Nursing assessment Musculoskeletal function

 Musculoskeletal system
o Bones
o Joints
o Muscles
o Tendons
o Ligaments
o Bursae
o Problems associated with these structures are common and affect all age groups
o Problems are generally not life threatening
 Have significant effect on pt normal activities and productivity
 Affect activities of daily living
 Can affect many other body systems
 Prolonged immobility leads to skin breakdown, constipation, and thrombus
formation
 Structure and function
o Osteocytes
 Mature bone cell
o Osteoblasts
 Builders of bone cell
o Osteoclasts
 Dissolve and reabsorb
o Collagen turns into bone in childhood it is modeling by early 20s it is remodeling
 Bone growth and maintenance
o Calcium rich foods Honan box 40-1
o Milk, yogurt, and cheese
o Rhubarb, cooked collard greens, cabbages, kale, and broccoli (green leafy)
o Sardines, oysters, clams, canned salmon with bones
o Tofu
o Calcium fortified fruit juices and fruit drinks and fortified cereals
o Bone growth and metabolism affected by numerous minerals and hormones
 Calcium and phosphorous- inversely proportioned
 As calcium rises, phos decreases
 Calcitonin
 When levels are altered, calcitonin and PTH work to maintain
equilibrium (feedback loop) of endocrine system
 Produced by thyroid gland
 Decreases the calcium if concentration above normal
 Will inhibit bone reabsorption and increases renal excretion of calcium
and phosphorus as needed to maintain homeostasis
 Vitamin D
 Transported in blood to promote the absorption of calcium and phos
from small intestine
 Decreases can result in osteomalacia (softening of bone)
 Parathyroid hormone, growth hormone
 Secreted by anterior lobe of pit gland
  Responsible for increasing bone length
 Glucocorticoids, estrogens, and androgens
o Bone serves as vast reservoir of calcium
 Stimulating net resorption of bone mineral releases calcium and phosphate into
blood
 Suppressing this effect allows calcium to be deposited in bone
 Bone healing- watch video
o Hematoma formation
o Inflammatory phase
o Reparative phase
o Remodeling
 Functions of bone
o Framework
o Support and protect structures of body
o Movement
o Shape
 Weight bearing framework
o Assist in regulating calcium and phosphate concentrations
o Maintain position
o Attachment of muscles, tendons, and ligaments
o Protects organs
o Storage of minerals
o Hematopoiesis
o Tissue support
o Remodeling
o Reformation
o Movable joints
o Contain tissue in central cavities which aid in formation of blood vessel
 Manufacture RBC
 Types of bones
o Flat bone
 Sternum
 Scapula
 Protect vital organs
o Short bone
 Metacarpals
 Non weight bearing
o Irregular bone
 Carpal bones
 Bones in ears
o Long bone
 Femur
 Weight bearing
o Sesamoid bone
 Bones that develop within a tendon
 Patella
 Tendons
 o Bands of fibrous connective tissue that tie bone to muscle
 Ligaments
o Strong, dense and flexible bands of fibrous tissue connecting bones to another bone at
joints
 Joints
o Part of the skeleton where two or more bones are connected
 Cartilage
o Dense, flexible connective tissue that consists of fibers embedded in strong gel like
substance
o Found in joints between bones, rib cage, ear, nose, bronchial tubes, and intervertebral
discs
o Not as hard and rigid as bone but stiffer and less flexible than muscle
 Types of joints
o Synarthrodial
 Completely immovable
 Cranium
o Amphiarthrodial
 Slightly movable
 Pelvic
o Diarthrodial (synovial joints)
 Freely movable
 Elbow and knee
 Lined with synovium
 Membrane that secretes synovial fluid for lubrications and shock
absorption
 Subtypes by an atomic structure
 Ball and socket
o Shoulder and hip
o Permit full freedom of movement
 Hinge
o Elbow and knee
o Permit bending in one direction only
 Saddle
o Allow movement in two planes at right angles to each other
o Thumb
 Elliposoidal or gliding
o Allow limited movement in all direction s
o Wrist
 Pivot
o Rotations only like turning doorknob
o Radioulnar
o Bursa
 Thin walled sac lined with synovial fluid to prevent friction between bones and
structures
 Allow the movement of tendons and muscles over bony prominences
 Found in elbow, shoulder, knee, and some other joints
 Changes associated with aging: Honan table 40-1
o Osteopenia
 Decreased bone density
o Osteoporosis
 Severe osteopenia
o Synovial joint cartilage
 Less elastic
 Osteoarthritis
 Weight bearing joints most affected
o Muscle tissue atrophies
 Increase in activity can restore muscle strength
o Changes can cause
 Decreased coordination
 Loss of muscle strength
