The Musculoskeletal System Notes

Musculoskeletal Part I: Anatomy + Physiology Skeletal System ● Parts ○ ○ ● Axial Appendicular Function: ○ ○ ○ ○ ○ Support body Protect internal organs Provide leverage to muscles to move Source of calcium Makes blood cells Bone Cells ● Osteoblasts ○ ○ ● Osteocytes ○ ○ ● Form bone Mature into osteocytes that become embedded into bone Maintain bone Respond to parathyroid hormone Osteoclasts ○ Break down bone PTH and bones Joints ● ● ● Where two or more bones connect Provide mobility Synovial joints ○ ○ Allow the most movement Have a capsule filled with fluid: synovial fluid ■ Lubricates the joint ● Ligaments ● Tendons ○ ○ Connect two bones at a joint Connect bones to muscles Muscular System ● Function: Movement ○ ○ Voluntary Involuntary Types of muscles Muscle cells ● Muscle cells ○ ○ Connect to the nervous system Motor unit - functional unit of the neuromuscular system ■ Muscle fiber ■ Motor nerve Neurovascular Assessment - The 5-P’s Pain Pulse Pallor Paresthesia Paralysis Part II: Musculoskeletal Pharmacology Antiarthritic Drugs ● ● ● Nonsteroidal antiinflammatory drugs (NSAIDs) Glucocorticoids Disease-modifying antirheumatic drugs (DMARDs) Methotrexate Therapeutic Class: DMARD Indication: Rheumatoid arthritis Action: Reduce joint destruction and slow disease progression by interfering in immune and inflammatory responses. Nursing Considerations: ● ● Lifelong therapy; treats symptoms but disease continues to progress Must treat RA aggressively: start a DMARD early—within 3 months of RA ○ Can be possible to delay or even prevent serious joint injury. Antigout Drugs ● ● ● Nonsteroidal antiinflammatory drugs (NSAIDs) Glucocorticoids Anti uric acid agents Allopurinol Therapeutic class: Hypouricemic agent Indication: Gout Action: Inhibits xanthine oxidase to prevent uric acid from forming. Nursing Considerations: ● ● ● Monitor for side effects of leukopenia, fever, and rash Dosage must be individualized Teach to avoid foods high in purine ○ Beer, wine, cheeses, beans, anchovies, sardines, liver, kidneys, and cream. Drugs for bone health ● ● ● ● Calcium Vitamin D Calcitonin Bisphosphonates Calcium Calcium acetate, calcium carbonate (Tums!!), calcium citrate, calcium gluconate Indication: Hypocalcemia, dietary supplement Action: Supplement calcium Nursing Considerations: ● Monitor for hypercalcemia Vitamin D Cholecalciferol, Calcitriol, Ergocalciferol Indication: Hypoparathyroidism, Hypocalcemia, Vitamin D deficiency Action: Supplements Vitamin D stores Nursing Considerations: ● ● ● Monitor for toxicity - fat soluble ○ Osteoporosis, hypercalcemia With sufficient exposure to sunlight, the body can manufacture all the vitamin D it needs!! Therapeutic responses to vitamin D require adequate calcium intake. Encourage intake of foods that are high in calcium. Calcitonin Indication: Osteoporosis, Paget’s disease, hypercalcemia Action: Inhibits the activity of osteoclasts and thus decreases bone resorption, and inhibits tubular resorption of calcium, thereby increasing calcium excretion Nursing Considerations: ● Usually administered by nasal spray ○ Side effects: Nasal dryness and irritation Alendronate Therapeutic class: Bisphosphonate Indication: Osteoporosis Action: Decreases bone resorption by osteoclasts Nursing Considerations: ● Side effect: Esophagitis ● ● Take with a full glass of water Remain upright for 30 minutes after taking (do not take supine or lie down after taking) If difficulty or pain with swallowing, or heartburn develop, clients should discontinue the medication and contact their provider. ○ ● Contraindicated in clients with a pre-existing esophageal disorder! Baclofen Therapeutic class: Centrally Acting Muscle Relaxer Indication: Muscle spasticity: MS, CP, SCI Action: Acts within the spinal cord to suppress hyperactive reflexes involved in regulation of muscle movement Nursing Considerations: ● ● Monitor for CNS depression Do not discontinue abruptly - taper over 1 to 2 weeks ○ Can cause seizure Part III: Musculoskeletal Disorders Injuries ● Dislocation ○ Complete loss of contact between the surfaces of two bones Subluxation ● Sprain ● ○ Partial loss of contact between two bones ○ Ligament tears ○ Complete separation of a tendon or ligament from its attachment ○ ○ ○ ○ ○ Open vs. closed Stress Fatigue Insufficiency Direction of fracture ● Avulsion ● Fractures Direction of fracture Treatment ● ● Pain management RICE ○ ● Immobilization ○ ○ ○ ○ ● Rest, Ice, Compression, Elevation Cast Splint Brace Monitor the casted extremity closely for perfusion!! Traction ○ Used temporarily for proper alignment and healing Traction T - Temperature - Monitor the temperature of the extremity. R - Ropes - The ropes should be hanging freely A - Alignment - Ensure proper alignment of the extremity. C - Circulation - Circulation checks on extremity are #1! The 6 P’s! T - Tension - No tension on the skin. HIGH RISK FOR SKIN BREAKDOWN!! I - Intake - Monitor I&O’s O - Overhead