alterations in the musculoskeletal system studentsnapavalley.edu/people/jwhitmer/documents/n 142...
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Alterations in the Musculoskeletal SystemSystem
NURS 142ADN Program Carole Chassereau
Musculoskeletal SystemNormal structure– Tissues
• CartilageLigaments/tendons
Function– Support
P t ti• Ligaments/tendons• Fascia• Bursae
– Bones– Muscles– Joints
– Protection– Movement– Mineral storage– Hematopoiesis
Bone Structure& Development
Continuous process of bone remodeling
Osteoblasts = builders = depositionf b
Growth zone for longitudinal growth in children
Epiphyseal plate
of new bone
Osteoclasts = removal of old bone = resorption
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JointsDIARTHHROTIC
Ligaments attach bone to bone – joint stability
Tendons attach muscle to bone – joint movement
Normal Diarthrodial Joint (Freely movable)
bone joint movement
Fibrous tissue – low blood supply
Cartilage - avascular
Factors Influencing Musculoskeletal Health
Age– Infant – Child
Adolescent– Adolescent– Senior
Environment– Job– Sun exposure– Activity
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Risk Factors for Alterations in Musculoskeletal Health
History– Injuries– Family history
Medical conditions– Medical conditions• Metabolic alterations• Gastrectomy• Renal tubular
necrosis• Hypoparathyroidism
– SurgeryGender
Risk Factors for Alterations in Musculoskeletal Health
History– Injuries– Family history
Medical conditions
AgeMedications– Musculoskeletal drugs
– Medical conditions• Metabolic alterations• Gastrectomy• Renal tubular
necrosis• Hypoparathyroidism
– SurgeryGender
– Antiseizure meds– Phenothiazines– Corticosteroids– K-depleting diuretics
DietObesityPosture
Assessment
History & interview– Chief complaint
M t b h i– Movement behaviors– Functional assessment– Self-care behaviors– Questions
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AssessmentGeneral– Posture– Gait– Muscle strength– Assistive devices
Vital signsInspection & palpationNeurovascular assessment - CSM
Diagnostic TestsBlood chemistry– Calcium– Alkaline phosphatase– Creatine kinase (CK)– ESR– RF– ANA
Diagnostics - Visualizations
X-rayCTMRI
ArthrogramArthroscopyArthrocentesisMRI
Bone scanBiopsy
ArthrocentesisElectromyogram (EMG)Bone Mass Measurements
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The Etiology of Injuries
Be alert and be aware of the environment.environment.The causes of musculoskeletal injuries are variable.
Health Alterations –Soft Tissue Injuries
Strains/sprains– Cause– Healing time– RICE
Dislocation/subluxation– Inspection
Slipped Capital Femoral Epiphysis
Soft Tissue Injuries
Rotator cuff tearsLigament injuriesMeniscus injuriesRepetitive motion injuries
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Herniated Nucleus pulposusCommon cause of acute & chronic low back pain.
Degenerative disk disease leads to intervetebral narrowing & decreased efficiency of the “shock absorbing” affects of the disks
Risk factors for low back pain – undue strain, osteoarthritis, obesity, smoking, stress, prolonged periods of sitting
Osteomyelitis
Direct or indirect invasion of microorganisms (Staph A)
Bacteria lodge & grow –i i h iincrease pressure – ischemia and vascular compromise –sequestration = infected island of bone.
Chronic if persists for more than 4 weeks
Osteoporosis“Silent disease”Resorption > deposition (formation)– Porous & brittle bones
Risk factors– Postmenopausal women– Thin,small frame– Family history– Long-term steroid use– Inactivity– Caucasian/ Asian-American
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Osteoporosis
Signs & symptoms– Bone mineral density
(BMD) decreased –DEXA study
Management goal –prevent or stop process– Adequate calcium intake
& Vit i D– Pathological fractures– Loss of height– Kyphosis
& Vitamin D– Exercise program – Medications
• HRT• SERM• Biphosphonates• Calcitonin
GoutMetabolic disorder– Genetic/familial tendency– 90% middle-aged men
Risk factorsDiabetes
Signs & symptoms– Swollen, tender, painful
joints, “great toe” –reddened to dusky
– Deposit of Na urate – Diabetes– Obesity– HTN
Hyperuricemia– purine synthesis
and/or– renal excretion
crystals in joint fluid = tophi
Treatment– Fluids & low-purine diet– Colchicine– Probenecid– Allopurinal– Acetominophen
ArthritisType Osteoarthritis
(OA) (DJD)Rheumatoid Arthritis (RA)
Juvenile RA
Process Degeneration of joint cartilageRough surfacesM l i
InflammationGranulation tissue
Fib
Inflammation of joints
M h MalaciaCartilage
fragmentationBone spurs
Fibrous connective tissueAnkylosisImmobilizationExtraarticular manifestations
May have extraarticular manifestations
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ArthritisType Osteoarthritis
(OA) (DJD)Rheumatoid Arthritis (RA)
Juvenile RA
Response LocalNoninflammatory
SystemicInflammatory
Local /systemicInflammatory
Incidence 1/3 of adultsAge 60 60 80%
>women 75% >girlsAge 60 – 60-80%>men>Native-Americans
Young adult –Child-bearing age
Age 2-5 or 9-12 & adolescence
Jointsaffected
Small &/or large Small &/or large
PauciarticularSystemicPolyarticular
ArthritisType Osteoarthritis Rheumatoid
Arthritis (RA)Juvenile RA
Pattern AsymmetricalChronic
SymmetricalChronic
VariableAcuteRarely chronic
