Adult health Musculoskeletal Disorders

Musculoskeletal Disorders Review

• Musculoskeletal system provides structural framework, protects internal organs, allows movement, stores minerals (calcium, phosphorus, magnesium), and produces blood cells.

Assessment-Subjective

• Assessment of joints, muscles, and bones.
• Evaluation of functional assessment and self-care behaviors.
• Reporting of numbness.

Assessment-Objective

• Assessment of body alignment and symmetry.
• Evaluation of edema, pulses, and skin color.
• Evaluation of ability to perform activities of daily living (ADLs).
• Assessment of range of motion (ROM).
• Assessment of muscle strength (5 P's).

Diagnostic Tests

• ESR:
  • Men: 0-15 mm/hr
  • Women: 0-20 mm/hr
• CBC:
  • RBC
  • WBC
  • HCT
  • Hgb
  • Platelets
• RF: 40-60 units/mL (normal). High levels indicate autoimmune diseases (e.g., rheumatoid arthritis).
• Calcium: 9-10.5 mg/dL
• Phosphorus: 2.5-4.5 mg/dL
• ANA
• Uric Acid:
  • Males: 2.1-8.5 mg/dL
  • Females: 2.0-6.6 mg/dL
• X-rays
• Arthroscopy
• Arthrocentesis
• Arthrogram
• MRI
• CT
• EMG
• Bone Scan
• DXA Scan
• Myelogram

Patient Positioning

• Positioning necessary to prevent complications related to limited mobility.
• Active and passive range of motion (AROM/PROM) exercises.
• Isometric exercises (muscle tightening/relaxation without movement).
• Turning regularly.

Neurovascular Integrity

• Assessment of sensation, color, pain, pulses, and capillary refill is crucial to detect any impairment in blood flow to a limb.
• Assess every 30 minutes after surgery or cast application.
• Include assessment of signs of arterial or venous impairment (edema, coolness, pallor/cyanosis,pain/numbness/tingling).
• Assess trauma, tight bandages, splints, or casts.

Pain Assessment

• Fractures cause acute, deep pain.
• Fractured hip pain often is severe due to muscle spasms.
• Pain recurrence after reduction indicates a potential underlying issue.
• Spinal column disorders can yield chronic pain that may alternate with sharp pain and extend to both extremities.

Rheumatoid Arthritis

• The most serious form of autoimmune disorder affecting joints and synovial membranes.
• Most prevalent ages 30-60.
• More common in women than men.
• Can begin with acute or insidious(gradual) onset.
• Affected mostly fingers, hands, feet, and wrists.
• Can experience remissions and exacerbations.

Rheumatoid Arthritis (Assessment)

• Symptoms include unexplained weight loss, muscle aches, fever, malaise, and swollen/tender joints.
• Another key symptom is morning stiffness that lingers.
• Deformities of the affected joints may manifest in later stages.

Rheumatoid Arthritis (Diagnostic Tests)

• Elevated RF titer and ESR
• Anti-CCP antibody tests.
• Anti-nuclear antibody tests.
• C-reactive protein tests.
• RBC count
• Synovial fluid aspiration and biopsy.
• X-rays to detect joint damage.

RA Treatment

• Anti-inflammatory medications, Disease Modifying Anti-Rheumatic Drugs (DMARDs).
• Pain relief using these drugs.
• Reduce symptoms and slow the progression of joint damage.
• Promote daily living activities and exercise to support health.

Nursing Interventions (RA)

• Positioning interventions (straight extension without under-knee pillows, trochanter rolls, head pillows)
• Proper drug administration (with food to decrease stomach upset, monitor for side effects)
• Functional needs assessment and assistance, planned activity with rest periods.
• Exercise to prevent joint stiffness and muscle weakness.
• Encourage patients to do as much as they comfortably can.

Ankylosing Spondylitis

• Chronic, progressive rheumatic disorder, primarily affecting the spine.
• Often part of the broader rheumatic disease category.
• Sacroiliac and hip joints may be affected if the disease progresses beyond the spine.

Ankylosing Spondylitis (Clinical Manifestations)

• Spine fusing and becoming immobile.
• Kyphosis (humped posture) might develop.
• Difficulty expanding rib cage may arise.
• Issues with the digestive system (IBS) might manifest.
• Potential eye problems (blindness).
• Heart abnormalities and pericarditis (inflammation of the sac around the heart).