trapeze - Bar overhead to help with range of motion. N - NO weights on the floor! - DON’T release the traction! Halo device ● ● ● ● ● Used when patients have a spinal cord injury to the cervical spine Allows patients to be mobile while maintaining spinal alignment Worn for weeks-months Never tug or pull on frame Pain at pin sites may indicate infection External Fixators ● ● ● External device used to keep broken bones together when fractures are complex or comminuted Device is connected to bone through pins which pass through the skin Pin sites require care to prevent incidence of infection Pin site care ● ● ● ● Performed daily-weekly as ordered by health care provider Can be performed by RN or LPN Pin sites should be assessed every shift New gauze should be used for each sweep and for each pin Steps to pin site care: ● Hand hygiene and assess the site ● Use sterile gauze soaked in normal saline to cleanse around pin site ● Remove drainage or pus that has formed ● Dry with a new sterile gauze ● Cleanse the length of the pin, cleansing upwards from site NCLEX Question The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with what finding? A. B. C. D. E. Inflammation Serous drainage Pain at pin insertion site Swelling of the extremity Red streaks going up the patient’s affected extremity Answer: B A small amount of serous drainage is normal and to be expected at pin sites. Items the nurse should be worried about include inflammation, purulent drainage and red streaks up the patient’s affected extremity. Pain at the pin insertion sites is not to be expected and should be reported to the patient’s HCP. Osteoporosis ● ● ● ● Metabolic disease characterized by bone demineralization, loss of calcium and phosphorus salts leading to fragile bones and then further risk for fractures Bone resorption accelerates as bone formation slows Most commonly occurs in wrist, hip and vertebra May be asymptomatic until the bones become fragile and a minor injury causes a fracture Osteoporosis Risk Factors ● ● ● ● ● ● ● ● Early menopause Smoking Family history Female Gender Excessive use of ETOH Sedentary Lifestyle Thin, small frame Increasing age Interventions ● ● Assess risk for injury and prevent injury in patients environment Provide personal care to client to reduce injuries ○ ● Provide client instructions to promote optimal level of health and function ○ ● Move patient gently, assist with ambulation if unsteady, gentle ROM Good body mechanics, exercises to strengthen core, avoid activities that causes vertebral compression, encourage diet high in calcium, vitamin D, iron and protein Avoid Alcohol Rheumatoid Arthritis ● ● ● ● ● Chronic systemic inflammatory disease Leads to destruction of connective tissue and synovial membrane within the joints Weakens the joint, leading to dislocation and deformity of the joint Pannus forms at the junction of synovial tissue and articular cartilage and projects into the joint space which causes necrosis RA exacerbations or “flares” occur during periods of fatigue and stress (emotional or physical) Assessment findings ● ● Inflammation, tenderness, stiffness of the joint Decreased ROM in joints Moderate to severe pain with morning stiffness lasting longer than 30 minutes Joint deformities Spongy, soft feeling in joints ● ● ● Elevated ESR and positive rheumatoid factor X-ray shows joint deterioration Synovial fluid shows inflammation ● ● ● Treatment Medications: NSAIDS, disease-modifying anti-inflammatory drugs and glucocorticoids ● ● ● ● ● Preserve joint function Heat or cold therapy as prescribed Encourage consistent exercise program Avoid weight bearing on inflamed joints Surgical: Synovectomy, arthrodesis, joint replacement Osteoarthritis ● ● ● ● Age related disorder Cartilage decreases Bones become sclerosed Bones spurs form ○ Osteophytes Causes ● Most common in ○ ○ ○ ○ ● Hands Knees Hips Spine Causes: ○ ○ ○ Age (most common in over 40 year olds) Overweight Strenuous work environment Assessment Findings Outgrowths ● ○ ○ ○ Bone spur formations Heberden’s node ■ Close to fingernail Bouchard’s node ■ Middle finger joint ● Stiffness ● Tenderness ● Exercise makes it worse ○ Stiffness in the morning lasting less than 30 min ○ Hard, bony, tender joints ○ ○ Crepitus with movement Pain with activity - goes away with rest ○ Not systemic - so no inflammation, redness, fever, fatigue or other such symptoms. ONLY in the joints ● Nursing Interventions ● Physical exercise ○ ● ● ● Low impact ■ Walking, aerobics, strength training ■ Avoid running, jump rope, etc. - puts too much pressure on the joints. Encourage weight loss Corticosteroids Analgesics ○ ○ NSAIDs Acetaminophen RA vs. OA ● RA ○ ○ ○ ○ ○ ○ ● Overactive immune system Affects the synovium Morning is worst Morning stiffness > 30 min Warm, boggy, tender joints Systemic OA ○ ○ ○ ○ ○ ○ Normal wear and tear Affects the cartilage End of day is worst Morning stiffness < 30 min Hard, bony, tender joints Localized Gout ● ● ● ● ● Body cannot