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Download Diagnostic Tests for the Musculoskeletal System
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N124IN Spring 2013 Camille Jackson, MSN, RN Skeletal and muscular systems work together for movement ◦ Also need nervous, cardiovascular, respiratory systems Skeleton: framework ◦ Voluntary muscles attached to skeleton ◦ Joints: articulations in between bones Muscle contraction: bone is pulled and joint angle is altered Skeletal system tissues ◦ Bone tissue Protects organs and tissues from mechanical injury Stores calcium ◦ Cartilage Covers most joint surfaces ◦ Fibrous connective tissue Forms ligaments Muscular system tissues ◦ Skeletal (aka striated, voluntary) muscle Skeleton movement and stabilization Heat production Blood return from legs ◦ Fibrous connective tissue Forms tendons ◦ Fasciae Enclose individual muscles Bone Tissue ◦ Osteocytes ◦ Osteoblasts ◦ Osteoclasts Bone ◦ Compact ◦ Spongy ◦ Periosteum Proper Nutrition ◦ Provides raw materials for bone production Calcium Phosphorus Protein Vitamins A, D, C Hormones ◦ ◦ ◦ ◦ ◦ ◦ Growth hormone-anterior pituitary gland Thyroxine-thyroid gland Insulin-pancreas Parathyroid-parathyroid gland Calcitonin-thyroid gland Estrogen & testosterone 206 bones ◦ Axial skeleton Skull, vertebral column, rib cage ◦ Appendicular skeleton Arms/legs, shoulder, pelvic girdles 8 cranial bones ◦ Frontal, 2 parietal, 2 temporal, occipital, sphenoid, ethmoid 14 facial bones 3 auditory bones in both middle ear cavities Sutures: joints between cranial bones and most of the facial bones Vertebrae are individual bones in vertebral column ◦ 7 cervical vertebrae Atlas is first vertebra and articulates with occipital bone Atlas creates pivot joint with axis (second vertebra) ◦ ◦ ◦ ◦ 12 thoracic 5 lumbar 5 sacral (fused together to make sacrum) 4 or 5 coccygeal (fused together to make coccyx) Functions ◦ Supports trunk, head ◦ Contains and protects spinal cord ◦ Intervertebral foramina: openings where spinal nerves and blood vessels enter/exit ◦ Allows for movement 12 rib pairs and the sternum ◦ 7 true rib pairs ◦ 3 false ribs ◦ 2 floating ribs Functions ◦ Protects heart, lungs, upper abdominal organs ◦ Muscles pull rib cage up and out with breathing Freely movable joints Articular cartilage: along bone’s joint surface Joint capsule: fibrous connective tissue that makes a sheath around joint Synovial membrane: lines joint capsule and secretes synovial fluid into joint cavity Bursae: synovial fluid sacs Tendons: fibrous connective tissue that attaches muscles to bones ◦ Origin: attachment that is more stationary ◦ Insertion: attachment that is more movable Contraction ◦ Muscle contracts, muscle shortens, pulls bone Pulls on insertion and moves bone in certain direction Agonist: muscle that is making bone move in certain direction Antagonist: opposite function of agonist Synergistic muscles: muscles that function similarly or cooperate together Nerve impulse results in acetylcholine release ◦ Acetylcholine moves across synaptic cleft Acetylcholine attaches to acetylcholine receptors on sarcolemma (on muscle fiber membrane) Sarcolemma becomes permeable to sodium ions Sodium ions move into cell Electrical impulse/action potential is created along sarcolemma Reactions occur in sacromeres (internal units of contraction) Actin protein filaments move over myosin protein filaments Sarcomere shortens The Aging Musculoskeletal System Bone Calcium Loss Fractures Articular Cartilage Wears Down Joint Stiffness Joint Pain Muscle Strength declines Falls Muscle mass and strength decline Number of muscle cells decrease Elasticity of ligaments, tendons, cartilage decrease Smaller intervertebral spaces Gait and posture changes Age related changes can lead to: ◦ Impaired mobility ◦ Increased risk of falls ◦ Pain Let’s try some Nursing diagnoses!! ◦ Impaired mobility r/t…….. ◦ Risk of falls r/t…….. ◦ Pain r/t……… History Physical Assessment Psychosocial Assessment Frequent neurovascular assessments may be needed Injury-how and when it happened Occupation and activities Risk factors for musculoskeletal injuries Family history Current health status Diet history Information specific to the patient’s musculoskeletal problems Previous diagnoses, pain/stiffness/tenderness, meds, treatments, procedures Inspection Palpation Range of motion Assess muscle size, strength, shape, tone Physical therapy and occupational therapy assess patient further in depth Neurovascular ◦ Color ◦ Temperature ◦ Pain ◦ Movement ◦ Sensation ◦ Pulses ◦ Capillary refill assessments Assess for withdrawal Assess pain effects Assess coping ability Mr. Smith, age 80, is brought to the emergency department with a fractured left hip. He is positioned for comfort while you collect data. 1. What information should you obtain in Mr. Smith’s history? 