Chapter 45 Musculoskeletal System PDF

LEARNING OUTCOMES Explain the anatomy and function of the musculoskeletal system. Describe the effects of aging on the musculoskeletal system. List subjective data that are collected when caring for a patient with a disorder of the musculoskeletal system. List objective data to collect for a patien...

LEARNING OUTCOMES Explain the anatomy and function of the musculoskeletal system. Describe the effects of aging on the musculoskeletal system. List subjective data that are collected when caring for a patient with a disorder of the musculoskeletal system. List objective data to collect for a patient with a disorder of the musculoskeletal system. List areas included for neurovascular data collection for the musculoskeletal system. Identify diagnostic tests for musculoskeletal problems. Describe the nursing care provided for patients undergoing diagnostic tests of the musculoskeletal system. MUSCULOSKELETAL SYSTEM ANATOMY AND PHYSIOLOGY The skeletal and muscular systems can be considered as one system because together they move the body. The skeleton is the framework of the body to which the voluntary muscles are attached. The framework includes the joints, or articulations, between bones. Contraction of a muscle stabilizes or changes the angle of a joint. Movement would not be possible without the proper functioning of the nervous, cardiovascular, and respiratory systems. Voluntary muscles require nerve impulses to contract, a continuous supply of blood provided by the circulatory system, and oxygen provided by the respiratory system. MUSCULOSKELETAL SYSTEM TISSUES AND THEIR FUNCTIONS The tissues that make up the skeletal system are primarily bone tissue, articular (joint) cartilage (cushions joint and reduces friction), and fibrous connective tissue that forms the ligaments (that connect bone to bone) and other structures within joints. Tissues of the muscular system include skeletal muscle tissue and fibrous connective tissue. Fibrous connective tissue forms tendons that connect muscle to bone and fasciae (the strong membranes enclosing individual muscles). Besides its role in movement, the skeleton has other functions. It protects organs and tissues from mechanical injury. The brain is protected by the skull, and the heart and lungs are protected by the thoracic cage. Flat and irregular bones as well as the ends of long bones contain red bone marrow, the hematopoietic (blood-forming) tissue. These bones also store excess calcium, which may undergo resorption (bone broken down with minerals including calcium released into blood) for blood calcium homeostasis. Calcium in the blood is needed for blood clotting and for the proper functioning of nerves and muscles. Although the primary function of the muscular system is to move or stabilize the skeleton, the voluntary muscles collectively contribute significantly to heat production, which maintains normal body temperature. Another important function of the muscular system is to aid in the return of blood from the legs through muscular compression on the leg veins. Bone Tissue and Bone Growth Bone tissue is composed of bone cells, called osteocytes, within a strong, nonliving matrix made of calcium salts and the protein collagen. In compact bone, the osteocytes and matrix are in precise, densely structured arrangements called osteons. In spongy bone, the arrangement of cells and matrix is irregular and sparse, resembling a sponge. Compact bone forms the diaphyses (shafts) of the long bones, covers the spongy bone of the epiphyses of long bones, and covers the spongy bone that forms the bulk of short, flat, and irregular bones. The periosteum (connective tissue) covers all outer bone surfaces except at the joints, where cartilage covers the end of the bone. The periosteum provides protection, is involved in bone growth and repair (producing osteoblasts) and participates in the blood supply of bone. Osteoblasts produce bone matrix during growth and replace matrix during normal remodeling or in repair of fractures. Other cells called osteoclasts resorb bone matrix when more calcium is needed in the blood or during repair when excess bone must be removed as bone changes shape. The growth of bone from fetal life until final adult height depends on many factors. Proper nutrition (particularly vitamins and minerals) provides the raw material to produce bone matrix, comprising calcium, phosphorus, and protein. Vitamin D is essential for the efficient absorption of calcium and phosphorus in the small intestine. Vitamins A and C are required for the production process of bone matrix. Hormones directly needed for growth include growth hormone (GH) from the anterior pituitary gland, thyroxine from the thyroid gland, and insulin from the pancreas. GH increases mitosis and protein synthesis. Thyroxine stimulates osteoblasts and increases energy production. Insulin is essential for the efficient use of glucose to provide