control uric acid production or exertion High uric acid builds up in the body Uric acid crystallizes and deposits in connective tissue Causes inflammation and destruction of joints Most common location ○ ● Great toe Complication ○ Gouty arthritis Assessment findings ● Pain ○ ● ● ● Inflammation Redness Decreased mobility ○ ○ ● Very stiff Intense pain with pressure Tophi ○ ○ ○ ● Gets worse as the day goes on Large clumps of uric acid crystals that have accumulated over time White/yellow Can permanent damage joints High uric acid level Nursing Interventions ● ● ● ● ● ● Alternate cold and warm compresses Hydration Bed rest NSAIDs Corticosteroids Allopurinol ○ ○ ● Prevents future attacks - does not treat current symptoms Decreases production of uric acids Low purine diet High purine foods ● Meat ○ ○ ● Organ meats Red meat Seafood ○ ○ ○ Anchovies Sardines Scallops *They should also avoid alcohol…. It will decrease how much uric acids gets excreted!* Muscular Disorders Injuries ● Strain ● Tendonitis ○ Tendon tears Contractures ● ● Permanent muscle shortening caused by muscle spasticity Foot drop ○ ○ Plantar flexion contracture Prevent with boots! https://www.devinemedical.com/Posey-6147ML-Deluxe-Po dus-Boot-p/26-posey-6147ml.htm https://en.wikipedia.org/wiki/Foot_drop Myopathy ● ● Primary muscle disorder causing weakness and atrophy Assessment findings: ○ ○ ● Decreased muscle strength Decreased muscle tone Causes: ○ ○ ○ Drugs Alcohol abuse Idiopathic Musculoskeletal Complications Rhabdomyolysis ● There is injury to the skeletal muscle ○ ○ ○ ● Muscles release their intracellular contents into the blood ○ ○ ○ ○ ● ● Burns Trauma Compartment syndrome Myoglobin Creatinine Kinase Potassium Phosphorus These substances become toxic in circulation Major kidney damage as the nephrons try to filter the toxins out Rhabdomyolysis Assessment Treatment ● Fluids ○ ○ ● Diuretics ○ ○ ○ ● Decreased swelling Increase UOP Flush out toxins Dialysis ○ ● ● NS Hydration and flushing the kidneys If K too high or kidneys unable to clear the toxins on their own Bedrest Monitor electrolytes and CK ○ Worried about high K?? → TELEMETRY! NCLEX Question A client that has sustained a sports injury has just finished an arthroscopy on his left knee. The nurse caring for him should FIRST assess the client for which of the following factors? a. b. c. d. Skin and wound integrity Mobility assessment Vascular and skin assessments Circulatory and neurologic assessments Answer: D The nurse should always focus on assessing the client’s; neurological and circulatory status following an arthroscopic procedure. The swelling of the extremity can impair the neurologic and circulatory function of the leg. The nurse can address the other concerns of skin integrity, mobility, and pain once neurologic and circulatory integrity is established. Compartment Syndrome ● There is increased pressure within a confined space ○ ○ ● ● ● Limbs ■ Especially in a cast! Abdomen This increased pressure compromises circulation Without circulation, the distal tissue becomes ischemic Tissue and nerve damage occurs Assessment ● ● ● ● ● ● ● ● Extremely painful Limb feels tight Swelling Numbness Tingling Paralysis diminished or absent pulses Decreased sensation Treatment ● FASCIOTOMY ○ ○ Must relieve the pressure in the compartment Cut open the compartment https://www.ncbi.nlm.nih.gov/books/NBK448124/figure/article-19772.image.f1/?report=objectonly Fat embolism Symptoms: ▪ Hypoxia ▪ Dyspnea ▪ Tachypnea ▪ Confusion ▪ Altered level of consciousness ▪ Petechial rash (does not always occur) Associated with orthopedic fractures such as long bone and pelvic fractures. Priority Nursing Actions Actions to take if a patient develops a fat embolism 1. 2. 3. 4. 5. 6. Notify the HCP Administer oxygen Administer IV fluids Monitor vitals and respiratory status Prepare for intubation and mechanical ventilation Document the event, actions take and the patient’s response Osteomyelitis ● ● ● Infection of the bone Usually caused by a staph infection Infection can be ○ ○ ● ● Exogenous Endogenous Spreads through bone shaft or into bone marrow Treatment: ○ Antibiotics https://radiopaedia.org/cases/osteomyelitis-femur-1?lang=gb NCLEX Question The nurse had provided teaching to a patient with an arm cast about the signs and symptoms of compartment syndrome. The nurse determines the patient understands the teaching when the patient is able to teach back what early sign of compartment syndrome? a. b. c. d. Pain out of proportion to the severity of the fracture Numbness and tingling in the fingers Cold and blue tipped fingers Pain that increases when the arm is dependent Answer: B The earliest sign of compartment syndrome is paresthesia. Other symptoms involve pain that is not relieved by medications (opioids), pain that increased with limb elevation, and pallowrand coolness to the affected limb. Cyanosis is a late sign. Pain out of proportion to the severity of the fracture is not an early manifestation