Slide 1Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Chapter 44Care of the Patient with a Musculoskeletal Disorder
Slide 2Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Overview of Anatomy and Physiology
• Functions of the skeletal system Support
• Skeleton provides body framework support internal tissues and organs
Protection• Skeleton forms cagelike structures
Protects internal structureso Cranium protects brain, ribs and sternum protects
heart and lungs Movement
• Skeletal muscles attached to bones, bones provide leverage for movement
• Muscle contracts, it exerts pull on the bone and movement occurs
Slide 3Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Overview of Anatomy and Physiology
• Functions of the skeletal system Mineral storage
• Calcium and phosphorus• Not enough are taken in by the body, the bone will
release these minerals
Hematopoiesis• Blood formation takes place in the red bone marrow
Red bone marrow – spongy bone found in the long ends of the long bones
Red bone marrow as a person ages will convert to yellow which consist of mainly fat cells
Slide 4Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Overview of Anatomy and Physiology
• Structure of bones Four classifications based on form and shape
• Long Found in extremities
• Short Found in hands and feet
• Flat Found in skull and sternum
• Irregular Make up vertebrae (backbone)
Slide 5Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Figure 44-2
Skeleton, anterior view. (From Thibodeau, G.A., Patton, K.T. [1997]. The human body in health and disease. [2nd ed.]. St. Louis: Mosby.)
Slide 6Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Figure 44-3
Skeleton, posterior view. (From Thibodeau, G.A., Patton, K.T. [1997]. The human body in health and disease. [2nd ed.]. St. Louis: Mosby.)
Slide 7Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Overview of Anatomy and Physiology
• Articulations (joints) Allow movement Three types according to degree of movement
• Synarthrosis—no movement• Amphiarthrosis—slight movement• Diarthrosis—free movement
• Divisions of the skeleton Axial skeleton
• Consist of skull, spine, thorax Appendicular skeleton
• Consists of upper and lower extremities
Slide 8Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Figure 44-1
Structure of a freely movable (diarthrotic) joint.
(From Thibodeau, G.A., Patton, K.T. [2004]. Structure and function of the body. [12th ed.]. St. Louis: Mosby.)
Slide 9Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Overview of Anatomy and Physiology
• Functions of the muscular system Motion (for movement)
• Result from contraction and relaxation of muscles Maintenance of posture Production of heat
• 85% of body heat is produced by muscle contraction Contraction results in return of venous blood and
lymph to the right side of the heart Voluntary vs involuntary control
Slide 10Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Overview of Anatomy and Physiology
• Skeletal muscle structure Epimysium
• Connective tissue that surrounds each skeletal muscle Perimysium Endomysium
Epimysium connects/joins with perimysium and endomysium extending beyond the muscle to form a tendon
• Tendons anchor muscles to bone
Slide 11Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Figure 44-5
Anterior view of the body (From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
Slide 12Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Figure 44-6
Posterior view of the body.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
Slide 13Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Overview of Anatomy and Physiology
• Nerve and blood supply Blood vessels provide a constant supply of oxygen
and nutrition and nerve cells/fibers supply a constant source of information
NMJ, ACh, AChase, synaptic cleft• Muscle contraction
Muscle stimulus—when a muscle cell is adequately stimulated, it will contract (“all or non” law)
Muscle tone—skeletal muscles are in a constant state of readiness for action
Types of body movements—flexion, extension, abduction, adduction, rotation, supination, pronation, dorsiflexion, and plantar flexion
Slide 14Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Laboratory and Diagnostic Examinations
• RADIOGRAPHIC STUDIES Diagnostic study for musculoskeletal system integrity
• Radiographic, roentgenographic• Commonly known as: x-ray examination or diagnostic
imaging Reveals joint fluids, irregularity of joint with spur formation,
changes in size of joint contour Determine fractures Ask if patient is pregnant Laminography or planography
• Also known as body section roentgenography Useful in locating small cavities, foreign bodies, and lesions
overshadowed by opaque structures Scanography
• Allows accurate measurement of bone’s length
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Laboratory and Diagnostic Examinations
• RADIOGRAPHIC STUDIES – cont’d Myelogram
• Injection of radiopaque dye in subarachnoid space at lumbar spine
Determines herniated disk syndrome or tumors• Allergic reaction in people allergic to iodine & seafood• Most common discomfort is headache
Nuclear scanning• Done in the nuclear medicine department• Nursing precaution:
1. written consent of patient 2. radioactive isotope won’t affect family/visitors 3. follow instructions outlined by nuke med dept
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Laboratory and Diagnostic Examinations
• RADIOGRAPHIC STUDIES – cont’d Magnetic resonance imaging (MRI)
• Detects pathologic conditions of cerebrum and SC• Detects herniated disk• Give detailed pictures of fluid-filled soft tissue and blood
vessels• Patient prep: no metallic objects• Patient with metal prosthesis such as heart valves,
orthopedic screws or cardiac pacemakers • Need to be motionless
May use sedative if extremely anxious or patient is claustrophobic
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Laboratory and Diagnostic Examinations
• RADIOGRAPHIC STUDIES – cont’d Computed axial tomography (CT or CAT scan)
• Body sections can be examined from many angles• 3-D picture of structure is made• Iodine contrast dye sometimes used• Locating injuries to tendons, ligaments, tumors and fractures• Preparation:
1. signed consent 2. any allergies 3. NPO 3-4 hours prior to test 4. VS as baseline 5. void before test 6. remove jewelries and hair pins 7. lie still during test
