Ch 52: Assessment of the Musculoskeletal System

long bones

cylindric with rounded ends and often bear weight (femur)

short bones

small and bear little or no weight (fingers)

flat bones

-protect vital organs
-often contain blood forming cells

irregular bones

unique shapes (wrist bones)

sesamoid bone

develops within a tendon

cortex

-outer layer of bone
-composed of dense compact bone tissue

haversian system

microscopic blood vessels that supply nutrients and oxygen to bone as well as lacunae

osteocytes

bone cells

cancellous tissue

contains large spaces (trabeculae) filled with red and yellow marrow

Hematopoiesis

production of red blood cells occurs in the red marrow

yellow marrow

contains fat cells which can dislodge, enter the bloodstream and cause fat embolism syndrome (FES)

periosteum

outermost covering of the bone

osteoblasts

bone forming cells

osteoclasts

bone destroying cells

the skeletal system

-provides a framework for the body and allows the body to be weight bearing or upright
-supports the surrounding tissues
-assists in movement
-protects vital organs
-manufactures blood
-storage for mineral salts

by 35 yrs old

bone destruction is more frequent and formation slows down

as calcium levels rise

phosphorus levels decrease

in response to PTH

calcium is released into the bloodstream by the bones

calcitonin

-produced by the thyroid
-decreases serum calcium concentration
-inhibits bone resorption (destruction)
-increases renal excretion of calcium and phospherus when needed

Vit D

-produced in the body
-transported in the blood to promote absorption of calcium and phosphorus

a decrease in Vit D

can result in osteomalacia (softening of the bone)

mineral and hormones affecting bone growth

-calcium
-phosphorus
-calcitonin
-Vit D
-parathyroid hormone (PTH)
-growth hormone
-glucocorticoids
-estrogens & androgens
-thyroxine
-insulin

PTH

-released when calcium levels are low
-stimulates bone to promote osteoclastic activity which releases calcium into blood

growth hormone

-secreted by the pituitary gland
-increases bone length
-determines the amount of bone matrix formed before puberty

adrenal glucocorticoids

-regulate protein metabolism
-reduce or intensify organic matrix of bone

estrogens

-stimulate osteoblastic
-inhibit PTH

androgens

increase bone mass

thyroxine

increase the rate of protein synthesis

insulin

works with growth hormone to build and maintain healthy bone tissue

synarthrodial joint

completely immovable (cranium)

amphiarthrodial joint

slightly movable (pelvis)

diarthrodial (synovial)

-freely movable (elbow, knee)
-most common
-synovial fluid lubricates and absorbs shock

synovitus

synovial inflammation

ball-and-socket joint

permit movement in any direction (shoulder, hip)

hinge joint

allow flexion and extension (elbow)

smooth muscle

-contractions of organs and blood vessels
-controlled by autonomic nervous system

cardiac muscle

-striated
-involuntary muscle
-autonomic nervous system

skeletal muscle

-striated
-voluntary muscle
-controlled by central and peripheral nervous system
-main function: movement of the body and its parts

tendons

bands of tough, fibrous tissue that attach muscle and bones

ligaments

attach bones to other bones at joints

Osteopenia

-decreased bone density (bone loss)
-when severe causes osteoporosis

Osteoporosis

-causes postural and gait changes
-predisposes the person to fractures

Osteoarthritis (OA)

a result from the synovial joint cartilage becoming less elastic and compressible leading to joint damgage

Nursing Interventions (NI) for decreased bone density

-teach pt safety tips to prevent falls
-reinforce need to exercise, especially weight-bearing exercise

NI for Increased bone prominence

prevent pressure on bone prominences

NI for kyphotic posture

-teach proper mechanics
-instruct pt to sit in supportive chairs with arms

NI for cartilage degeneration

assess the pt's ability to perform ADL's and mobility

NI for muscle atrophy, decreased strength

teach isometric exercises

NI for slowed movement

-do not rush pt
-be patient

taking patient history

-ask about any previous traumatic or sports injuries no matter how old
-ask about any previous hospitalizations, illnesses, or complications
-ask about ability to perform ADL's (ind. or assisted?)
-ask about current lifestyle
-exercise?
-alcohol?
-tobacco

arthralgias

joint aching

taking a nutrition history

-significant weight gain or loss?
-what is a typical food day?
-getting enough calcium?
-afford healthy food?
-enough vitamins, minerals?
-vit C & D deficiency slows bone and tissue healing

obesity

-places stress and strain on bones and joints
-result in fractures and trauma to joint cartilage
-inhibits mobility
-can lead to resp and circulatory problems

family history/genetic risk

-any serious illness/disease?
-cancer?