energy. If a child is lacking any of these hormones, growth is slower, and the child may not reach his or her genetic potential for height. Bone is not a fixed tissue, even when growth in height has ceased. Calcium and phosphate are constantly being removed and replaced (remodeled) to maintain normal blood levels of these minerals. Parathyroid hormone, secreted by the parathyroid glands, increases the removal of calcium and phosphate from bones. The hormone calcitonin from the thyroid gland promotes the retention of calcium in bones. Structure of the Skeleton The 206 bones of the adult human skeleton are in two divisions: the axial and appendicular skeletons (Fig. 45.1; axial in white, appendicular in turquoise). The axial bones are flat or irregular bones and contain red bone marrow (hematopoietic tissue). Within the appendicular skeleton, the limbs consist of long bones (except the carpals, tarsals, and patella). All long bones have the same general structure: a central diaphysis, or shaft, with two ends called epiphyses. Skull The skull consists of eight cranial bones and 14 facial bones. It also contains the three auditory bones found in each middle ear cavity. All the joints between the cranial bones and between most of the facial bones are immovable joints called sutures (synarthrosis). Vertebral Column The vertebral column (or spinal column) is made of 33 individual bones called vertebrae (Fig. 45.2). Atlas, the first of seven cervical vertebra, articulates with the occipital bone of the skull and forms a pivot joint with the axis, the second cervical vertebra. The 12 thoracic vertebrae articulate with the posterior ends of the ribs. The five lumbar vertebrae are the largest and strongest. The sacrum, consisting of five fused sacral vertebrae, articulates with the os coxae at the sacroiliac joints. The coccyx, composed of four fused coccygeal vertebrae, serves as an attachment point for some muscles of the perineum. The vertebrae as a unit form a flexible backbone that supports the trunk and head and that contains and protects the spinal cord. Spinal nerves and vessels exit via intervertebral foramina. Intervertebral discs cushion and permit movement of the column. Thoracic Cage The thoracic cage consists of 12 pairs of ribs and the sternum that protect the heart and lungs as well as upper abdominal organs, such as the liver and spleen, from mechanical injury. During breathing, the flexible thoracic cage is pulled upward and outward by the external intercostal muscles to expand the chest cavity and bring about inhalation. Synovial Joints The primary joints of the appendicular skeleton are summarized in Table 45.1. All freely movable joints (diarthroses) are synovial joints (Fig. 45.3). Many synovial joints also have bursae (small sacs of synovial fluid between the joint and structures that cross over the joint). Bursae lessen wear in areas of friction. WORD BUILDING periosteum: peri—surrounding + osteo—bone osteoblast: osteo—bone + blastanō—germinate osteoclast: osteo—bone + klastēs—breaker epiphyses: epi—upon + phyein—to grow synarthrosis: sun—together + arthrosis—jointing FIGURE 45.1 Adult skeleton—anterior and posterior views. Muscle Structure and Arrangements One muscle can consist of thousands of skeletal muscle cells (fibers), which are specialized for contraction. When a muscle contracts, it shortens and exerts force on a bone. Each muscle fiber receives its own motor nerve ending. The number of fibers that contract depends on workload. Muscles are anchored to bones by tendons made of fibrous connective tissue. A muscle usually has at least two tendons, each attached to a different bone. The more stationary muscle attachment is called its origin; the more movable attachment is the insertion. The muscle itself crosses the joint formed by the two bones to which it is attached. When the muscle contracts, it pulls on the insertion, moving the bone in the intended direction. The muscle causing the action is termed the agonist. The body has approximately 700 skeletal muscles (Fig. 45.4). Their general arrangement is the agonist with opposing antagonists and the cooperative synergists. Without synergism, balance and fine motor control for writing or talking would be difficult, if not impossible. ROLE OF THE NERVOUS SYSTEM Skeletal muscles are voluntary: conscious control initiates nerve impulses to cause contraction. Nerve impulses originate in the motor areas of the frontal lobes of the cerebral cortex. The coordination of voluntary movement is a function of the cerebellum. Neurons in the central nervous system (CNS) act involuntarily to regulate muscle tone, the state of slight contraction usually present in muscles. Healthy muscle tone is important for posture and coordination. FIGURE 45.2 Vertebral column. Table 45.1 Joints of the Appendicular Skeleton Type of Joint and Description Examples Symphysis—disk of fibrous cartilage between bones Between vertebrae Between pubic