Musculoskeletal Presentation PDF

Musculoskeletal Created by Sarah Kate Nixon RN MN Slides adapted from: Justin Burkett MN RN CHSE Kara Sealock EdD MEd BN RN CBCC(C) CCNE Leah Tellier MN CCNE CHSE January 21 2025  Topics The Immobilized Client and Aging Disord...

Musculoskeletal Created by Sarah Kate Nixon RN MN Slides adapted from: Justin Burkett MN RN CHSE Kara Sealock EdD MEd BN RN CBCC(C) CCNE Leah Tellier MN CCNE CHSE January 21 2025  Topics The Immobilized Client and Aging Disorders of the joint Metabolic bone disease Neuromuscular disorders Neural tube defects Objectives Topics and Reflect on Anatomy and Physiology of the Objectives musculoskeletal system and look at how it relates to chronic illness Explain pathophysiology of the above conditions Examine relevant nursing assessments, clinical manifestations, and relevant lab values related to various conditions 2  Aging and the Musculoskeletal system and the Immobilized patient  Significance Significance Age related Structure to the to the Nursing Implication change structure person Bones Reduced bone Decreased Assess for osteoporosis risk Loss of bone mass strength and height, posture, factors, educate on prevention and density increased risk of and mobility and treatment, monitor for falls fractures and injuries Joints Loss of joint Increased joint Reduced range Assess for joint disorders, flexibility and stiffness and pain of motion and educate on exercise and pain mobility function management, provide assistive devices and support Muscles Loss of muscle Reduced muscle Decreased Assess for muscle disorders, mass and tone and endurance and educate on nutrition and strength contractility performance physical activity, promote safety and independence  Age Physical health Injuries Nutrition Factors that Mental health affect Environmental factors Mobility Medications Lifestyle Personal values and attitudes 5 Physiological What do we worry will happen to the various complication systems in the body if s there is increased immobility present? 6 Factors that increase the risk of developing MSK Disorders Intrinsic factors: These are factors that are related to the individual’s characteristics, such as: Age: Older adults have weaker bones, muscles, and joints. Gender: Women are more prone to osteoporosis, rheumatoid arthritis, and fibromyalgia. Genetics: Some people have inherited conditions or genes that make them more susceptible to MSK disorders, such as osteogenesis imperfecta, Marfan syndrome. Health status: Some people have chronic diseases or conditions that affect the musculoskeletal system, such as autoimmune disorders, metabolic disorders, neoplastic disorders, or postmenopausal states. Extrinsic factors: These are factors that are related to the environment or the behavior of the individual, such as: Lifestyle: Smoking, alcohol consumption, poor nutrition, physical inactivity, and stress can all negatively affect the health of the musculoskeletal system. Occupation: Some jobs involve heavy lifting, repetitive motion, awkward postures, or vibration, which can increase the risk of MSK disorders, such as low back pain, carpal tunnel syndrome, or tendinitis. Exposure to hazards: Some events or situations can cause damage or injury to the musculoskeletal system, such as falls, infections, trauma, or violence1 7  RNPI 101 Understanding Patho from a CJMM lense: Resource in D2L- start with person and work towards diagnosis 8 Disorders of the Joint: Osteoarthritis Disorder of the Description Example Joint Degeneration of the cartilage within a joint, A patient with osteoarthritis may have difficulty Osteoarthritis causing pain, stiffness, and reduced mobility walking, climbing stairs, or opening jars Inflammation of the joint due to a buildup of uric A patient with gout may have a gout flare in Gout acid crystals, causing sudden and severe pain, the big toe, ankle, or knee swelling, and redness An autoimmune disease that causes chronic A patient with rheumatoid arthritis may have Rheumatoid arthritis inflammation of the joint, leading to joint swollen, tender, and warm joints, especially in damage, deformity, and disability the hands, wrists, and feet A type of arthritis that affects the spine, causing A patient with ankylosing spondylitis may have Ankylosing spondylitis inflammation, stiffness, and fusion of the lower back pain, reduced spinal mobility, and a vertebrae hunched posture Inflammation of the bursa, which are fluid-filled A patient with bursitis may have