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The Musculoskeletal System Structure and functions of bones Structure and functions of muscles Age-related changes Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 1 The musculoskeletal systems consists of the bones, cartilage, ligaments, tendons, and muscles. There are two distinct groups of bones cells that are transformed into mature cells. These cells form Cartilage Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.2 Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 3 There are 206 bones that make up the Human Skeleton Bone is either compact or spongy Spongy bone is made up of red bone marrow. Bones are classified as long, short, flat or irregular Each bone has markings on it that make it unique See Table 32-1 Bone Markings The haversian system is a canal system that runs through the bone and contains the blood and lymph vessels Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.4 Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 5 Bones provide shape to the body Provides a ridged framework that supports and protects the internal organs of the body Provides attachments for the tendons and ligaments and contribute to the movement of the body The red bone marrow in the spongy bones forms red blood cells, white blood cells, and platelets. Store and release minerals such as calcium and phosphorous Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.6 Joint Articulation point between two or more bones of the skeleton Immovable EX: The skull Slightly moveable EX: Vertebrae And freely moveable EX” Knee, elbow Ligaments : Join the bones of a joint together Tendons: Connective tissues that provide joint movement Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.7 Cartilage Connective : tissue in which fibers and cells are embedded in a semisolid gel material. Serves as a cushion Example is the meniscus in the knee Bursa : Fluid filled sac that provides cushioning at friction points in a freely moveable joint . Skeletal muscle is made up of hundreds of muscle fibers bundled together surrounded by connective tissue. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.8 Fascia is connective tissue that surrounds and separates the muscles The muscle coverings contain blood vessels and and nerves Muscles have properties that allow it to be electrically excites causing it to contract, extend or stretch, and provide elasticity. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc.9 Contraction of the skeletal muscle produces synchronized contraction of many muscle fibers Skeletal muscles contract, thereby producing movement and joint stability, maintaining posture, and producing body heat. Muscles provide movement of the joints Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 10 Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 11 Ossification occurs which is the replacement of cartilage by more boney tissue Bone density decreases because of resorption of minerals The loss of bone mass or osteoporosis, more common in women Bone injury or fracture takes longer to heal Bones in the elderly are more brittle and break easily Thinning of the intervertebral cartilage causes a collapse of the vertebrae creating a kyphosis (hump) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 12 Joint cartilage thins and erodes resulting in stiffness and grating of the joints Joint motion may decrease, causing limited mobility and swelling Los of muscle mass and less strength Muscle cramping especially at night increase due to impaired circulation Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 13 Safety Measures Using proper body mechanics when moving or lifting objects. (large muscle groups) Using seat belts when riding in cars If riding bicycles or motorcycles use helmets Calcium and Vitamin D throughout life span Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 14 Disease, trauma, malnutrition, and aging all contribute to musculoskeletal problems Trauma may cause bruising, strain, sprain, or fracture Poor nutrition may deprive the body of sufficient nutrients such as calcium and phosphorous to build strong bones Inadequate protein can cause muscle wasting Malignant tumors can invade bone either as a primary cancer or a metastatic disease Decreased Estrogen after menopause can lead to osteoporosis Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 15 Inc. Preservation of motion and mobility are important to prevent long term orthopedic problems Weight-training and exercise throughout life to maintain bone mass and contribute to increase muscle strength, improved coordination and balance all decrease incidence of falls Nutrition for bone growth and density No Smoking contributes to musculoskeletal health Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 16 Inc. Diagnostic Tests evaluate for Autoimmune disorders Blood counts Blood Culture Erythrocyte sedimentation rate (ESR) Serum protein electrophoresis See charts 32-2 pgs 740-741 Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 17 Inc. Calcium Phosphorous AlP (Alkaline phosphotase) CPK Needed for bone formation Needed for bone formation Useful in determining if primary or metastatic cancer present Used to test for skeletal muscle trauma or disease Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 18 Uric Acid Rheumatoid Factor ANA (Anti nuclear Antibody) Used to detect gout To detect antibodies, indicating rheumatoid arthritis, lupus or scleroderma Useful to diagnosis rheumatoid arthritis, lupus, and other connective tissue disorders Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 19 Imaging and use of contrasts to diagnose musculoskeletal disorders MRI CAT scan X-rays of joints or bones Goniometry and range of motion Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 20 Inc. DEXA Scan Measures bone density To detect bone injury/tumor To detect bone problems especially tumor Provides pictures of the joint cavity and soft tissue structures Bone Scan Gallium/Thallium Scan Arthrogram Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 21 Arthroscopy Arthrocentesis To inspect the interior aspect of a joint, usually knee with a fiberoptic scope to diagnoses problems with the meniscus, or arthritis To extract synovial fluid for analysis or to reduce swelling Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 22 Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 23 Arthrocentesis Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 24 The measurement of a joint. Each joint is evaluated in terms of degrees it can be moved from the 0 degrees position Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 25 Inc. Nursing Care post arthroscopy/ Arthrocentesis Observe for signs of bleeding or swelling: ice packs may be used post procedure Assess for swelling, circulation, sensation, pulses, and color of extremity. Apply ice packs post procedure Wrap with elastic bandage if ordered Instruct patient not to overuse joint until pain and selling decrease Analgesics as ordered. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 26 Bone marrow biopsy Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 27 Biopsy EMG Done to detect tumor cells. Muscle biopsy may be done to diagnose several muscles disorders To determine abnormal nerve transmission to the muscle and abnormal muscle function. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 28 Family history may be significant for musculoskeletal problems osteoporosis, rheumatoid arthritis Assess pain. What makes it worse precipitating factors Pain in wrists, knees, hips or feet? Note problems of movement and changes in facial expression related to activities of daily living Family members’ and patient’s ability to perform the activities of daily living Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 29 Inc. History Taking/Nursing Assessment When reviewing the patient history the nurse needs to keep in mind the significance of disorders that affect other systems but secondarily affect bones and muscles. Example: psoriasis is sometimes the first sign of psoriatic arthritis. Nutritional deficiencies can affect the nutritional composition of bone and muscle Example: Osteoporosis (Risk for falls/fracture. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 30 Has the patient experienced any sensory changes? Sensation in feet, hands or elsewhere? Any trouble sleeping because of muscle or joint pain? Any restriction in movement? Does the [patient have any joint deformity? Example: Bunion, Hammertoe, Swan neck deformity Any previous injury to the bone? Have any problems with ADL’s Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 31 Posture, gait, and balance Mobility, range of motion, and strength Spine Appearance of joints Skeletal muscle appearance in arms and legs Ability to perform activities of daily living Elder considerations Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 32 Inc. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 33 HAMMERTOE Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 34 Rheumatoid Arthritis Swan Neck Deformity Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 35 All movements need to be gentle and firm movements Sufficient help and adequately trained personnel If the patient can help without damaging the diseased joint or limb, he should be to do so If the patient is not able to help, explain the procedure to him and instruct him to relax completely during the procedure Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 36 Inc. Within a few days, the structures of immobilized muscles and joints begin to undergo changes The forming of contractures, loss of muscle tone, and the fixation of joints can be prevented in most cases by consistent nursing intervention: The major components of this intervention: Gradual mobilization Exercise program Proper positioning 37 Patient and family teaching Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. The major components of this intervention: Gradual mobilization Exercise program Proper positioning Instruction of the patient and family Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 38 Preventing contractures: When muscles are not regularly stretched and contracted they attempt to adapted them selves and become shorter “Adaptive shortening” Can begin in 3 7 days after immobilization of a body part. Most common: “footdrop,” knee and hip flexion contractures, “wrist drop,” and contractures of the fingers and arms Loss of muscle tone ROM exercises important in preventing this and must begin as soon as possible . Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 39 Inc. Prevent ankylosis –Result of injury the tissues of the joint are replaced by a bony overgrowth that completely obliterates the joint Proper positioning and movement of the joint can help prevent this Gradual mobilization Nursing responsibility: Recognize patients who are at risk for falls while they are learning to regain their mobility Set goals for progressive mobilization. Must take into account the pathological condition or cause for immobilization Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 40 Inc. Caring for immobile patients requires careful planning. Making beds for the bed confined orthopedic patient is best done by two people. Bathing and grooming are more time consuming when a patient has an immobilized limb, or a immobilizing device Planning for toileting at regular Intervals for the patient who can’t get out of bed by self. Repositioning the patient is important q 2 hours and for comfort. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 41 ROM exercises 3-4 times a day Physical/Occupational Therapy needs to be involved as soon as possible for evaluation and treat. Patients experiencing intense pain need to be assess and proper analgesics and anti inflammatory drugs administered before their exercises. 30-60 minutes before CPM –Post joint surgery. This machine provides passive motion of the joint Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 42 Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 43 Inc. CPM machine passive exercise Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 44 Exercise and ROM exercises Isometric exercises Administration of analgesic and antiinflammatory drugs Continuous passive motion Positioning and special beds Foot drop (Footboard may be appropriate) for flaccid paralysis Foot Cradle may be appropriate for patients with specific paralysis (Relieves the pressure of bed sheets and blankets) Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 45 Inc. Foot Board and Bed Cradle Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 46 Speciality Beds Use Often use for patient in cervical traction Beds turn the patient 300 times a day. Allows access to all areas of te body. Use of slings and splints Teaching ambulation with assistive devices Crutch safety see page 730-731 Special maneuvers on crutches Psychosocial care Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 47 Inc. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 48 Inc. Psychosocial Care Many orthopedic conditions require prolonged periods of confinement to bed, immobilization, and restricted physical activity This can lead to frustration and depression due to the dependence on others for care. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 49 Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 50 Inc. Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. 51 Determine effectiveness of interventions Be alert to nuances of body language Observe patient’s ability to accomplish ADLs Check x-rays and laboratory tests Collaborate among all health professionals Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier 52 Inc.