bones Ball and socket—movement in all planes Scapula and humerus (shoulder) Pelvic bone and femur (hip) Hinge—movement in one plane Humerus and ulna (elbow) Femur and tibia (knee) Between phalanges (fingers and toes) Combined hinge and planar Temporal bone and mandible (lower jaw) Pivot—rotation Atlas and axis (neck) Radius and ulna (distal to elbow) Gliding—side-to-side movement Between carpals (wrist) Saddle—movement in several planes Carpometacarpal of thumb Source: Modified from Scanlon, V. C., & Sanders, T. (2019). Essentials of anatomy and physiology (8th ed.). Philadelphia, PA: F.A. Davis. Neuromuscular Junction Each muscle fiber has its own motor neuron ending. The neuromuscular junction is the termination of the motor neuron at the muscle fiber (synapse). The neuron releases the neurotransmitter acetylcholine (ACh), signaling the muscle to contract. Figure 45.5 illustrates the following steps: When an impulse reaches the end of a motor neuron, it causes small vesicles in the axon terminal to release the neurotransmitter (chemical messenger) ACh into the synaptic cleft (narrow space between the motor neuron and muscle fiber). The ACh diffuses across the synaptic cleft, where it stimulates receptors in the sarcolemma (muscle fiber membrane). This sends an electrical impulse over the sarcolemma and inward along the T tubules. The impulse in the T tubules causes the sacs in the sarcoplasmic reticulum to release calcium. The calcium binds with the troponin on the actin filament to expose attachment points. In response, the myosin heads of the thick filaments grab onto the thin filaments and muscle contraction occurs. If a muscle has little work to do, few of its many muscle fibers contract; but if the muscle has more work, more muscle fibers contract. AGING AND THE MUSCULOSKELETAL SYSTEM The amount of calcium in bones depends on several factors. Good nutrition is certainly one, but age is another, especially for women. One function of estrogen (and testosterone in men) is the maintenance of a strong bone matrix. For women, after menopause, bone matrix loses more calcium than is replaced. The loss can be offset by weight-bearing physical exercise, which stimulates bone matrix deposition, increasing bone density. Weight-bearing joints are also subject to damage after many years. Often the articular cartilage wears down and becomes rough, leading to pain and stiffness. Muscle strength declines with age as protein synthesis decreases. Such loss of strength need not be exaggerated because aging muscles also benefit from regular exercise. Furthermore, maintenance of muscle strength reduces falls and accidents. Figure 45.6 presents a concept map that shows the effects the aging process has on the musculoskeletal system. MUSCULOSKELETAL SYSTEM DATA COLLECTION Health History Subjective data collection on the patient begins with a history that includes the condition’s impact on the patient’s life (Table 45.2). The WHAT’S UP? model can be used to collect data about pain (see Chapter 1). FIGURE 45.3 Synovial joints. Deformities resulting from arthritis or other musculoskeletal disorders can affect a patient’s body image and self-concept and may result in social withdrawal (see Chapter 46). Chronic pain may keep the patient from working or socializing. Data collection should include questions related to the psychological effects of the musculoskeletal disorder. Ask about the patient’s support systems. Determine ability to cope by asking what previous coping strategies were used for other life stressors. As needed, consult social work, clergy, or support groups to meet the psychosocial needs of the patient. Physical Examination Objective musculoskeletal data collection includes three important areas: inspection, range of motion (ROM), and muscle tone and palpation (Table 45.3). If the patient can walk, inspect posture and gait, noting poor posture or alterations in movement, such as limping. Note the use of mobility aids, such as a cane or walker. Document other gross deformities, such as unequal limbs, malalignment, or contractures. Spinal deformities are especially significant as they can compromise breathing and balance. Inspect the joints and muscles of the arms, hands, legs, and feet for deformity, redness, and swelling. Listen for crepitation (grating sound as joint or bone moves). Also note the patient’s general nutritional status (e.g., normal, obese, emaciated). Observe ROM and muscle tone as the patient performs activities of daily living. To check ROM in the hands, ask the patient to touch each finger, one by one, to the thumb (known as opposition) and then make a fist. Note the size, shape, strength, and tone of muscles. Evaluate bilateral muscle strength by asking the patient to grip your hands. This enables you to feel the strength and equality. The push of an extremity against your hand generally indicates muscle strength. A physical therapist or an occupational therapist performs