pain, swelling, Bursitis sacs that cushion the joint, due to overuse, and tenderness near the joint, such as the injury, or infection shoulder, elbow, or hip Osteoarthritis (OA) A type of arthritis that affects the joints, especially in older people. It is caused by the breakdown of the cartilage and bone in the joints, which leads to pain, stiffness, and reduced mobility. Effects Degradation and loss of articular cartilage Sclerosis of bone underneath cartilage Formation of bone spurs (osteophytes) OA Pathophysiology Main steps of OA pathophysiology  1. Breakdown of cartilage due to physical stress, aging, or genetics  2. Release of enzymes and inflammatory factors that damage the cartilage and bone  3. Formation of bone spurs and thickening of the joint capsule  4. Narrowing of the joint space and increased friction between the bones OA Risk Factors Demographic factors: age (> 50), gender (more common in women after age 50), family history of OA Lifestyle factors: obesity (increases stress on joints), smoking (reduces blood flow to joints), occupation (repetitive actions that strain joints), posture (sitting or standing improperly) Medical factors: joint injury (damages cartilage and bone), endocrine disorders (affect bone metabolism), drugs (steroids, indomethacin), rheumatoid arthritis (causes chronic inflammation of joints), congenital or acquired skeletal deformities (alter joint alignment) OA Affected Type Cause Joints Diagnostic Tests Clinical Manifestations Joint pain, stiffness, and reduced Any joint, but mobility that worsen with activity No known cause, but commonly the Clinical assessment based on and improve with rest; crepitus related to aging, Primary knees, hips, symptoms and physical (cracking or grinding sensation) in genetics, obesity, hands, and examination the joint; swelling and tenderness in and joint stress spine the joint; bony enlargement or deformity of the joint X-ray studies of affected joints to Preexisting Usually one or a show joint space narrowing, condition, such as Similar to primary OA, but may also few joints, subchondral sclerosis, subchondral injury, infection, include signs and symptoms of the Secondary depending on cysts, and osteophytes metabolic disorder, underlying condition, such as fever, the underlying Hyaluronic acid measurement in or other type of rash, fatigue, or weight loss cause synovial fluid to indicate the arthritis presence and severity of OA Nursing Assessment Details and Examples - Risk factors, history, and impact of OA and joint pain. Pain characteristics and HISTORY management. - Nerve compression or damage symptoms. Bladder and bowel function NEURO changes. Cognitive and mental status changes. CV - Vital signs and cardiovascular problems. Peripheral circulation and skin color. - Respiratory function and problems. Effects of kyphosis or osteophytes on RESP chest wall and lung expansion. - Nutritional status and intake of anti-inflammatory foods. Gastrointestinal GI problems and effects of kyphosis. GU - Urinary function and problems. Effects of OA medications on the kidneys. - Joint function and mobility. Joint problems and bone mineral density (BMD) MSK test. INT - Skin integrity and problems. Effects of OA medications on the skin. - Laboratory tests to evaluate inflammation and rule out secondary causes. LABS/Diagnostics Laboratory tests to monitor OA medications and adverse reactions. Imaging tests to detect joint damage and assess joint structure and quality. Osteoarthritis Rheumatoid Arthritis Nursing Implications Assess the patient’s history, risk factors, symptoms, and functional ability; monitor the patient’s vital signs, A type of arthritis that occurs when the joint function, mobility, and skin integrity; administer A type of arthritis that occurs when the immune system attacks the lining of the medications, such as NSAIDs, corticosteroids, or cartilage and bone in the joint break down joints, causing chronic inflammation and joint DMARDs; provide pain relief, physical therapy, and due to physical stress, aging, or genetics damage supportive devices; educate the patient about self- management, lifestyle changes, and prevention of complications Identify the affected joints and organs and provide appropriate care and referrals; assess for signs and Affects mainly the small joints of the hands, symptoms of organ involvement, such as dry eyes, Affects any joint, but commonly the knees, wrists, and feet, but can also affect other dyspnea, or chest pain; monitor the patient’s