SUSPENSION


DUNLOP’S SKIN TRACTION

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

COMPLICATIONS OF FRACTURES

• Fat embolism

• Compartment syndrome

• Infection and osteomyelitis

• Avascular necrosis

• Pulmonary emboli

• Venous thrombosis

• Delayed union & nonunion

FAT EMBOLISM• DESCRIPTION

• ASSESSMENT

• IMPLEMENTATION

COMPARTMENT SYNDROME

INFECTION AND OSTEOMYELITIS

• DESCRIPTION

• ASSESSMENT

• IMPLEMENTATION

AVASCULAR NECROSIS

• DESCRIPTION

• ASSESSMENT

• IMPLEMENTATION

PULMONARY EMBOLISM• DESCRIPTION

– Caused by immobility precipitated by a fracture

Venous Thrombosis

• Description

• Assessment

• Implementation

Delayed Union & Nonunion

• Description

• Assessment

• Implementation

Other Skeletal Trauma

• Dislocation• Subluxation• Injuries to Support Structures

– Tendon tear– Ligament tear– Strain– Sprain– Avulsion– Tendonitis– Bursitis

Soft Tissue Injury of Hip

CARPAL TUNNEL SYNDROME

Associated with occupations that require continuous wrist movement.

Sports-Related Injuries

• Rotator Cuff Tears

• Epicondylitis (Tennis Elbow)

• Lateral & Medial Collateral Ligament Injury

• Anterior & Posterior Cruciate Ligament Injury

• Meniscal Injuries

• Rupture of Achilles Tendon

CRUTCH WALKING

CRUTCH GAITS


SINGLE- AND QUAD-FOOT CANES


WALKERS

HERNIATION: INTERVERTEBRAL DISC

CERVICAL DISC

CERVICAL COLLAR

LUMBAR DISC


LOW BACK CARE


TYPES OF DISC SURGERY

• CHEMOLYSIS• DISCECTOMY• DISCECTOMY WITH

FUSION• LAMINOTOMY• LAMINECTOMY

DISC SURGERY

• PREOPERATIVE

• POSTOPERATIVE: CERVICAL DISC

• POSTOPERATIVE: LUMBAR DISC

AMPUTATION OF A LOWER EXTREMITY

• DESCRIPTION– The surgical removal

of a lower limb or part of the limb

AMPUTATION FLAPS


AMPUTATION OF A LOWER EXTREMITY

• POSTOPERATIVE– Monitor vital signs– Monitor for infection and hemorrhage– Mark bleeding and drainage on the dressing if

it occurs– Keep a tourniquet at the bedside– Monitor for pulmonary emboli

STUMP WRAPPING


BELOW-THE-KNEE AMPUTATION

• POSTOPERATIVE– Prevent edema– Do not allow the stump to hang over the edge

of the bed– Do not allow the client to sit for long periods of

time to prevent contractures

ABOVE-THE-KNEE AMPUTATION

• POSTOPERATIVE– Prevent internal or external rotation of the

limb– Place a sandbag or rolled towel along the

outside of the thigh to prevent rotation

DISORDERS OF BONE

• Metabolic Bones Diseases

• Infectious Bone Disease

• Bone Tumors

Infectious Bone Disease: Osteomyelitis

• Difficult to treat

• Physical disability

• Bacteria– Exogenous– Endogenous

OSTEOMYELITIS

• DESCRIPTION• ASSESSMENT • IMPLEMENTATION

Bone Tumors

• Incidence

• Signs & Symptoms

• Diagnosis

DISORDERS OF JOINTS

• Noninflammatory joint disease

• Inflammatory joint disease

INFLAMMATORY JOINT DISEASE

• Rheumatoid arthritis• Ankylosing

Spondylitis• Gouty arthritis

RHEUMATOID ARTHRITIS (RA)

• DESCRIPTION• ASSESSMENT

RHEUMATOID ARTHRITIS

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

MUSCLE ATROPHY

BOUTONNIERE DEFORMITY

SWAN NECK DEFORMITY

RHEUMATOID NODULE



• NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDs)

• CORTICOSTEROIDS• ANTINEOPLASTIC

MEDICATIONS• GOLD SALTS


• PHYSICAL MOBILITY• SELF-CARE


• FATIGUE• BODY IMAGE

DISTURBANCE

RHEUMATOID ARTHRITIS (RA) SURGICAL INTERVENTIONS

• SYNOVECTOMY• ARTHRODESIS• JOINT REPLACEMENT

(ARTHROPLASTY)

Ankylosing Spondylitis

• Chronic Inflammatory Disease

• Systemic autoimmune disease

• Differs from RA

• Signs & Symptoms

• Treatment

GOUTY JOINT • Description• Phases• Assessment• Implementation

GOUT

From Clinical Slide Collection of the Rheumatic Diseases, © 1991,1995,1997. Used with permission of the American College of Rheumatology.

Noninflammatory Joint Disease

• Degenerative joint disease (osteoarthritis) is the most common

OSTEOARTHRITIS

• DESCRIPTION– Also known as

degenerative joint disease (DJD)

JOINT CHANGES IN OSTEOARTHRITIS

OSTEOARTHRITIS

From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.

SEVERE OSTEOARTHRITIS

HEBERDEN’S NODES

BOUCHARD’S NODES

OSTEOARTHRITIS

• PHYSICAL MOBILITY

OSTEOARTHRITISSURGICAL INTERVENTIONS

• OSTEOTOMY• TOTAL JOINT

REPLACEMENT (TJR)

RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS

CLIENT EDUCATION• Assist

• Instruct

• Review

Metabolic Bone Diseases

• Osteoporosis

• Osteomalacia

• Paget’s Disease

OSTEOPOROSIS

DOWAGER’S HUMP

OSTEOPOROTIC CHANGES


SEVERE OSTEOPOROSIS


MILWAUKEE BRACE


OSTEOMALACIA

• Metabolic disease

• Bone volume unchanged

• Osteomalacia – adults

• Rickets - children

Paget’s Disease

• Osteitis Deformans

• Increased metabolic activity

• Usually no TX

• Affects men and women equally

Nursing Diagnoses• Knowledge Deficit

• Impaired Physical Mobility

• Self-care Deficit

• Risk for Infection

• Impaired Skin Integrity

• Imbalanced Nutrition

• Acute/Chronic Pain

THE END OF MUSCULOSKELETAL

nur 105 module i

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