a more detailed assessment. Next, gently palpate the skin for warmth and tenderness in the areas of swelling and in areas where the patient reported pain. Reddened joints are palpated for synovitis (swollen synovial tissue within the joint) or the presence of bony nodes. Joints and muscles may seem healthy but can be tender when palpated. Frequent neurovascular checks are needed with the risk of circulation impairment, which may occur if the patient has a fracture or has had musculoskeletal surgery (Table 45.4). WORD BUILDING synovitis: synovia—joint + itis—inflammation FIGURE 45.4 Superficial muscles. FIGURE 45.5 How muscle fibers contract. (See Neuromuscular Junction on page 887 for explanation of numbered steps.) FIGURE 45.6 Aging and the musculoskeletal system. PRACTICE ANALYSIS TIP Linking NCLEX-PN® to Practice The LPN/LVN will perform focused data collection based on client condition (e.g., neurological checks, circulatory checks). CLINICAL JUDGMENT Mrs. O’Donnell, age 80, is brought to the emergency department with a fractured left hip. She is positioned for comfort while you collect data. 1. What health history and subjective data do you collect for Mrs. O’Donnell? 2. What objective data do you collect for Mrs. O’Donnell? Suggested answers are at the end of the chapter. DIAGNOSTIC TESTS FOR THE MUSCULOSKELETAL SYSTEM Diagnosis of musculoskeletal problems is assisted by laboratory tests and diagnostic imaging and procedures (Table 45.5, Table 45.6). Specific tests for connective tissue diseases are described in Chapter 46. Laboratory Tests Alkaline Phosphatase Alkaline phosphatase (ALP) is an enzyme that increases when bone is damaged. In metabolic bone diseases and bone cancer, ALP increases to reflect osteoblast (bone- forming cell) activity. Calcium and Phosphorus Bone disorders commonly cause changes in calcium and phosphorus (or phosphate) levels. In a healthy person, calcium and phosphorus have an inverse relationship. This means that when serum calcium increases, serum phosphorus decreases, and vice versa. Muscle Enzymes When muscle tissue is damaged, many serum enzymes are released into the bloodstream, including skeletal muscle creatine kinase (CK-MM [CK3]), aldolase (ALD), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH). Myoglobin Myoglobin is a protein found in striated (skeletal or cardiac) muscle that causes its red color. When skeletal muscle is damaged, myoglobin levels rise in the blood. RHABDOMYOLYSIS. Rhabdomyolysis is a very serious, potentially fatal condition associated with muscle destruction due to an injury (such as crush syndrome), high fever, convulsions, or prolonged muscle compression. It commonly affects older adults who fall and lie in one position for an extended period as they are alone and cannot get up. If the patient has muscle destruction, watch for elevated creatine kinase (CK) up to five times greater than normal, myoglobin, and serum potassium levels to monitor for rhabdomyolysis. Observe for dark urine, muscle weakness, and myalgia (muscle pain). The goal of treatment is to restore normal fluid and electrolyte balance. Uric Acid Uric acid is a waste product found in the blood normally excreted in the urine. When serum uric acid levels rise, a condition called gout can occur (Chapter 46). Diagnostic Procedures Arthrocentesis Arthrocentesis is a procedure in which synovial fluid is aspirated from a joint for analysis or to relieve pressure (improves pain and mobility). The fluid build-up often occurs secondary to an inflammatory process such as bursitis. Analysis of the synovial fluid can help diagnose crystals, hemarthrosis (blood in the joint cavity), noninflammatory conditions, and septic arthritis. Using aseptic technique, the health-care provider (HCP) administers a local anesthetic. A needle is used to aspirate the contents of the joint space. For analysis, the fluid is sent to the laboratory. If required, the HCP can instill medications such as corticosteroids, anti- inflammatories, or antibiotics. The site is covered with a sterile dressing to prevent infection. Monitor the injection site for increased bruising, bleeding, redness, and warmth. Table 45.2 Subjective Data Collection for the Musculoskeletal System Questions to Ask During the Health History Rationale/Significance Demographic What is your age, gender, socioeconomic status? Increased age, being female, and lower socioeconomic status can increase risk of musculoskeletal injury/problems. What is your occupation? Enables discharge planning if occupation may be affected by condition. Where do you live geographically? Regions where sunlight is limited increases the risk of vitamin D deficiency, leading to increased risk for skeletal injuries. Prior Health History Do you have allergies? Prevents exposure to medication or compounds used in diagnostic tests, treatments, and therapies. What prior medical conditions, surgeries, or problems with anesthesia (e.g., malignant