laboratory hips, hands, and spine organs, such as the eyes, lungs, or heart tests, such as ESR, CRP, RF, ANA, and uric acid; evaluate the patient’s response to treatment and adjust accordingly Provide comfort measures, such as heat and cold Causes pain, stiffness, and reduced mobility Causes pain, stiffness, and reduced mobility therapy, massage, and relaxation techniques; assist the that worsen with activity and improve with that are worse in the morning and improve patient with daily activities, such as bathing, dressing, rest; crepitus, swelling, and tenderness in the with activity; swelling, warmth, and redness and feeding; encourage the patient to perform gentle joint; bony enlargement or deformity of the in the joint; symmetrical joint involvement; exercises and range of motion exercises; prevent joint joint joint damage and deformity stiffness and contractures; promote rest and sleep Assist the patient with diagnostic procedures, such as Diagnosed based on symptoms and physical Diagnosed based on symptoms, physical blood tests, X-rays, CT, MRI, or ultrasound; explain the examination; X-ray studies may show joint examination, and laboratory tests; X-ray purpose and results of the tests; prepare the patient for space narrowing, subchondral sclerosis, studies may show joint space narrowing, possible joint surgery, such as total joint replacement subchondral cysts, and osteophytes bone erosion, and joint deformity or synovectomy; provide preoperative and postoperative care Metaboli c Bone Disease Metabolic Bone Disease Description Example Loss of bone mass and density, A patient with osteoporosis may Osteoporosis making the bones thin and have fractures in the spine, hip, porous or wrist A patient with osteomalacia Softening and weakening of the may have bone pain, muscle Osteomalacia bones, due to a lack of vitamin weakness, and bowed legs or D or a defect in its metabolism curved spine Fragility and easy breakage of A patient with osteogenesis the bones, due to a genetic imperfecta may have frequent Osteogenesis imperfecta defect in collagen production or fractures, blue sclera, and quality hearing loss Abnormal and disorganized A patient with Paget’s disease bone structure, due to a chronic may have bone pain, Paget’s disease disorder of the bone remodeling deformities, arthritis, and nerve process compression Osteoporosis Osteoporosis or Porous Bone Metabolic disease characterized by bone demineralization, with loss of calcium and phosphorus salts leading to fragile bones and subsequent risk for fractures. Occurs from imbalance between new bone formation and old bone resorption Occurs most commonly in the wrists, hip, and vertebral column (thoracic and lumbar). Affects 1 in 4 Canadian women and 1 in 8 Canadian men over 50 Fractures from osteoporosis are more common than heart attack, stroke, and breast cancer combined. Osteoporosis: Pathophysiology A metabolic bone disease that causes bone loss and increased fracture risk. Affects both the quantity and the quality of bone tissue. Both the cortical and the trabecular bone. Influenced by various hormones that regulate the Hormones most associated bone metabolism. with osteoporosis are: Growth hormone Thyroid hormone Parathyroid hormone Cortisol Osteoporosis: Primary or Secondary Primary osteoporosis: Most common type of osteoporosis, affecting mainly postmenopausal women and older men Caused by natural aging, hormonal changes, and genetic factors Leads to bone loss and increased fracture risk, especially in the spine, hip, and wrist Can be prevented and treated by lifestyle modifications, supplements, and medications Secondary osteoporosis: Less common type of osteoporosis, affecting people of any age, sex, or hormonal status Caused by another medical condition or medication that affects bone metabolism Leads to bone loss and increased fracture risk, which may be reversible if the underlying cause is identified and treated Can be prevented and treated by addressing the cause, monitoring the Image Source: Creative Commons bone health, and using appropriate interventions  OPG/RANKL/RANK Pathway RANK (Receptor Activator of Nuclear Factor-κB): A receptor located on the surface of osteoclast precursors and mature osteoclasts (bone- Pathophysiology resorbing cells). When activated, it triggers signals that stimulate osteoclast differentiation, activity, and survival, promoting bone resorption. More RANKL → RANKL (RANK Ligand): Bone Resorption. A protein expressed on the surface of osteoblasts (bone-forming cells) and osteocytes. More OPG → Function: Binds to RANK on osteoclast precursors, Bone Formation. activating them to mature into active osteoclasts and resorb bone. OPG (Osteoprotegerin): A "decoy receptor" secreted by osteoblasts. Function: Binds to RANKL and prevents it from interacting with RANK, thereby inhibiting osteoclast activation and reducing bone resorption.  