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ALTERATIONS IN MOBILITY
Assessment of the Musculoskeletal System
And How Mobility can be Altered
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Skeletal SystemBrief Overview of Anatomy
• Bone types• Bone structure• Bone function• Bone growth and metabolism affected by
calcium and phosphorus, calcitonin, vitamin D, parathyroid hormone, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin
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Bone Structure
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Joints
• Types include synarthrodial, amphiarthrodial, diarthrodial.
• Structure synovial joint.• Subtyped by anatomic structure:
– Ball-and-socket– Hinge– Condylar– Biaxial– Pivot
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Structure Diarthrodial Joint
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Muscular system assessmentand how it can affect mobility.
• Patient history• Nutritional history• Family history and genetic risk• General inspection:
– Posture and gait
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Muscular System Assessment (Cont.)
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Specific Assessments
• Face and neck• Spine• Hand• Hip• Ankles, feet • Neurovascular assessment• Psychosocial assessment
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Diagnostic Assessment
• Laboratory tests—serum calcium and phosphorus, alkaline phosphatase, serum muscle enzymes
• Radiographic examinations—standard radiography, bone density, tomography and xeroradiography, myelography, arthrography, and CT
• Other diagnostic tests—bone and muscle biopsy
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Question?
What is the patient at risk for developing during a CT scan with contrast material?
A. ClaustrophobiaB. Renal failureC. Allergic reaction to the contrast materialD. Panic attack
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Neuromuscular affects on mobility
The electromyography
• EMG aids in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders; usually with nerve conduction studies.
• Low electrical currents are passed through flat electrodes placed along the nerve.
• If needles are used, inspect needle sites for hematoma formation.
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Arthroscopy
• Fiberoptic tube is inserted into a joint for direct visualization.
• Patient must be able to flex the knee; exercises are prescribed for ROM.
• Evaluate the neurovascular status of the affected limb frequently.
• Analgesics are prescribed.• Monitor for complications.
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Arthroscopy (Cont’d)
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Other Tests
• Bone scan• Gallium or thallium scan• Magnetic resonance imaging• Ultrasonography
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Mobility can be affected by diseases
Exemplar: Osteoporosis
• Chronic metabolic disease, in which bone loss causes decreased density and possible fracture
• Osteopenia (low bone mass), which occurs when osteoclastic activity is greater than osteoblastic activity
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Exemplar: Osteoporosis (Cont’d)
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Exemplar: Osteoporosis (Cont’d)
• Etiology and genetic risk• Genetic considerations• Incidence/prevalence• Cultural considerations
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Classification of Osteoporosis
• Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s.
• Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility.
• Regional osteoporosis occurs when a limb is immobilized.
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Health Promotion/Illness Prevention
• Teaching should begin with young women who begin to lose bone after 30 years of age.
• The focus of osteoporosis prevention is to decrease modifiable risk factors.
• Ensure adequate calcium intake.• Avoid sedentary lifestyle.• Continue program of weight-bearing
exercises.
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Assessment
• Physical assessment• Psychosocial assessment• Laboratory assessment• Imaging assessment:
– DXA– QCT– QUS
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Nursing Interventions
• Nutrition therapy• Exercise• Other lifestyle changes
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Drug Therapy
• Calcium and vitamin D supplements • Estrogen or hormone therapy• Bisphosphonates• Selective estrogen receptor modulators• Calcitonin• Other agents used with varying results
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Surgical Interventions
• Vertebroplasty • Kyphoplasty
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Cultural Consideration Question?
Which ethnic group typically has the least amount of
bone density of any group?
A. African-American women B. Asian women C. Caucasian womenD. American-Indian women
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Diseases that affect mobility continued
Exemplar: Osteomalacia
• Loss of bone related to vitamin D deficiency
• Bone softens because of inadequate deposits of calcium and phosphorus in the bone matrix
• Rickets
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Collaborative Care
• Assessment• The major treatment for osteomalacia is
vitamin D
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Alterations in Mobility
Exemplar: Paget’s Disease
• Chronic metabolic disorder in which bone is excessively broken down and reformed
• Genetic considerations• Collaborative care:
– Physical assessment– Diagnostic assessment
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Nonsurgical Management
• Analgesics• Decrease bone resorption• Selected bisphosphonates• Calcitonin• Plicamycin• Diet therapy• Nonpharmacologic pain-relief measures
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Surgical Management
• Tibial osteotomy• Partial or total joint replacement• Surgical decompression and stabilization of
the spine
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• Exemplar: Osteomylitis– Infection of the bone
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Osteomyelitis of the tibia of a young child. See the numerous abscesses in the bone.