hyperthermia) have you had? Identifies any pre-existing conditions that may influence the musculoskeletal system. What activities do you participate in, and how often? Provides baseline information about the patient’s activity level before the problem. What risk factors for musculoskeletal problems are present (e.g., smoking, sedentary lifestyle, weight gains/losses)? Smoking and a sedentary lifestyle are risk factors for musculoskeletal problems. What is your nutritional intake? Nutritional intake of calcium and vitamin D influences some musculoskeletal disorders. What is your family’s medical history? Some musculoskeletal conditions or anesthesia problems have genetic and familial tendencies. Injury or Present Concern What is the history of the injury or current concern? Provides information that helps in the diagnosis of the problem as well as possible complications of the injury. What is your pain level (use pain assessment scale)? What medications, treatments, and procedures are used to alleviate pain? Pain or related stiffness and tenderness may be acute or chronic and may limit the patient in everyday life. Psychosocial Are deformities, changes in body image, or self-concept present? The patient may need assistance with strategies to cope with the stress of a possible chronic musculoskeletal condition. What coping skills do you use? Whom do you consider your support system? Some musculoskeletal conditions require lifestyle alterations that can cause increased stress and difficulties in coping. CUE RECOGNITION 45.1 You are visiting a home health patient who had an arthrocentesis of his right shoulder 3 days ago. You note red streaks that are warm to the touch down the patient’s affected arm. What action do you take? Suggested answers are at the end of the chapter. WORD BUILDING arthroscopy: arthro—joint + scopy—to examine Table 45.3 Objective Data Collection for the Musculoskeletal System Abnormal Findings Possible Causes Circulation Decreased capillary refill Impaired circulation Diminished or absent pulses Compartment syndrome, fractures, trauma Ecchymosis Fractures, trauma Swelling Arthritis, infection, fractures, trauma Skin color: Lighter pigmentation – Pale; reddened Darker pigmentation – Pale palms or soles; Purplish/Blue, Eggplant color Impaired circulation: inflammation, infection Skin temperature: Cool; warm Impaired circulation: inflammation, infection Neuromuscular Impaired movement Compartment syndrome, trauma Weakness Compartment syndrome, trauma Musculoskeletal Extremities: Asymmetry, contractures, crepitation, deformity, malalignment, unequal limbs Arthritis, fractures, trauma Impaired range of motion Arthritis, dislocation, fractures, trauma Altered gait Arthritis, fractures, osteoporosis, trauma Deformed posture Osteoporosis, spinal deformity Arthroscopy An arthroscope allows the surgeon to directly visualize a joint using a small tube. The knee and shoulder are the joints most often evaluated. Because arthroscopy is an invasive procedure performed under local or light general anesthesia, the patient is treated in a same-day surgery setting. The surgeon makes a small incision to insert the scope and visualize the joints. Other incisions may be needed for other tools. The joint is moved through ROM so tears, defects, or other soft tissue damage can be observed and/or repaired through the scope using special instrumentation. Depending on procedure, a bulky or small dressing with an elastic bandage may be applied. The perianesthesia care nurse monitors the neurovascular status of the surgical limb frequently (see Table 45.4). A mild analgesic usually relieves pain. The patient resumes activities as ordered, usually within 24 to 48 hours. If a surgical repair was performed, the patient may have activity restrictions and require a stronger analgesic. In this case, the surgeon sees the patient in 1 week to check for complications and progress. Although complications are uncommon, explain to the patient to report these signs to the HCP: thrombophlebitis (extremity warmth, redness, swelling, tenderness, pain), infection (fever or warmth, pain, redness, swelling at surgical site), and increased joint pain. Physical or occupational therapy may be ordered (see “Home Health Hints”). CUE RECOGNITION 45.2 You are caring for a resident who had a left knee arthroscopy. You note his left lower leg is warm to the touch. What action do you take? Suggested answers are at the end of the chapter. BE SAFE! AVOID FAILURE TO RECOGNIZE! You can prevent your patient from having a serious postoperative complication by recognizing signs and symptoms of infection early. If you respond when you notice warmth, redness, pain, or swelling, you can prevent further complications. Be vigilant during frequent observations of your patients. Bone or Muscle Biopsy Bone or muscle tissue can be extracted for microscopic examination to confirm cancer, damage (muscle biopsy), infection (bone biopsy), or