common symptoms of musculoskeletal problems

-pain
-weakness

current health problem

-date of onset
-factors that cause or worsen problem
-clinical manifestations
-what improves manifestations

assessment of pain

-can be related to bone, muscle, or joint
-acute or chronic
-intensity (0-10)
-dull, burning, aching, stabbing
-location, radiation
-pt should describe in his/her own words

weakness

-one muscle, or a group of muscles
-proximal, distal
-proximal; may indicate myopathy
-distal; may indicate neuropathy
-location
-lower extremeties; increase risk for falls
-upper extremities; may interfere with ADL's

posture and gait

-assess curvature of spine
-assess length, shape, and symmetry of extremities
-inspect muscle mass of size and symmetry
-evaluate balance, steadiness, and stride

mobility and functional assessment

-need for ambulatory devices
-ability to perform ADL's
-assess bones, joints, and muscles by:
-inspection
-palpation
-assessing ROM

goniometer

used to provide an exact measurement of flexion and extension or joint ROM

antalgic gait

-an abnormality in the stance phase of gait
-pt shortens step on affected side

lurch gait

-abnormality in the swing phase of gait
-shoulders are moved side-to-side or front-to-back for help in shifting the weight from one leg to the other

crepitus

a grating sound

effusion

fluid accumulation

genu valgum

inward kness "knock knees

genu varum

bow legged

Lovet's scale

used for grading muscle strength

Lovet's scale 5

normal: ROM unimpaired against gravity with full resistance

Lovet's scale 4

Good: can complete ROM against gravity with some resistance

Lovet's scale 3

Fair: can complete ROM against gravity

Lovet's scale 2

poor: can complete ROM with gravity eliminated

Lovet'sscale 1

trace: no joint motion and slight evidence of muscle contractility

Lovet's scale 0

Zero: no evidence of muscle notractility

neurovascular assessment (circ chack)

-palpation of pulses in extremities below level of injury
-assess sensation
-assess movement
-assess color
-assess temp
-assess pain in injured part

psychosocial assessment

-anxiety and depression are common with chronic pain
-deformity/amputation can affect a person's body image and self-concept

muscle enzymes affected in disease or injury

in result to damage, muscle tissue releases additional amounts of these enzymes, increasing serum levels:
-creatine kinase (CK-MM)
-aspartrat aminotransferase (AST)
-aldolase (ALD)
-lactic dehydrogenase (LDN)

hypercalcemia may indicate

-metastatic cancers of the bone
-Paget's disease
-bone fractures in healing stage

hypocalcemia may indicate

-osteoporosis
-osteomalacia

hyperphosphatemia may indcate

-bone fractures in healing stage
-bone tumors
-acromegaly

hypophosphatemia may indicate

-osteomalacia

elevations in ALP may indicate

-metastatic cancers of the bone
-Paget's disease
-osteomalacia

elevations in CK may indicate

-muscle trauma
-progressive muscular dystrophy
-effects of electromyography

elevated LDH levels my indicate

-skeletal muscle trauma
-extensive cancer
-progressive muscular dystrophy

elevated AST may indicate

-skeletal muscle trauma
-progressive muscular dystrophy

elevated ALD may indicate

-polymyositis and dermatomyositis
-muscular dystrophy

what x-rays show

bone:
-bone density
-alignment
-swelling
-intactness
joints:
-size of joint space
-smoothness of articular cartilage
-synovial swelling

arthroscopy

a tube is inserted into the joint for direct visualization of ligaments, menisci, and articular surfaces of joint.

post-arthroscopy

-assess neurovascular of affected limb q1hr
-monitor/document:
-distal pulses
-warmth
-color
-capillary refill
-pain
-movement
-sensation of affected limb
-pt should perform taught exercises
-take prescribed analgesics/opioids for pian
-may have short ter