Musculoskeletal Lecture

1. Musculoskeletal Lecture NUR 216 Professor Shugart

2. Structures • Bones • Joints • Ligaments • Bursae • Muscles • Tendons • Cartilage

3. Functions • What are the functions of the………… • Bones (206) Structure; protection; produce red blood cell; act as levers; stores calcium • Muscles (650) Allow for movement and position; produce heat

4. Functions • What are the functions of the………… • Joints: Point of articulation of two bones; provide ROM • Tendons: Connect muscle to bone

5. Functions • What are the functions of the………… • Ligaments: Connect bone to bone • Cartilage: Support and shapes; acts as a shock absorber

6. Functions • What are the functions of the………… • Bursae: Sacs filled with synovial fluid; cushions and reduce friction between joints

7. Movements • Range of Motion: (ROM) • The degree of movement of a joint is called the range of motion. Diarthrotic, or freely movable, joints are the only joints that have one or more ranges of motion.

8. Movements • Flexion: Is the bending forward of the joint to decrease the angle between the bones that it connects. • Extension: Is the straightening of a limb to increase the joint angle. • Abduction: Is the movement of the limb away from the midline of the body. • Adduction: Is the movement of the limb toward the central axis of the body.

9. Movements • Internal Rotation: Is the turning of the body part inward toward the central axis of the body. • External Rotation: Is the turning of the body part away from the midline

10. History What can a history tell you about the musculoskeletal system?............. • Health History • Occupational or recreational activity • Previous occurrence of the following: Musculoskeletal or systemic disease, Injury, Difficulty with joint movement, Tenderness, Erythema, Difficutly with ADL

11. History • Family History • Developmental Considerations • Health promotion and protection patterns • Abilities to perform ADLs

12. History • Subjective Data *For any symptom the person has you should ask about …………. • Location • Quality • Quantity • Timing • Aggravating Factors

13. History • Subjective Data *For any symptom the person has you should ask about …………. • Relieving Factors • Associated Symptoms • Effects on ADLs

14. Symptoms What symptoms would signal a problem with the musculoskeletal system?........... • Joints: pain, stiffness, heat or limitation of movement • Bones: pain, deformity, or trauma • Muscles: pain, weakness • Balance and coordination problems

15. Physical Assessment • Inspection is first:

16. Physical Assessment • Posture: The position the body parts assume in relationship to other body parts. The client/patient posture is upright with good alignment of the head, shoulders, and hips. • Spine: Includes having the person stand up straight and then bend forward at the waist.

17. Physical Assessment • Common Abnormalities: • Lordosis (swayback): exaggerated concave curvature of the lumbar spine. • Kyposis (hunchback): excessively convex (backward curvature of the thoracic spine). • Scoloiosis: abnormal lateral curvature of the spine. Best detected when a person bends at the waist.

18. Common Abnormalities:

19. Physical Assessment • Inspection 3. Gait: observe person walking, turning and returning.

20. Physical Assessment • Inspect Joints: Size, shape, redness, or masses. • Inspect Muscles: Involuntary movement, mass, size, symmetry. • Measure Length and Circumference: Arms and Legs

21. Physical Assessment • Palpation is next:

22. Physical Assessment • Palpate the bones, joints and spine for….. • Temperature • Tenderness • Swelling • Masses • Crepitus: Grating feeling or sound in joint during ROM

23. Physical Assessment • Palpate joint during ROM • Active ROM is voluntary movement of the joints by the person. Should be done first, before testing for muscle strength. • Passive ROM is movement of the relaxed joint of the patient by the examiner through the limits of its movement.

24. Physical Assessment • Hand grips • Foot push/leg raise • Muscle Strength (0-5) • Muscle Tone

25. Physical Assessment Muscle strength is tested against resistance of the examiner. GradeDescription • Full ROM against gravity with extreme resistance • Full Rom against gravity with some resistance • Full ROM against gravity with no resistance • Full Rom with gravity eliminated • Slight contraction visible 0 No contraction

26. Physical Assessment • Documentation is next

27. Physical Assessment • Musculoskeletal Muscles developed without atrophy/ hypertrophy. Arms and legs symmetrical. No edema, varicosity’s, or tenderness. Joints non-tender, without swelling, and with full ROM. Muscle tone and strength 5/5 bilaterally. Spine has full Rom and is without tenderness or deformities.