inflammation. Afterwards, a sterile pressure dressing is applied because bone is highly vascular. The nurse monitors the biopsy site for bleeding, swelling, and hematoma formation. Increased pain that is unresponsive to analgesic medication may indicate bleeding into the soft tissue. Vital signs and neurovascular checks are monitored (see Table 45.4). Table 45.4 Neurovascular Data Collection Monitor Report Neuro Movement Alterations in movement Pain Disproportionate to the injury; unrelieved with narcotics Sensation Alterations in feeling; tingling or paresthesia Vascular Capillary refill Nailbed that does not blanch in 3–5 seconds Pulses Diminished or absent distal pulses Skin color Pallor, cyanosis, redness, or discoloration Swelling Tight, shiny skin Temperature Unusual coolness or warmth Table 45.5 Laboratory Tests for the Musculoskeletal System Test (Serum) Normal Value Significance of Abnormal Findings Alkaline phosphatase (ALP), total Male: 35–142 units/L Female: 25–125 units/L ↑ in Paget disease, metastatic bone cancer, new bone formation Calcium, total 8.4–10.2 mg/dL ↑ in bone cancer, extended immobilization, hypophosphatemia, Paget disease ↓ in hyperphosphatemia, nutritional deficiency, osteomalacia Creatine kinase (CK) Male: 50–204 units/L Female: 36–160 units/L ↑ in cellular destruction of cells that store CK, intramuscular injections CK3 (CK-MM) isoenzyme 96%–100% ↑ in conditions that cause cellular damage Phosphorus 2.5–4.5 mg/dL ↑ in hypocalcemia, bone cancer ↓ in hypercalcemia, gout, vitamin D deficiency Myoglobin Male: 28–72 ng/mL Female: 25–58 ng/mL ↑ in skeletal muscle destruction Uric acid Male: 4–8 mg/dL Female: 2.5–7 mg/dL Over 60 years: Male: 4.2–8.2 mg/dL Female: 3.5–7.3 mg/dL ↑ in gout Table 45.6 Diagnostic Procedures for the Musculoskeletal System Procedure Definition Significance of Abnormal Findings Nursing Management (if applicable) Noninvasive X-rays Visualization of skeletal abnormality or deformity, dense or inflamed tissues, and joints. Guides treatment plan and information for care. Example: Broken ribs demand increased attention to respiratory system. Inform patient of what to expect during ordered procedures. Computed tomography Radiographic “slices” of bone or soft tissue images. Shows bone cancer, damage, fractures, and infections. Before test, nothing by mouth (NPO) for 4 hours. If contrast used: Ask if history of reaction to contrast medium (reaction to iodine-based contrast dye is not the same as a shellfish allergy, as iodine is not an allergen [Long et al, 2019]). Magnetic resonance imaging (MRI) Electromagnets provide a three-dimensional visualization of the area. Shows bone, joint, and soft tissue abnormalities. Screen for contraindications to MRI such as certain metals or implants, claustrophobia, and allergy to contrast medium, if used. Inform patient of the need to lie still and the noise of the machine during the procedure. Ultrasonography Visualizes bone or soft tissue using sound waves. Inform the patient that the jelly-like conducting substance will feel cold when applied. Nerve conduction studies Electromyography (EMG) is the electrical testing of nerves and muscles. Alterations usually indicate a problem with the nerves or the muscles. Explain that there may be some discomfort during nerve and muscle stimulation as well as when needles are inserted (if needed). Invasive arthrography Air or a contrast medium is injected into a synovial joint which is then x-rayed. Aids in the diagnosis of joint abnormalities. Inform patient that the test is uncomfortable during injection. Joint swelling is common after the procedure. Apply ice and elevate limb. Rest extremity for 12–24 hours after procedure. Myelogram Visualizes the spine and spinal cord. May use injection of a contrast medium. Identifies spinal problems. Postprocedure: Monitor for headache and nausea. Maximum head raise is 45 degrees for 3 hours or as ordered. Nuclear medicine scans Radioisotope is injected to help visualize bone and other soft tissue abnormalities. Finding a “hot spot” usually indicates metastases or bone infection. Explain test is not dangerous and may take up to 90 minutes. Gallium/thallium scans A radioactive element is injected that migrates to bone, and inflammatory tissue. Gallium concentrates in areas of tumors, inflammation, and infections. Thallium detects osteosarcoma. Verify if agency recommends that children and pregnant women stay a few feet away from the patient for the first 48 hours. Arthroscopy Provides direct visualization of a joint and its capsule using an instrument inserted into the joint space. Identifies joint abnormalities. Perform neurovascular checks. Apply ice, and keep limb elevated to minimize swelling (if ordered). Arthrocentesis Withdrawal of synovial fluid from a joint space. Used for analysis of synovial fluid or reduction of excess fluid pressure. Arthritis, bleeding, gout, infection, and inflammation. Monitor patient for