Chapter 44 Care of the Patient with a Musculoskeletal Disorder

1. Chapter 44 Care of the Patient with a Musculoskeletal Disorder

2. Overview of Anatomy and Physiology • Functions of the skeletal system • Support • Skeleton provides body framework • support internal tissues and organs • Protection • Skeleton forms cagelike structures • Protects internal structures • Cranium protects brain, ribs and sternum protects heart and lungs • Movement • Skeletal muscles attached to bones, bones provide leverage for movement • Muscle contracts, it exerts pull on the bone and movement occurs

3. Overview of Anatomy and Physiology • Functions of the skeletal system • Mineral storage • Calcium and phosphorus • Not enough are taken in by the body, the bone will release these minerals • Hematopoiesis • Blood formation takes place in the red bone marrow • Red bone marrow – spongy bone found in the long ends of the long bones • Red bone marrow as a person ages will convert to yellow which consist of mainly fat cells

4. Overview of Anatomy and Physiology • Structure of bones • Four classifications based on form and shape • Long • Found in extremities • Short • Found in hands and feet • Flat • Found in skull and sternum • Irregular • Make up vertebrae (backbone)

5. Figure 44-2 (From Thibodeau, G.A., Patton, K.T. [1997]. The human body in health and disease. [2nd ed.]. St. Louis: Mosby.) Skeleton, anterior view.

6. Figure 44-3 (From Thibodeau, G.A., Patton, K.T. [1997]. The human body in health and disease. [2nd ed.]. St. Louis: Mosby.) Skeleton, posterior view.

7. Overview of Anatomy and Physiology • Articulations (joints) • Allow movement • Three types according to degree of movement • Synarthrosis—no movement • Amphiarthrosis—slight movement • Diarthrosis—free movement • Divisions of the skeleton • Axial skeleton • Consist of skull, spine, thorax • Appendicular skeleton • Consists of upper and lower extremities

8. Figure 44-1 (From Thibodeau, G.A., Patton, K.T. [2004]. Structure and function of the body. [12th ed.]. St. Louis: Mosby.) Structure of a freely movable (diarthrotic) joint.

9. Overview of Anatomy and Physiology • Functions of the muscular system • Motion (for movement) • Result from contraction and relaxation of muscles • Maintenance of posture • Production of heat • 85% of body heat is produced by muscle contraction • Contraction results in return of venous blood and lymph to the right side of the heart • Voluntary vs involuntary control

10. Overview of Anatomy and Physiology • Skeletal muscle structure • Epimysium • Connective tissue that surrounds each skeletal muscle • Perimysium • Endomysium • Epimysium connects/joins with perimysium and endomysium extending beyond the muscle to form a tendon • Tendons anchor muscles to bone

11. Figure 44-5 (From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.) Anterior view of the body

12. Figure 44-6 (From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.) Posterior view of the body.

13. Overview of Anatomy and Physiology • Nerve and blood supply • Blood vessels provide a constant supply of oxygen and nutrition and nerve cells/fibers supply a constant source of information • NMJ, ACh, AChase, synaptic cleft • Muscle contraction • Muscle stimulus—when a muscle cell is adequately stimulated, it will contract (“all or non” law) • Muscle tone—skeletal muscles are in a constant state of readiness for action • Types of body movements—flexion, extension, abduction, adduction, rotation, supination, pronation, dorsiflexion, and plantar flexion

14. Laboratory and Diagnostic Examinations • RADIOGRAPHIC STUDIES • Diagnostic study for musculoskeletal system integrity • Radiographic, roentgenographic • Commonly known as: x-ray examination or diagnostic imaging • Reveals joint fluids, irregularity of joint with spur formation, changes in size of joint contour • Determine fractures • Ask if patient is pregnant • Laminography or planography • Also known as body section roentgenography • Useful in locating small cavities, foreign bodies, and lesions overshadowed by opaque structures • Scanography • Allows accurate measurement of bone’s length

15. Laboratory and Diagnostic Examinations • RADIOGRAPHIC STUDIES – cont’d • Myelogram • Injection of radiopaque dye in subarachnoid space at lumbar spine • Determines herniated disk syndrome or tumors • Allergic reaction in people allergic to iodine & seafood • Most common discomfort is headache • Nuclear scanning • Done in the nuclear medicine department • Nursing precaution: • 1. written consent of patient • 2. radioactive isotope won’t affect family/visitors • 3. follow instructions outlined by nuke med dept

16. Laboratory and Diagnostic Examinations • RADIOGRAPHIC STUDIES – cont’d • Magnetic resonance imaging (MRI) • Detects pathologic conditions of cerebrum and SC • Detects herniated disk • Give detailed pictures of fluid-filled soft tissue and blood vessels • Patient prep: no metallic objects • Patient with metal prosthesis such as heart valves, orthopedic screws or cardiac pacemakers • Need to be motionless • May use sedative if extremely anxious or patient is claustrophobic

17. Laboratory and Diagnostic Examinations • RADIOGRAPHIC STUDIES – cont’d • Computed axial tomography (CT or CAT scan) • Body sections can be examined from many angles • 3-D picture of structure is made • Iodine contrast dye sometimes used • Locating injuries to tendons, ligaments, tumors and fractures • Preparation: • 1. signed consent • 2. any allergies • 3. NPO 3-4 hours prior to test • 4. VS as baseline • 5. void before test • 6. remove jewelries and hair pins • 7. lie still during test