Ankylosing Spondylitis (Diagnostic Tests)

• Decreased hemoglobin and hematocrit (H&H) levels.
• Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels.
• Elevated serum alkaline phosphatase levels.
• Elevated levels of HLA-B27.
• X-rays to show inflammation, bone erosion, and joint space fusion of spine and sacroiliac joints

Ankylosing Spondylitis (Treatment)

• Oral analgesics and NSAIDs.
• Corticosteroids.
• TNF inhibitors.
• Exercises.
• Surgery (for severe cases).

Nursing Interventions (Ankylosing Spondylitis)

• Maintaining a posture that supports spinal alignment and promoting spinal mobility.
• Encouraging and monitoring activity levels to promote physical fitness and strength.
• Educating patients about their condition, treatment, and potential complications.

Osteoarthritis

• Degenerative joint disease.
• Non-inflammatory disorder; most common type of arthritis.
• Often a result of aging or factors like joint injury or overuse.
• Commonly affects hands, cervical/lumbar vertebrae, hips, and knees.

Osteoarthritis (Assessment)

• Symptoms include pain with movement and stiffness, especially in the morning.
• Characterized by Heberden's nodes (on distal interphalangeal joints) and Bouchard’s nodes (on proximal interphalangeal joints).

Osteoarthritis (Treatment)

• Weight reduction and exercise programs.
• Analgesics (painkillers).
• Intra-articular injection with hydrocortisone.
• Treatments to relieve symptoms and enhance joint motion.

Surgical Intervention (OA)

• Arthrodesis (fusion of the joint).
• Arthroplasty (increasing joint mobility through surgery).
• Arthroscopy (visual examination).
• Total hip replacement (THR) or hip hemiarthroplasty (replacement of a part of the hip joint).
• Complications can include bleeding, infections and poor circulation to the affected limb.
• Osteotomy (surgical reshaping of bone).

Gouty Arthritis

• Inflammatory arthritis caused by excess uric acid in blood.
• Primary/Hereditary or secondary (due to medications or other conditions).
• Idiopathic means unknown cause.

Gouty Arthritis (Assessment)

• Excruciating pain, swelling and redness in affected joints, especially the big toe.
• Heat, discoloration.
• Uric acid deposits (tophi) in joints/kidneys.

Gouty Arthritis (Treatment)

• Colchicine or Indocin for acute attacks.
• Zyloprim and Febuoxstat for maintenance or chronic gout.
• Anti-inflammatory medicines and rest.
• Reduce intake purine-rich foods.
• Ensure enough fluids.

Osteoporosis

• Bone density loss.
• Primarily affects women between ages 55-65; likely related to estrogen loss.
• Factors include lifestyle, genetics, and certain conditions/medications.

Osteoporosis (Signs & Symptoms)

• First signs may be a bone fracture, a stooped posture/loss of height, and back pain.
• Low back pain usually worsens during and immediately after activity.

Osteoporosis (Diagnosis)

• Complete blood count (CBC).
• Calcium and phosphorus levels.
• Blood urea nitrogen (BUN) and creatinine testing for kidney function.
• 24-hour urine collection tests.
• Thyroid function testing.
• Bone density tests (DXA scans).

Osteoporosis (Medical Management)

• Daily calcium intake of 1200mg.
• 800 IU of Vitamin D.
• Weight-bearing exercises.
• Medications to inhibit bone breakdown (i.e., bisphosphonates such as alendronate/Fosamax or risedronate/Actonel).
• Selective estrogen receptor modulators (SERMs).
• Parathyroid hormone (PTH) treatment.

Osteoporosis (Nursing Interventions)

• Fall prevention strategies
• Use of assistive devices (i.e., canes, walkers)
• Diet and exercise encouragement
• Calcium and vitamin D supplementation.

Osteomyelitis

• Bone inflammation usually caused by pathogenic bacteria, sometimes following injury/trauma.

Osteomyelitis (Assessment)

• Signs of infection include severe pain, swelling warmth, and redness.
• Increased body temperature, tachycardia.

Fibromyalgia

• Chronic syndrome with unknown cause.
• Pain in muscles, bones, and joints with pronounced tenderness.

Fibromyalgia (Assessment)

• Poor sleep, headaches, confusion, depression, muscle aches, and other cognitive changes.
• Typically affects women between ages 20-50.

Fibromyalgia (Treatment)

• No cure, but treatment aims to relieve symptoms
• Tricyclic antidepressants.
• Anticonvulsants.
• Pain relievers (analgesics).
• Non-impact exercise.
• Regular sleep patterns.