infection, inflammation, or hemarthrosis. Bone or muscle biopsy Needle aspiration (closed) or surgical extraction (open) of bone or muscle tissue. Bone tumors, infection, lymphoma, and leukemia. Monitor site of biopsy for bleeding. Provide wound care for open biopsy. Perform neurovascular checks as needed. Bone Density Scan A bone density test measures bone strength. There are several types of scans. One that uses a special x-ray process is the dual-energy x-ray absorptiometry (DEXA), which measures the spine, hip, and total body bone density. DEXA is used to diagnose osteoporosis (see Chapter 46). Other types of scans examine the heel, fingers, or wrist. Computed Tomography Computed tomography (CT) scan can help diagnose problems of the joints or vertebral column (Fig. 45.7). FIGURE 45.7 Computed tomography (CT) scan of fifth cervical vertebra showing a burst fracture of the vertebral body (top arrow) and both laminae (bottom arrows). Magnetic Resonance Imaging Magnetic resonance imaging (MRI) diagnoses musculoskeletal problems, especially involving soft tissue. An MRI is more accurate than a CT scan for diagnosing issues affecting the vertebral column (Fig. 45.8). If the patient has had previous spinal surgery, a contrast medium is used. Before the test, determine whether the patient has any cardiac or orthopedic implants and whether they are designated MR safe (no hazard), MR conditional (able to carefully use MRI), or MR unsafe (unacceptable risk). It cannot be assumed that a cardiac implant prevents an MRI from being performed. Studies show that people with non- MRI conditional cardiac devices can safely have MRIs (Gupta et al, 2020). Inform HCP if the patient has a cardiac device or orthopedic implant. See patient teaching guidelines for screening and preparation information for MRI on Davis Advantage. FIGURE 45.8 Magnetic resonance image (MRI) of a normal cervical spine. (A) Cerebellum. (B) Spinal cord. (C) Marrow of C2 vertebral body. (D) C4–C5 intervertebral disk. Myelography Myelography is usually reserved for patients unable to have a CT scan or MRI or for complicated spinal surgery revisions. Inform patients that they may be positioned head down briefly to allow injected contrast medium to flow up to the level of the neck. Nerve Conduction Studies Electromyography (EMG) measures a muscle’s electrical impulses. This study helps diagnosis muscle diseases or nerve damage, which may follow a traumatic injury. Instruct the patient not to apply lotions before the test and to remove all jewelry. Occasionally, slight discomfort and bruising may occur at the site. Warm compresses or mild analgesics can be offered for pain relief. Nuclear Medicine Scans A bone scan allows visualization of the entire skeleton. The patient is injected with a radioisotope that is attracted to bone and travels to bone tissue. Images are taken at intervals to see how the radioisotope has collected in the bone. Gallium and thallium are radioisotope examples. Gallium concentrates in areas of tumors, inflammation, and infections. Thallium identifies bone cancer, especially osteosarcoma. Patients are instructed to remove all jewelry before the test. For an accurate test, the patient must be able to lie still for up to 90 minutes during scanning. Patients who are older, restless, agitated, or in pain may find this test uncomfortable. Sedatives or analgesics may have to be administered before or during the procedure. The HCP looks for “hot spots” on the test results created by increased circulation in abnormal bone areas that concentrates the radioactive substance there. Hot spots indicate bone disease. Radiographs (X-Rays) X-ray examination is used to determine bone alignment, density, erosion, swelling, and soft tissue damage (e.g., ligaments and tendons) because of alterations in bone position and spacing. Arthrogram (or arthrography) is an x-ray examination of a synovial joint, most often the knee or shoulder, after joint trauma. Air or a contrast medium is injected into a synovial joint, which is then x-rayed. Inform the patient that the test is uncomfortable during injection. Joint swelling is common after the procedure. Apply ice, elevate the limb, and inform the patient to rest the joint for 12 to 24 hours after procedure as ordered. Ultrasonography Sound waves are used to detect osteomyelitis (bone infection), soft tissue disorders, traumatic joint injuries, and surgical hardware placement. CRITICAL THINKING & CLINICAL JUDGMENT Mrs. Gardenio, 84 years old, fell when using a step stool in her home as she was getting ready to attend her church’s worship service. She was taken to the hospital, where it was determined that she had a femoral neck fracture of her left hip. Critical Thinking (The Why) 1. What tests may be performed to identify the condition creating her problem? Clinical Judgment (The Do) 2. What data do you obtain from Mrs. Gardenio? 