Slide 18Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Laboratory and Diagnostic Examinations
• RADIOGRAPHIC STUDIES – cont’d Bone scan
• Detects metastatic and inflammatory bone disease• Administer IV nuclides 2-3 hours prior to test• Drink fluids next 2-3 hours to aid renal clearance of
radioisotope not picked up by bone• Areas of concentrated nucleotide uptake represent
tumor or other abnormality
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Laboratory and Diagnostic Examinations
• Endoscopic examination Lighted tube is used to visualize inside of body cavity Preparation: similar to surgical prep
• 1. signed consent form• 2. pre-op checklist-remove jewelry, dentures, contacts• 3. NPO 6-12 hours before• 4. premed maybe given-atropine and sedative• 5. encouraged to void• 6. VS taken and recorded• 7. bed rest with side rails up after premed given
Slide 20Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Laboratory and Diagnostic Examinations
• Endoscopic examination – cont’d Arthroscopy
• Direct visualization of joints• Accomplishes the following:
Exploration of joint to determine presence of disease process
Drainage of fluid Removal of damage tissue or foreign bodies
• Commonly done in knee joint Visualizes: synovium, articular surfaces, meniscus
Slide 21Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Laboratory and Diagnostic Examinations
• Endoscopic examination – cont’d Endoscopic spinal microsurgery
• Treat spinal column disorder Herniated disk Spinal stenosis Spinal deformities
o Scoliosiso kyphosis
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Laboratory and Diagnostic Examinations
• Aspiration Obtain specimen of body fluid Sterile technique Biopsy at the same time Nursing interventions
• 1. consent form signed• 2. reinforcing physician’s explanation of procedure• 3. immobile during procedure• 4. void before procedure• 5. sterile technique• 6. emotional support• 7. sterile pressure dressing to puncture site• 8. assist with collecting, labeling and transport• 9. observe emotional and physical distress after procedure
Slide 23Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Laboratory and Diagnostic Examinations
• Aspiration-cont’d Synovial fluid aspiration
• Arthrocentesis Diagnosing trauma, SLE, gout, OA, and RA Normal-straw colored, clear, slightly cloudy Trauma or disease process
o Cloudy, milky, yellow, green, gray Support joint with pillow rest up to 12 hours
Slide 24Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Laboratory and Diagnostic Examinations
• Electrographic procedure Electromyogram (EMG)
• Insert electrodes in muscle so electrical activity can be heard, seen on oscilloscope, recorded on paper
• Nerves can be observed for neuropathy• Muscles observed for myopathy• Electromyography used to detect chronic low back pain
based on muscle fatigue pattern
Slide 25Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Laboratory and Diagnostic Examinations
• Laboratory tests Calcium Erythrocyte sedimentation rate (ESR) Lupus erythematosus (LE) preparation Rheumatoid factor (RF) Uric acid (blood)
Study table 44-3, pg 1372
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General Nutritional Needs/Modifications
• Osteoporosis Nutrition
• Low calcium intake• Low vitamin D intake• High phosphate intake
Carbonated beverages• Inadequate calories
o => reduces nutrients needed for bone remodeling
Slide 27Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
General Nutritional Needs/Modifications
• Osteoporosis – cont’d Nutritional factors contribute to its’ development Balanced diet
• Adequate calories and nutrients to maintain: Bone, calcium and vitamin D
• Vitamin D For calcium absorption For normal bone mineralization
• Dietary calcium and vitamin D Must be adequate to maintain bone remodeling and body
function• Source of calcium and vitamin D
Fortified milk (cup of milk = 300-mg of calcium)
Slide 28Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
General Nutritional Needs/Modifications
• Osteoporosis – cont’d Recommended adequate intake (AI) level of calcium
• 9 y/o to 19 y/o is 1300 mg/day To maximize peak bone mass
• 19 y/o to 50 y/o is 1000 mg/day• 51 years and older is 1200 mg/day
Estimated daily intake is 300 to 500 mg Recommended adult vitamin D intake is 400 to 600 IU
per day Inadequate calcium and vitamin D intake over time
• Result in development of osteoporosis
Slide 29Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
General Nutritional Needs/Modifications
• Osteoporosis – cont’d Protection against bone demineraliztion
• Balanced diet rich in calcium and vitamin D• Increased calcium intake during adolescence, young
adulthood, and middle years• 3 glasses of skim milk daily (food high in calcium)• Calcium supplements (caltrate, citrocal)
Taken with food or beverages high in vit C to promote absorption
S/E of calcium supplement: abdominal distention and constipation
Slide 30Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
General Nutritional Needs/Modifications
• Osteomalacia Cause is malabsorption
• Increase doses of vitamin D, with supplemental calcium• Exposure to sunlight
UV radiation to transform cholesterol substance (7-dehydrocholesterol) present in skin to vitamin D
Slide 31Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
General Nutritional Needs/Modifications
• Osteomalacia Cause is dietary origin
• Diet with adequate protein and increased calcium and vitamin D is provided
• Dietary sources of calcium and vitamin D Fortified milk and cereals, eggs, chicken livers
• High doses of vitamin D is toxic• Vitamin D raises concentration of calcium and
phosphorus in ECF makes these ions available for bone mineralization
Slide 32Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
General Nutritional Needs/Modifications
• Paget’s Disease (osteitis deformans) Disorder of localized rapid bone turnover commonly
• Skull, femur, tibia, pelvic bones, vertebrae Assymptomatic patient
• Managed with adequate calcium and vitamin D in the diet and periodic monitoring
• Osteomyelitis Infection of the bone General supportive measure
• Hydration, diet high in protein and vitamins, correction of anemia
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