 Gait changes
 Risk for falls
o Up to age 30
 Bone formation and resorption work in balance
 Osteoblasts work to secrete boney matrix
 Foundation of bone formation
 Osteoclasts work to dissolve and resorb bone
 When this balance is disrupted
 Physical activity
 Dietary intake of certain nutrients (calcium)
 Hormone levels
o Calcitrol
o PTH
o Calcitonin
o Cortisol
o Thyroid hormones
o Growth homes
o Sex hormones
 Estrogen
 Testosterone
o Nursing alert
 Important to note that after age 30-45, resorption of bone exceeds bone
formation
 Imbalance is exaggerated in women after menopause
o Increases risk of osteoporosis related fractures
o Gradual and progressive bone loss causes decreased bone density
 Osteopenia- predisposes pt to fractures
 That decreased bone density leads to osteoporosis
o Progressive deterioration of cartilage in joints causing stiffness and pain ultimately
interfering with activities of daily living
 Years of wear and tear
 Work
 Sports play
o Myo atrophy due to reduced or lack of use
  Can be restored with increased activity
o Gerontological changes can cause decreased coordination, loss of muscle strength, gait
changes, risks for falls
 Assessment
o Pt history
 Accident
 Illness
 Lifestyle
 Exercise
 Occupation
 Drugs
 Medical hx
 Previous hospitalizations
 Alcohol
 Tobacco
 Allergies
 Medications
o Nutrition history
 Calcium
 Protein
 Vitamin c
 Vitamin D
 Obesity
 Anorexia Nervosa
 Bulimia
o Family history
 Identify disorders
 Osteoporosis
 Gout
 Osteopenia sarcoma
o Current health problems
 Pain
 Weakness
 Impaired mobility
o Extra notes
 Diabetics high risk for osteomyelitis with foot ulcers
 Excessive alcohol decreases vitamins and nutrients needed fro bone and muscle
growth
 Tobacco slows healing soft tissue and bone
 Occupation like computer based jobs can cause carpal tunnel
 Construction workers back injuries
 Allergies to dairy products can cause low calcium
 Steroids can have negative effect on calcium metabolism and promote bone loss
 Medications for arthralgia
 Insufficient amounts of proteins and vitamin C and D slows bone and tissue
healing
 Obesity- weight bearing issues
  Anorexia and bulimia
 Risk for osteoporosis related to inadequate C and D
 Assessment of musculoskeletal system
o Posture and gait
 Scoliosis
 Lordosis
 Kyphosis
o Bone integrity and joint function
 Functional mobility compare from side to side
 ROM
 Contractures/effusion/deformities/crepitus/nodules
o Muscle strength and size
 Clonus
 Fasciculation
o Neurovascular assessments :Box 40-4
 6 Ps
 Pain, paresthesia, pallor- polar, paralysis, pulselessness
o Goniometer
 Used to provide exact measurement of flexion and extension or joint ROM
o Active ROM
 Ask pt to move each joint through the ROM themselves
o Passive ROM
 Hold part with one hand above and one hand below joint to be evaluated and
allow PROM
o Specific assessment
 Pain in face or neck TMJ (temporomandibular joints for crepitus (grating sound))
 Swelling pain
 Spine assess for lordosis (swayback) and scoliosis by asking pt to flex forward
from hips and inspect for curvature
 Extremities
 Compare side to side
 Hip
 Degree of mobility
 Joint is deep and difficult to inspect or palpate
 Pain is usually in groin can radiate to knees
 Knees
 Limitation in movement with accompanying PAIN with fluid
accumulation is common
 Muscle strength
 Imaging assessment
o Myelography
 Contrast medium into the subarachnoid space of spine for visualization
 Raise HOB 30-50
 Look for problems that can develop in spinal canal and surrounding tissues
 Radiologist injects contrast medium into subarachnoid space for visualization
 Procedure takes 30-60 minutes
  Post procedure pt cannot lie flat for 6-8 hr this prevents contrast from irritating
meninges causing headaches
 Drink lots of fluid for next 18 hr to help eliminate contrast and prevent
headache caused by slight CSF leakage
 Diagnostic imaging test to look for problems that can develop in spinal canal and
its surrounding tissues
o Arthrogram
 Contrast medium into joint for visualization
 Joint is put through its ROM to distribute contrast agent, MRI is
obtained, and if tear is present the contrast leaks out of joint and is
evident on MRI image
 Used to Id acute or chronic tears of joint capsule or supporting ligaments
 Post procedure a compression elastic bandage is applied and joint is rested for
12 hr
 Analgesia and ice can be used for comfort measures
 Educate pt it is normal to experience clicking or cracking in joint for 1-2 days
post procedure until all of contrast medium or air is absorbed