3. Mrs. Gardenio is to receive morphine 4 mg by intramuscular injection now. You have available morphine 5 mg/mL. How many milliliters do you give?  You collect data on Mrs. Gardenio’s left leg 2 hours later. You are not able to palpate a pedal pulse. Her left foot is cool to the touch. 4. What action do you take now? You determine that there is only a very faint weak pulse present. 5. What action do you take based on your data collection? After a successful hip repair, Mrs. Gardenio’s recovery progresses well with the assistance of the health-care team. 6. With what health-care team members do you collaborate during Mrs. Gardenio’s postoperative care? 7. What discharge teaching should you reinforce for home safety for Mrs. Gardenio? Suggested answers are at the end of the chapter. Home Health Hints According to the Social Security Act, to be considered homebound, a Medicare patient must meet the following criteria: Because of illness or injury, the patient needs supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their place of residence. Leaving the home may be contraindicated because of a patient’s medical condition. There must also exist a normal inability to leave home, and leaving home must require a considerable and taxing effort. If the patient is not homebound, services such as physical and occupational therapy can be performed in an outpatient setting. Observe patients performing their activities of daily living to determine functional abilities. Observe the patient’s dress and hygiene. Do not rely on self-report of functional abilities. Older patients may hide their deficits out of fear that they will not be allowed to stay in their homes. If the home health nurse identifies that the patient is at risk for falls or if the patient has had recent falls, request a physical therapy referral. Inform the patient of the benefit in removing loose rugs that could be a trip hazard. Reinforce teaching to caregivers to use sand or cat box litter on icy steps to increase traction, preventing slips and falls. WORD BUILDING arthrogram: arthro—joint + gram—diagram Key Points  The skeletal and muscular systems move the body together. Voluntary muscles are attached to the skeleton, which includes the spaces between bones (joints). Bone tissue, articular cartilage, and fibrous connective tissue that forms the ligaments and other structures within joints make up the skeleton. Muscle comprises skeletal muscle tissue and fibrous connective tissue. The skeleton helps us move and protects organs and tissues from injury. The muscles move the skeleton and keep it stable, help maintain normal body temperature, and allow venous return from the legs through compression. Skeletal muscles are voluntary, or consciously controlled. Nerve impulses originate in the motor areas of the frontal lobes of the cerebral cortex. Coordination of voluntary movement is a function of the cerebellum. For postmenopausal women, the bone matrix loses more calcium than is replaced. Weight-bearing joints are subject to damage after many years. Often the articular cartilage wears down and becomes rough, leading to pain and stiffness. Muscle strength declines with age as protein synthesis decreases. Subjective data collection on the patient begins with a history that includes the condition’s impact on the patient’s life. Three areas of musculoskeletal data collection are important: inspection, range of motion, and muscle tone and palpation. Laboratory tests to diagnose musculoskeletal system problems include alkaline phosphatase, calcium, phosphorus, muscle enzymes, myoglobin, and uric acid. Arthrocentesis is a procedure in which synovial fluid is aspirated from a joint for analysis or pressure relief. The fluid buildup may be caused by an inflammation such as bursitis. An arthroscope allows the surgeon to directly visualize a joint. Bone or muscle tissue can be extracted for microscopic examination to confirm cancer, damage, inflammation, or infection. A bone density scan measures bone strength in the total body or areas such as the spine, hip, heel, fingers, or wrist. CT scan diagnoses joint or vertebral column disorders. MRI diagnoses musculoskeletal disorder, especially those involving soft tissue.  Myelography is reserved for patients who need spine surgery revisions or who cannot have an MRI or CT scan. Electromyography measures a muscle’s electrical impulses to diagnose nerve or muscle damage after trauma. A nuclear bone scan allows visualization of the entire skeleton through injection of a radioisotope that accumulates in the bone. X-ray examination determines bone alignment, density, erosion, swelling, and soft tissue damage (e.g., ligaments and tendons) from alterations in bone position and spacing. Arthrogram (or arthrography) is an x-ray examination of a synovial joint. Air or a contrast medium is injected into a synovial joint, which is then x-rayed. Ultrasounds detect osteomyelitis (bone infection), soft tissue disorders, traumatic joint injuries, and surgical hardware placement.