Glucocorticoids (e.g., prednisone) notorious for: Increasing osteoclast survival, Exacerbating Decreasing Factors - osteoblast formation, Chotiyarnwong & McCloskey (2020) Glucocorticoi Enhancing ds Secondary Osteoporosis osteocyte apoptosis, Increasing RANKL expression and Reducing OPG production. Osteoporosis: Clinical Manifestations Classic dowager’s hump or kyphosis of the dorsal spine Loss of height, often 2-3 inches Back pain, often radiating around the trunk Pathologic fractures: often occurring in the distal end of the radius and the upper third of the femur Compression fracture of spine: assess ability to void and defecate Fatal complications include fat or pulmonary embolism, pneumonia, hemorrhage, and shock. Nursing Assessment Details and Examples - Risk factors, history, and impact of osteoporosis and fractures. Pain HISTORY characteristics and management - Spinal cord or nerve compression symptoms. Bladder and bowel function NEURO changes. Cognitive and mental status changes CV - Vital signs and cardiovascular problems. Peripheral circulation and skin color - Respiratory function and problems. Effects of kyphosis on chest wall and lung RESP expansion - Nutritional status and intake of calcium and vitamin D. Gastrointestinal GI problems and effects of kyphosis - Urinary function and problems. Effects of osteoporosis medications on the GU kidneys - Bone density and fracture risk tools. Bone mineral density (BMD) test. MSK Musculoskeletal function and problems INT - Skin integrity and problems. Effects of osteoporosis medications on the skin - Laboratory tests to evaluate bone metabolism and rule out secondary causes. LABS/Diagnostics Laboratory tests to monitor osteoporosis medications and adverse reactions. Imaging tests to detect fractures and assess bone structure and quality Neuromuscular Disorders  Clinical Diagnostic Condition Definition Causes Nursing Interventions Manifestations Tests Most cases are A sideways curvature of idiopathic, while Bracing for mild curves; the spine that can some are caused by Uneven shoulders, hips, or Physical surgery for severe curves; affect people of all congenital waist; back pain; difficulty examination; X- wheelchair modifications; Scoliosis ages, but is most deformities, breathing; changes in rays; MRI; CT scan; physical therapy; pain common in children infections, or posture bone scan management; education aged 10 to 15 years neuromuscular and support conditions. Family history; physical No cure; supportive care; Difficulty walking, running, examination; medication; physical A group of inherited Genetic mutations or jumping; falls; enlarged muscle biopsy; therapy; occupational disorders that cause that affect the Muscular calf muscles; learning blood tests; therapy; speech therapy; progressive muscle production of muscle dystrophy challenges; muscle pain genetic tests; respiratory therapy; weakness and loss of proteins, such as and stiffness; cardiac and electromyography; nutritional therapy; muscle mass dystrophin respiratory problems echocardiogram; assistive devices; pulmonary function education and support tests Muscle stiffness or No cure; supportive care; A group of disorders Developmental Brain injury; lack of spasticity; involuntary medication; surgery; that affect movement, screening; physical oxygen; infections; movements; poor physical therapy; balance, and posture, examination; Cerebral bleeding; genetic coordination; difficulty occupational therapy; caused by damage to neurological palsy disorders; premature walking; speech problems; speech therapy; orthotic the developing brain examination; birth; low birth intellectual disability; devices; adaptive before, during, or after cranial ultrasound; weight seizures; vision, hearing, equipment; education and birth MRI; CT scan; EEG or swallowing problems support  - Structural versus nonstructural - Idiopathic, congenital, Scoliosis or tetralogical - Think about systemic concerns 32  Muscular Dystrophy Muscular Dystrophy Are a group of genetic disorders that cause progressive muscle weakness and wasting. Can affect various muscles of the body, depending on the type and the gene mutation involved. It can also affect other organs, such as the heart, lungs, or eyes. Can have different onset, severity, and progression, depending on the type and the gene mutation involved. It can affect both males and females, but some types are more common or severe in males.  