o Bone scan
 Radioactive material injected for viewing the entire skeleton
 Detects tumors, arthritis, osteomyelitis, compression fractures
 Not used to diagnose osteoporosis
 See concept mastery alert on pg 1182
 Bone densitometry is used in dx osteoporosis
 Used to detect metastatic and primary bone tumors, osteomyelitis, certain
fractures, and aseptic necrosis, but not osteoporosis
o Gallium scan
 Radioisotope used to detect Brian, liver, breast tissue problems (Thallium for
osteosarcoma)
 Excreted in stool and feces
 Test to look for swelling (inflammation), infection, or cancer in body
 Day or two before scan
 Dr injects gallium citrate into vein in arm
 Gallium then travels all over body
 It builds up in any cell that are actively dividing, such as cancer cells
 Also binds to cells and proteins involved in inflammation in body
o X-ray, CT, MRI, ultrasound, biopsy
 X-ray
 To determine bone density, texture, erosions, fractures, and joint
structure
 CT scan
 Can reveal tumors of soft tissues, or injuries to the ligaments and
tendons
 MRI
 Used to detect abnormalities of soft tissues such as muscles, tendons,
cartilage, and nerves
o Implementation
 Handle injured area carefully
  Administer analgesics are prescribed prior to procedure particularly if pt is in
pain
 Remove any radiopaque objects, such as jewelry
 Shield pt’s testes, ovaries, or pregnant abdomen
 Pt must lie still during X-ray
 Inform pt that exposure to radiation is minimal and not dangerous
 Dr is to wear lead apron if staying in room with pt
 Electromyography (EMG) and nerve conduction studies
o EMG is performed at bedside
 Thin needles are placed in muscle and attached to an electrode
 Electrical activity is recorded during muscle contraction
o Nerve conduction
 Electrodes are taped on skin
 Low electrical currents are sent through the electrodes and muscle response to
stimulus are recorded
o Used for neuromuscular disorders, motor neuron diseases (ALS, myasthenia gravis,
Guillian Barre), peripheral nerve disorders like carpal tunnel
o These tests help the provider to determine if pt having muscle problem or nerve related
problem
o Implementation
 Obtain consent form
 Instruct pt
 Needle insertion is uncomfortable
 Do not take stimulants or sedatives 24 hr prior to procedure
 Inform pt that slight bruising may occur at needle insertion sites
 If needles are used, inspect needle sites for hematoma formation and may be
contraindicated for pt undergoing anticoagulant therapy
 Have pt use ice if hematoma formation occurs
 Arthroscopy
o Provides an endoscopic exam of various joints
o Articulate cartilage abnormalities can be assessed, loose bodies can be removed, and
cartilage trimmed
o A biopsy may be performed during procedure
o Fiber optic tube inserted into joint for direct visualization of ligaments, menisci, and
articulate surfaces of joints
o Pt must be able to flex knee
 If candidate is unable to flex knee at least 40 degrees and has an infected knee
they will not be candidate for procedure
o Implementation
 Instruct pt to fast for 8-12 hr prior to procedure
 Obtain consent
 Administer pain med as prescribed post procedure
 Evaluate neurovascular status of affected limb every hr
 An elastic wrap should be worn for 2-4 days as prescribed post procedure
 Instruct pt
  That walking without weight bearing is usually permitted after sensation
returns but to limit activity for 1-4 days as prescribed following
procedure
 Elevate extremity as often as possible for 2 days following procedure
and place ice on site to minimize swelling
 Reinforce instructions regarding use of crutches
 May be used 5-7 days post procedure when walking
 Advise pt to notify dr of fever, increased knee pain, or edema continues for
more than 3 days post procedure
 Monitor for complications
 Laboratory diagnostic assessment
o Calcium
 Hypocalcemia
 Osteoporosis or osteomalacia
 Hypercalcemia
 Metastatic cancer of bones
 Healing of bone fractures
 Remember calcium and phosphorous are inversely related
o Phosphorus
o Alkaline phosphate (ALP)
 Elevations may indicate Paget’s disease, osteomalacia (softening of bones),
metastatic cancers of bones
o Serum muscle enzyme (CK-MM, LDH, AST)
 CK-MM
 Muscle trauma
 Begins to rise 2-4 hr after muscle injury and will elevate early in
muscular dystrophy
 Specific to skeletal muscle
 LDH
 Lactate dehydrogenase- lactic acid
 AST
 Aspartate aminotransferase
 Also found in muscles so when there is trauma and damage is released
into bloodstream
o Lab test Table 40-4 pg 1183