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Collaborative Care
• Assessment• Antibiotic therapy• Hyperbaric oxygen therapy• Surgical management:
– Sequestrectomy– Microvascular bone transfers
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Alterations in mobility
Exemplar: Benign bone tumors
• Often asymptomatic and may be discovered on routine x-ray or as a cause of pathologic fracture:– Chrondrogenic tumors—from cartilage– Osteogenic tumors—from bone– Fibrogenic tumors—from fibrous tissue; most
commonly found in children
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Interventions
• Non-drug pain-relief measures• Drug therapy—analgesics, NSAIDs• Surgical therapy—curettage (simple
excision of the tumor tissue), joint replacement, or arthrodesis
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Alterations in mobility
Exemplar: Bone Cancer
• Primary tumors• Metastatic lesions• Pathophysiology• Assessment• Nonsurgical management:
– Drug therapy– Radiation therapy
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Surgical Management
• Preoperative care• Operative procedure• Postoperative care
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Community-Based Care
• Home care management• Health teaching• Health care resources
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Disorders of the hand can affect a patient’s mobility
Exemplar:
• Dupuytren's contracture—slowly progressive contracture of the palmar fascia resulting in flexion of the fourth or fifth digit of the hand
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Alterations in mobility continued
Exemplar: Ganglion
• Round, benign cyst often found on a wrist or foot joint or tendon
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Disorders of the foot can affect a patient’s mobility
Exemplars:
• Hallux valgus• Hammertoe • Morton’s neuroma• Tarsal tunnel syndrome• Plantar fasciitis • Other problems of the foot
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Foot
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Disorders of muscles and ligaments can alter mobility
Exemplar: Scoliosis
• Changes in muscles and ligaments on the concave side of the spinal column
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What problems other then mobility can you see with this patient?
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Exemplar: Scoliosis (Cont’d)
• Pathophysiology• History• Treatment of children • Treatment of adults
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Diseases of the muscles can impair mobility
Exemplar: Progressive Muscular Dystrophies
• Pathophysiology• Genetic considerations• Diagnosis• Management • Nursing interventions
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Pediatric Differences
• Primary ossification
• Secondary ossification
• Long bones
• Muscles, Tendons, and Ligaments
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References
Centers for Disease Control and Prevention, National Institutes of Health. (2009). Arthritis, osteoporosis, and chronic back
conditions. Retrieved April 10, 2010, from http://www.healthypeople.gov/Document/HTML/ Volume1/02Arthritis#_Toc490538008
Chamley, C.A., Carson, P. Randoall, D, & Sandwell, M. (2005). Developmental anatomy and physiology of children. St. Louis, MO: Elsevier.
Harvey, C. (2005). Wound Healing. Orthopedic Nursing 24(2), 143-160.
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References
Ignatavicius, D., & Workman, M.L. (Ed.). (2010). Medical-Surgical Nursing Critical Thinking For Collaborative Care. (6th Ed.) St. Louis: Elsevier Saunders.
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References
Kallmes DF, Comstock BA, Heagerty PJ, et al. (August, 2009. “A randomized trial of vertebroplasty for osteoporotic spinal fractures.” New England Journal of Medicine 361(6): 569-579.
Medline Plus. (2010, July 22). Electromygraphy. Retrieved August 22, 2010, from: http://www.nlm.nih.gov/medlineplus/ency/article/003929.htm
MayoClinic.com (2010, July 22). Dupuytren’s Contracture. Retrieved August 23, 2010, from: http://www.mayoclinic.com/health/dupuytrens- contracture/DS00732
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References:
Wikipedia. (2010, August 19). Scoliosis. Retrieved August 23, 2010, from: http://en.wikipedia.org/wiki/Scoliosis
Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed). St. Louis, Missouri: Mosby.
Vitale, M.G., Gross, J.M., Matsumoto, H., Roye, D.P. (2006). Epidemiology of pediatric spinal cord injury in the United States. Journal of Pediatric Orthopedics, 26(6), 745-749.
Wikipedia. (2010, July 10). Ganglion . Retrieved Auguast 23, 2010, from: http://en.wikipedia.org/wiki/Ganglion_cyst