2. What should be assessed in Mr. Smith’s physical examination? Laboratory Tests ◦ Calcium(8.5-10.5 mg/dL)/phosphorus(2.6-4.5 mg/dL) Inverse relationship normally Disorders can make both increase or decrease Hypercalcemia May be related to metastatic bone disease or extended immobilization Hypocalcemia May be related to poor dietary intake. Can lead to osteoporosis Laboratory Tests, cont. ◦ Alkaline Phosphatase (ALP) Male: 45-115 units/L; Female: 30-100 units/L ALP increases may indicate a bone abnormality ALP increases when new bone is formed Laboratory Tests, cont. ◦ Myoglobin (50-120 µg/mL) Protein in striated muscle (skeletal/cardiac) Makes muscle reddish color Serum levels increase with skeletal or cardiac muscle damage (MI) Laboratory Tests, cont. ◦ Muscle Enzymes Enzymes that are released into bloodstream with muscle tissue damage Creatine kinase (CK) Male: 60-400 units/L; Female: 40-150 units/L Aldolase (ALD) Aspartate aminotransferase (AST) Lactate dehydrogenase (LDH) Specific muscle disease (muscular dystrophy, polymyositis, dermatomyositis) result in enzyme increase Laboratory Tests, cont. ◦ Uric Acid Male: 4.4-7.6 mg/dL; Female: 2.36.6 mg/dL Normally in blood Gout results when uric acid crystals precipitate on tendons, articular cartilage, tissues Serum levels increase with gout Radiographic Tests ◦ Standard X-Rays Can show bone density, texture, alignment alterations, bone relationship alterations, erosion, swelling, intactness Can help identify some soft tissue damage Patient education: remain still Radiographic Tests, cont. ◦ Computed Tomography (CT) Assists in diagnosing issues related to joints or vertebrae Contrast may or may not be used Patient education: Remain still Scanner will surround them Radiographic Tests, cont. ◦ Bone Density Screening Measures bone strength and weight-bearing capabilities Bone density measured by dualenergy x-ray absorptiometry (DEXA) http://www.youtube.com/watch?v= 7EkK1oMK5A8 Radiographic Tests, cont. ◦ Arthrography X-ray of synovial joint ◦ Myelogram Contrast medium inserted into subarachnoid space Provides for visualization of spine and spinal cord Patient education: Tell patients they might be in a head down position for a short time Assess headache/nausea after procedure Other Tests ◦ Magnetic Resonance Imaging (MRI) Used to diagnose musculoskeletal issues, particularly those related to soft tissue More accurate than CT with vertebral column diagnoses Contrast may or may not be used MRI contraindications: pacemakers, surgical clips, internally implanted metal object Other Tests, cont. ◦ Nuclear Medicine Scans: Bone Scan Radioactive material is used to visualize the skeleton Radioisotope injected into patient 2-3 hours prior to scan Radioisotope is attracted to bone and thus, moves toward bone tissue Physician assesses for “hot spots” Signifies concentrated radioactive substance Other Tests, cont. ◦ Gallium and Thallium Scans Like bone scan Radioactive element injected More specific, sensitive Gallium moves to bone, brain and breast tissue Thallium helps evaluate bone cancer Other Tests, cont. ◦ Arthroscopy Allows for direct visualization of joint Same-day surgery Local or light general anesthesia is used Several small incisions made Joint is distended with saline Scope inserted Scope helps with visualization and repair Other Tests, cont. ◦ Arthroscopy, cont. PACU Nursing considerations: Assess limb’s neurovascular status Have patient exercise leg if arthroscopy was only diagnostic Give pain medication Assess for and educate patient on: Thrombophlebitis Infection Increased joint pain Other Tests, cont. ◦ Bone or Muscle Biopsy Bone or muscle tissue is surgically removed for examination Can diagnose cancer, infection, inflammation or damage, malignant hyperthermia Biopsy may be open or closed Other Tests, cont. ◦ Bone or Muscle Biopsy Nursing considerations: Assess biopsy site Assess pain Don’t allow movement of area for 812 hours Assess vital signs Neurovascular assessments Wound care if open biopsy Other Tests, cont. ◦ Ultrasonography Sound waves can be used to find: Osteomyelitis, soft tissue disorders, joint injuries, surgical hardware Conducting matter applied over area Transducer moved over area Images recorded on ultrasound machine Patient education: Jelly-like matter will feel cold Other Tests, cont. ◦ Arthrocentesis Diagnostic or therapeutic Diagnostic: noninflammatory conditions, septic arthritis, crystal detection, hemarthrosis Therapeutic: relieves pressure, decreases pain, enhances mobility Joint’s synovial fluid is aspirated via needle Nursing considerations: Assess site for bruising, bleeding, redness, warmth Monitor for infection, inflammation, hemarthrosis Other Tests, cont. ◦ Nerve Conduction Studies Electromyography (EMG) measures electrical impulses of muscle Can help diagnose muscle disease, nerve damage Patient education: Educate on procedure Inform patient to remove all jewelry Inform patient to not apply lotions prior to test Inform patient that discomfort and bruising can occur at study site Mr. Allan, age 45, comes to the emergency room with extreme pain in his lower back. The pain radiates down his right buttock & down the back of his leg to his knee. He tells you that he hurt his back picking up a box in the warehouse where he works. 1. What other information should you obtain from Mr. Allan? 2. What is a probable cause of Mr. Allan’s pain? 3. What tests, procedures, & treatments may be done for Mr. Allan’s condition? 4. How might this injury impact Mr. Allan’s life? 5. Mr. Allan is to receive morphine 10 mg by intramuscular injection. You have available morphine 15 mg/mL. How many milliliters will you give?