Aspect Description Duchenn A rare genetic disorder that causes progressive Definition muscle weakness and wasting due to a lack of dystrophin, a protein that keeps the muscles intact e Causes A gene defect on the X chromosome that affects the production of dystrophin muscular Progressive muscle weakness and atrophy that begins in the legs and pelvis and spreads to the arms, neck, and other areas of the body; difficulty dystroph Clinical walking, running, jumping, and climbing stairs; Manifestations frequent falls and waddling gait; enlarged calf muscles; learning disabilities and developmental delays; cardiac and respiratory problems; muscle y Diagnostic Tests pain and stiffness; scoliosis Family history; physical examination; blood tests; genetic tests; muscle biopsy; various imaging and electrophysiological studies No cure; supportive care; medication; surgery; physical therapy; occupational therapy; speech Nursing therapy; respiratory therapy; nutritional therapy; Interventions assistive devices; education and support; collaboration with other health care professionals; advocacy for the patients and their families Nursing Assessment Description Ask the patient about their family history of muscular dystrophy, onset and progression of symptoms, HISTORY current medications, functional abilities, and quality of life Assess the patient’s level of consciousness, cognitive function, speech, vision, hearing, and cranial nerve NEURO function Monitor the patient’s blood pressure, heart rate, rhythm, and sounds. Assess for signs of cardiac CV involvement, such as chest pain, palpitations, dyspnea, edema, and cyanosis Monitor the patient’s respiratory rate, depth, pattern, and sounds. Assess for signs of respiratory RESP impairment, such as dyspnea, orthopnea, cough, sputum, wheezes, and crackles Assess the patient’s appetite, weight, bowel habits, and abdominal distension. Monitor the patient’s fluid GI and electrolyte balance, and nutritional status Assess the patient’s urinary frequency, urgency, output, and color. Monitor the patient’s fluid intake and GU hydration status Assess the patient’s muscle strength, tone, size, and symmetry. Observe the patient’s posture, gait, balance, MSK and coordination. Palpate the patient’s muscles for tenderness, spasm, or contracture. Assess for signs of musculoskeletal complications, such as scoliosis, joint deformities, and pressure injuries Assess the patient’s skin integrity, color, temperature, and turgor. Inspect the patient’s skin for lesions, INT rashes, bruises, or wounds. Palpate the patient’s skin for moisture, texture, and sensation Obtain the patient’s blood samples for creatine kinase, aldolase, lactate dehydrogenase, and genetic testing. Perform a muscle biopsy to confirm the diagnosis and type of muscular dystrophy. Perform various LABS/Diagnostics imaging and electrophysiological studies, such as X-rays, MRI, CT scan, electromyography, nerve conduction studies, echocardiogram, and pulmonary function tests Aspect Description A group of disorders that affect movement, muscle tone, balance, and posture, caused by Definition damage to the developing brain before, during, or after birth Brain injury; lack of oxygen; infections; bleeding; Cerebral Causes genetic disorders; premature birth; low birth weight Muscle stiffness or spasticity; involuntary Palsy Clinical movements; poor coordination; difficulty walking; Manifestations speech problems; intellectual disability; seizures; vision, hearing, or swallowing problems Developmental screening; physical examination; Diagnostic Tests neurological examination; cranial ultrasound; MRI; CT scan; EEG No cure; supportive care; medication; surgery; physical therapy; occupational therapy; speech Nursing therapy; orthotic devices; adaptive equipment; Interventions education and support; collaboration with other health care professionals; advocacy for the patients and their families  Prevalence in Possible Type Diagnostic Criteria Nursing Knowledge Alberta/Canada Motor Signs Stiff and jerky Increased muscle tone and Most common type of CP; Provide physical therapy, orthotic movements; exaggerated reflexes; affects accounts