A t i Etiology Age, FracturesInfectionCongenital deformity
Autoimmune responseGeneticViral
UnknownAutoimmune response
Course Usually self-limiting
Remissions & ExacerbationMild to progressive
Resolution
ArthritisType Osteoarthritis Rheumatoid
Arthritis (RA)Juvenile RA
Mobility Stiffness after rest and inactivityImpaired mobility due to pain and swelling
Nodules Heberden’s Rheumatoid NonePainfulInterphalangeal joints
Non-tenderSubcutaneous
Goals Control pain & fatigue Joint protectionMaintain ROM EducationPromote mobility Support measures
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Curvature of the Spine
Normal Kyphosis Lordosis MildScoliosis
Normal SevereScoliosis
Fractures by Communication
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Fracture Classification by Location
Fracture Management
First assess neurovascular status distal to the injury
Immobilization– Skeletal or skin
tractionj yReduction(alignment)– Open - surgical– Closed – manipulation
or traction
– External fixator– Cast– Splint– Brace
Healing Process of Fractures
Hematoma formation
Fibrous networkFibrous network
Osteoblasts – collagen –calcium deposition
Callus formation
Ossification –consolidation- remodeling
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Immobilization With TractionSkin – Bryant’s, Buck’s, Russell– No more than 5-10# weight– Concern – skin breakdown– Bryant’s – child < 35 # & <3years
Immobilization With TractionSkin –Buck’s, Bryant’s, Russell– No more than 5-10# weight– Concern – skin breakdown– Bryant’s – child < 35 # & <3years
Skeletal
Countertraction
Proximalfragment
– Weight – 5 – 45#– Pins – Skin care
General– Ropes & pulleys in straight alignment– Extremity in straight alignment– Knots not touching pulleys– Weights hang freely Traction
Distalfragment
Fracture
Immobilization with Casts
Drying – Use palm of hands– Heat production
Assess – CSM– Skin at cast edges
Teach– Elevation– Ice @ fracture site for 24 hrs.– Keep cast dry– No foreign objects– Exercise joints above & below the cast– Elevate extremity
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Hip Fracture – Internal FixationORIF
Femoral head endoprosthesis– Intracapsular fractures
Compression screw with side plate– Extracapsular fractures
Fracture ComplicationsUnion– Delayed– Non-union– Malunion
Compartment syndrome
OsteomyelitisVenous thrombosisFat embolism– Long bones & pelvis– Bone marrow or
– Compression - edema• Fascia• Circumferential device
– Consequences – CSM– Action
Avascular necrosis
catecholamine action– S & S
• 48 hours post fracture • Respiratory/Cardiac
signs• Petechiae – neck,
anterior chest wall, conjuctiva
Muscular DystrophyGenetic - malesMuscle fiber degeneration and muscle wastingProgressive weakness & muscle deformitySigns & symptoms– Generalized muscle weakness– Gower’s maneuver– Deficiency of dystrophin
Management– Supportive– ROM– PT
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Medical Management
MedicationsNutritionImmobilizationRestExercise– Active/passive– Isometric– Isotonic
Medical Management
MedicationsNutritionImmobilization
Cold– Vasoconstriction edema– Nerve transmission pain
RestExercise– Active/passive– Isometric– Isotonic
– Conduction velocity muscle spasmHeat– Edema– Comfort
Medical Management
Closed Reduction
Assistive devicesAssistive devices
Special beds &
frames
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Surgical Management
OsteotomyArthrodesisORIFORIFTotal hip, knee replacements– Special restrictions– Special goals
Surgical Management
OsteotomyArthrodesisORIF
Amputations– Assessment
S t ORIFTotal hip, knee replacements– Special restrictions– Special goals
– Support measures– Psychosocial
implications
Fluid & Electrolytes
Fluid intakeElectrolyte effectsElectrolyte effects–⇓ K+
–⇓Ca+
Acid-base imbalances
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Pharmacological TherapyAnalgesics– Acetaminophen (Tylenol)– Propoxyphene hydrochloride
(Darvon)Salicylates– Aspirin (acetylated)– Arthropan (nonacetylated)
NSAIDs– Ibuprofen (Advil, Nuprin,
Motrin)– Indomethacin (Indocin)– Diclofenac (Cataflam,
Voltaren)
NSAIDs– Cox-2 inhibitors
• Celebrex
Muscle relaxantsCalcium supplements
Pharmacological Therapy
EstrogenAntibioticsCorticosteroidsCorticosteroidsDisease-modifying antirheumatic drugs (DMARDs)– Immunosuppressives/Cytotoxics
• Methotrexate• Immuran• Cyclosporin• Arava
Nutrition
ProteinVitamins
FluidsFiber
Calcium Weight control
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Nursing Diagnosis
Altered nutrition: < or > than body requirementsAlteration in comfortRisk for infection Impaired physical mobilityAltered health maintenanceSocial isolationBody image disturbanceRisk for injury
Outcomes
Adequate nutritionVital signs WNLCSM WNLCSM WNLMobility/ ROMDecreased painNormal elimination patternUnderstanding of disease process
Nursing Interventions & Discharge Planning
AssessSupportTeach
Community resourcesTeach & evaluate activitiesTeach
– Diet– Medications– Assistive devices– Safety– Pain management
Referral
activitiesCoordinate home careS & S to reportMedication usage
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Legal & Ethical Issues
Pain control managementUse of cadaver bones, ligamentsAutonomyAutonomyConfidentialityBeneficience