28. Nursing Diagnosis • Pain • Activity Intolerance • Self-Care Deficit • Body Image Disturbances • Injury, risk for • Impaired physical mobility

29. Canes Standard T-handle Quad Crutches Axillary Lofstrand Walker Standard Foldable Wheels Assistive Devices

30. Terms • Weight bearing • Partial weight bearing • No weight bearing

31. Remember Safety • Review health status • Assess V/S • Assess level of orientation • Assess ROM • Assess environment • Assess level of understanding

32. Cane Assisted Ambulation 1. Used with partial weight bearing 2. Assess balance, strength, and confidence 3. Usually used unilaterally 4. Instruct client to hold cane on uninvolved side. • The cane and weaker leg work together while ambulating • Allow 15‑30 degrees elbow flexion with the cane

33. Cane Assisted Ambulation 5. Move cane forward 6‑10 inches, while keeping weight on both legs 6. Move affected leg forward so it is even with the cane 7. Bring the unaffected leg past the cane 8. Move affected leg even with the unaffected leg 9. Repeat steps • Do not use words like good or bad; instead, use involved/uninvolved, affected/unaffected, right/left

34. Crutches Assisted Ambulation • What disorders necessitate the use of crutches? • REMEMBER SAFETY • Assess arm and shoulder strength • Assess balance • Assess endurance • Proper measurement is important

35. Crutches Assisted Ambulation • Standing measurements­: • Two or three fingers should fit between the top of the crutch and the axilla and/or • Crutch pads should be 1 1/2‑ 2 inches below axilla • Rubber tips on crutch should reach 4 ‑ 6 inches to side of client's feet • (Handgrip) Elbow should be flexed 15‑30 degrees

36. Ambulation-4 Point Gate • 1. Begin with feet comfortably apart and crutches 6 inches in front and 6 inches to side of each foot. (Be sure body is in alignment) [tripod position] • 2. Keeping feet together, move right crutch forward 4‑6 inches • 3. (Crutch and foot move in opposition) Move left foot forward to be equal level with left cane

37. Ambulation-4 Point Gate • 4. Move left crutch forward 4‑6 inches • 5. (Crutch and foot move in opposition) Move right foot forward to be equal level with right crutch • 6. Repeat

38. Ambulation-3 Point Gate • 1. Begin in tripod position (above) • 2. Bring both crutches and affected leg forward • 3. Move unaffected leg forward • 4. Repeat

39. Ambulation-2 Point Gate • 1. Begin in tripod position (above) • 2. (Crutch and foot move together in opposition) • Move left crutch and right foot forward (together) • 3. Move right crutch and left foot forward (together) • 4. Repeat

40. Swing‑to gait • 1. Move both crutches forward • 2. Lift and swing legs to crutches • 3. Repeat

41. Swing‑through gait • 1. Move both crutches forward • 2. Lift and swing legs through and past the crutches • 3. Repeat

42. Walker Assisted Ambulation • 1. Position‑ Upper bar of walker is slightly below client's waist. • Elbows are flexed 15‑30 degrees (with hands on hand grips) • 2. Lift walker and move forward 6‑8 inches. Step forward. Follow‑through • with opposite foot. (If one side is affected, step forward with affected leg first) • 3. Repeat

43. Guidelines for ROM • 1. Wash hands • 2. Explain/teach • 3. Use proper body mechanics • 4. Provide privacy • 5. ROM‑ Support joint and limb • 6 Move smoothly, slowly, rhythmically • 7. Move to resistance (not pain) • 8. Return joint to neutral alignment • 9. Perform 2‑3 times per day • 10. Assess client • 11. Document

44. Suggested order for performing ROM • 1. Wash hands • 2. Explain ROM • 3. Raise bed (body mechanics) • 4. Position client close to side of bed • 5. Neck‑ flexion, extension, rotation, hyperextension • 6. Shoulder‑ flexion, extension, hyperextension, abduction, adduction external rotation, internal rotation, circumduction

45. Suggested order for performing ROM • 7. Elbow‑ flexion, extension • 8. Forearm‑ supination, pronation • 9. Wrist‑ flexion, extension, hyperextension, radial deviation, ulnar deviation • 10. Hands/fingers‑ flexion, extension, hyperextension, abduction, adduction • 11. Thumb‑ flexion, extension, abduction, adduction, opposition

46. Suggested order for performing ROM • 12. Hip‑flexion, -extension, abduction, adduction, external rotation, internal rotation, circumduction, hyperextension • 13. Knee‑ flexion, extension • 14. Ankle‑ dorsiflexion, plantar flexion • 15. Foot‑ inversion, eversion • 16. Toes‑ flexion, extension, abduction, adduction • 17. Documentation • 18. Nursing diagnosis‑ Impaired Mobility