Knee Replacement (Partial/Total)

• Assess the surgical site.
• Aseptic dressing changes.
• Pain and comfort measures (analgesics).
• Monitor for complications.
• Box 44.4

Hip Fractures (Signs and Symptoms)

• Pain localized at the fracture site.
• Shortening of the affected limb.
• External rotation of the affected leg.
• Inability to move the affected leg.

Hip Fractures (Complications)

• Pulmonary complications (pneumonia, atelectasis).
• Deep vein thrombosis (DVT) or pulmonary embolism.
• Skin breakdown (decubitus ulcers).
• Urinary retention.
• Constipation.
• Depression.

Hip Fractures (Treatment)

• Temporary immobilization using traction (e.g., Buck's traction).
• Internal fixation (e.g., surgical nailing or pinning).
• Total hip replacement.
• Follow-up treatment plan.

Nursing Interventions (Hip Fracture)

• Neurovascular assessment regularly.
• Monitor for pain.
• Assess surgical wounds or site of fracture.
• Maintain proper body alignment and positioning.
• Monitor for complications, including constipation.

Complications of Fractures (Fat Embolism)

• Fat globules from bone marrow/fat tissues enter bloodstream.
• Occurs within 48 hours following injury.

Complications of Fractures (Compartment Syndrome)

• Edema/pressure increase to nerves and blood vessels inside a closed space.
• Can cause irreversible damage to nerves/tissues.

Complications of Fractures (Shock)

• Blood loss causing severe hypotension, tachycardia, and shock.
• Assess and treat the related symptoms.

Complications of Fractures (Gas Gangrene)

• Clostridium bacteria infection in skeletal muscle causing severe tissue damage, pain, and gas under skin.

Complications of Fractures (Thromboembolism)

• Clot forms and travels to a vessel.
• Causes vessel obstruction.
• Occurs in lungs or other areas of the body causing pain, shortness of breath, and possible danger.

Cast Care

• Handling of casts, especially wet ones, should be done carefully.
• Provide care to prevent further injury.

Hip Spica/Body Casts

• Cautious handling/lifting to avoid causing further injury to the patient.
• Smaller/more frequent meals.
• Breathing exercises prevent atelectasis (lung collapse).
• Monitor for cast syndrome (NV, abdominal pain, obstruction).

Cast Removal

• Tools and care needed for cast removal.
• Promoting healing after injury.

Traction

• Pulling force with weights or similar mechanisms.

Traction (Types)

• Skin traction (skin attached to a material to apply pulling force).
• Skeletal traction (inserting pins in bone to apply pulling force),overhead, and other types.

Nursing Care (Traction)

• Maintain proper alignment.
• Secure and safe positioning.
• Promote general well-being.
• Monitor/prevent complications.

Other Orthopedic Devices

• Splints (support/immobilize).
• Walking casts (enhanced mobility).
• Air casts (inflatable supports).
• Neck collars (support neck).
• Milwaukee brace (encompassing thoracic cavity and for spinal deformity correction).

Traumatic Injuries (Contusions, Sprains, Strains)

• Contusions (bruises), involve soft tissue trauma.
• Sprains (ligaments/tendons) require rest, elevation, ice.
• Strains (muscle tissue) may require rest, elevation, and potentially bracing/casting
• RICE (rest, ice, compression, elevation).
• Care needed for recovery from these injuries.

Whiplash

• Common neck injury involving severe flexion and extension movements.
• Symptoms may not be immediate but can appear days later.
• Treatment includes pain relief measures.

Traumatic Injuries (Dislocations)

• Dislocations imply bone displacement from their normal joint alignment.
• Resulting pain can be severe.
• Need to be manipulated/realigned.

Carpal Tunnel Syndrome

• Painful condition in the wrist associated with repetitive movement activities and other factors.
• Symptoms include numbness, tingling, and pain.
• Treatment usually involves rest, pain management, and splinting.

Bone Tumors

• Can be primary (originating in bone) or secondary (metastasizing from another site).
• Benign tumors can put pressure on nerves/tissues but usually do not spread.

Bone Tumors (Treatment)

• Malignant tumors need wide excision, curettage, or amputation.
• Radiation/chemotherapy also used to treat malignant tumors.

Nursing Interventions (Post-op Bone Tumor Surgery)

• Monitoring neurovascular status (5 P's).
• Managing pain.
• Providing cast/dressing care.
• Assisting with physical therapy and occupational therapy.
• Educating patients about tumor recurrence.

Amputations

• Pre-operative interventions involve assessing the patient for any conditions needing addressing.
• Post-operative care can include promoting healing, positioning, and monitoring for pain and complications.

Amputations (Complications)

• Phantom limb pain is a common complication of amputation, and can require treatment.