18. Laboratory and Diagnostic Examinations • RADIOGRAPHIC STUDIES – cont’d • Bone scan • Detects metastatic and inflammatory bone disease • Administer IV nuclides 2-3 hours prior to test • Drink fluids next 2-3 hours to aid renal clearance of radioisotope not picked up by bone • Areas of concentrated nucleotide uptake represent tumor or other abnormality

19. Laboratory and Diagnostic Examinations • Endoscopic examination • Lighted tube is used to visualize inside of body cavity • Preparation: similar to surgical prep • 1. signed consent form • 2. pre-op checklist-remove jewelry, dentures, contacts • 3. NPO 6-12 hours before • 4. premed maybe given-atropine and sedative • 5. encouraged to void • 6. VS taken and recorded • 7. bed rest with side rails up after premed given

20. Laboratory and Diagnostic Examinations • Endoscopic examination – cont’d • Arthroscopy • Direct visualization of joints • Accomplishes the following: • Exploration of joint to determine presence of disease process • Drainage of fluid • Removal of damage tissue or foreign bodies • Commonly done in knee joint • Visualizes: synovium, articular surfaces, meniscus

21. Laboratory and Diagnostic Examinations • Endoscopic examination – cont’d • Endoscopic spinal microsurgery • Treat spinal column disorder • Herniated disk • Spinal stenosis • Spinal deformities • Scoliosis • kyphosis

22. Laboratory and Diagnostic Examinations • Aspiration • Obtain specimen of body fluid • Sterile technique • Biopsy at the same time • Nursing interventions • 1. consent form signed • 2. reinforcing physician’s explanation of procedure • 3. immobile during procedure • 4. void before procedure • 5. sterile technique • 6. emotional support • 7. sterile pressure dressing to puncture site • 8. assist with collecting, labeling and transport • 9. observe emotional and physical distress after procedure

23. Laboratory and Diagnostic Examinations • Aspiration-cont’d • Synovial fluid aspiration • Arthrocentesis • Diagnosing trauma, SLE, gout, OA, and RA • Normal-straw colored, clear, slightly cloudy • Trauma or disease process • Cloudy, milky, yellow, green, gray • Support joint with pillow rest up to 12 hours

24. Laboratory and Diagnostic Examinations • Electrographic procedure • Electromyogram (EMG) • Insert electrodes in muscle so electrical activity can be heard, seen on oscilloscope, recorded on paper • Nerves can be observed for neuropathy • Muscles observed for myopathy • Electromyography used to detect chronic low back pain based on muscle fatigue pattern

25. Laboratory and Diagnostic Examinations • Laboratory tests • Calcium • Erythrocyte sedimentation rate (ESR) • Lupus erythematosus (LE) preparation • Rheumatoid factor (RF) • Uric acid (blood) • Study table 44-3, pg 1372

26. General Nutritional Needs/Modifications • Osteoporosis • Nutrition • Low calcium intake • Low vitamin D intake • High phosphate intake • Carbonated beverages • Inadequate calories • => reduces nutrients needed for bone remodeling

27. General Nutritional Needs/Modifications • Osteoporosis – cont’d • Nutritional factors contribute to its’ development • Balanced diet • Adequate calories and nutrients to maintain: • Bone, calcium and vitamin D • Vitamin D • For calcium absorption • For normal bone mineralization • Dietary calcium and vitamin D • Must be adequate to maintain bone remodeling and body function • Source of calcium and vitamin D • Fortified milk (cup of milk = 300-mg of calcium)

28. General Nutritional Needs/Modifications • Osteoporosis – cont’d • Recommended adequate intake (AI) level of calcium • 9 y/o to 19 y/o is 1300 mg/day • To maximize peak bone mass • 19 y/o to 50 y/o is 1000 mg/day • 51 years and older is 1200 mg/day • Estimated daily intake is 300 to 500 mg • Recommended adult vitamin D intake is 400 to 600 IU per day • Inadequate calcium and vitamin D intake over time • Result in development of osteoporosis

29. General Nutritional Needs/Modifications • Osteoporosis – cont’d • Protection against bone demineraliztion • Balanced diet rich in calcium and vitamin D • Increased calcium intake during adolescence, young adulthood, and middle years • 3 glasses of skim milk daily (food high in calcium) • Calcium supplements (caltrate, citrocal) • Taken with food or beverages high in vit C to promote absorption • S/E of calcium supplement: abdominal distention and constipation

30. General Nutritional Needs/Modifications • Osteomalacia • Cause is malabsorption • Increase doses of vitamin D, with supplemental calcium • Exposure to sunlight • UV radiation to transform cholesterol substance (7-dehydrocholesterol) present in skin to vitamin D

31. General Nutritional Needs/Modifications • Osteomalacia • Cause is dietary origin • Diet with adequate protein and increased calcium and vitamin D is provided • Dietary sources of calcium and vitamin D • Fortified milk and cereals, eggs, chicken livers • High doses of vitamin D is toxic • Vitamin D raises concentration of calcium and phosphorus in ECF makes these ions available for bone mineralization

32. General Nutritional Needs/Modifications • Paget’s Disease (osteitis deformans) • Disorder of localized rapid bone turnover commonly • Skull, femur, tibia, pelvic bones, vertebrae • Assymptomatic patient • Managed with adequate calcium and vitamin D in the diet and periodic monitoring • Osteomyelitis • Infection of the bone • General supportive measure • Hydration, diet high in protein and vitamins, correction of anemia