for 70-80% of devices, and medication to reduce difficulty walking, one or more limbs or one side cases2; prevalence of 2.57 spasticity and prevent contractures; Spastic speaking, and of the body; classified as per 1000 live births in monitor for associated conditions such swallowing; hemiplegia, diplegia, or Alberta and 2.30 per 1000 as intellectual disability, seizures, and abnormal posture quadriplegia children in Quebec vision problems and reflexes Involuntary and uncontrolled Provide speech and language therapy, Slow and writhing Less common type of CP; movements of the limbs, face, feeding assistance, and medication to movements; facial Dyskineti accounts for 10-20% of and tongue; affects the whole control movements and drooling; grimacing; tongue c cases; no specific prevalence body; classified as athetoid, monitor for hearing problems and thrusting; difficulty data for Alberta/Canada dystonic, or choreoathetoid dental issues sitting and walking Unsteady and wide- Impaired balance and Rare type of CP; accounts for Provide occupational therapy, adaptive based gait; difficulty coordination; affects the 5-10% of cases; no specific equipment, and medication to improve Ataxic with fine motor skills whole body; classified as prevalence data for coordination and stability; monitor for and depth hypotonic or hypertonic Alberta/Canada speech and visual impairments perception Provide individualized and holistic care Varies depending on Variable type of CP; accounts Combination of two or more based on the specific mix of symptoms the mix of types; for 10% of cases; no specific Mixed types of CP; usually spastic and impairments; collaborate with may include any of prevalence data for and dyskinetic other health care professionals and the signs mentioned Alberta/Canada caregivers above  The most commonly identified early features of CP are early hand preference (before 18 months), delayed or absent achievement of motor development, and persistent primitive reflexes (Garfinkle et al., 2020). Six attributes that should prompt referral for diagnosis of CP include (Boychuk et al., 2020): Early Early handedness in a child under 12 months diagnosis of Stiffness or tightness in the legs between 6 and 12 months Cerebral Persistent fisting of the hands in a child over 4 months Palsy Persistent head-lag in a child over 4 months Inability to sit without support in a child over 9 months Any asymmetry in posture or movement Kennan-Lindsay et al. (2022) p. 1482 42 Cerebral Palsy Developmental Delays Motor delays: These are delays in the development of gross and fine motor skills, such as sitting, rolling, walking, climbing, grasping, and feeding. Motor delays are often the first sign of CP and can affect the child’s mobility, independence, and daily activities. Cognitive delays: These are delays in the development of thinking and reasoning skills, such as smiling, responding, following, imitating, and solving. Cognitive delays can affect the child’s learning, memory, attention, and problem-solving abilities. Language delays: These are delays in the development of communication skills, such as babbling, talking, listening, and understanding. Language delays can affect the child’s speech, vocabulary, grammar, and comprehension. Social-emotional delays: These are delays in the development of emotional and social skills, such as making eye contact, showing affection, playing, sharing, expressing, and empathizing. Social-emotional delays can affect the child’s relationships, emotions, and behavior. Neural Tube Defects Spina Bifida Spina Bifida 45 Type Pathophysiology Impact to Person Nursing A small gap in one or more Monitor development and vertebrae, but no damage to the May not cause any symptoms or problems; symptoms; provide spinal cord or nerves; the mildest in rare cases, may cause back pain, Spina bifida occulta education and support; and most common form of spina weakness, numbness, bladder or bowel refer to other health care bifida; prevalence of 2.57 per dysfunction, or tethered cord syndrome professionals if needed 1000 live births in Alberta A fluid-filled sac that protrudes May cause minor disabilities, such as through the opening in the spine, Perform surgery to repair mobility, balance, and coordination but the spinal cord and nerves are the sac; prevent infection; Spina bifida meningocele problems; may also cause bladder or not affected; a rare form of spina improve movement; bowel dysfunction, or hydrocephalus bifida; no specific prevalence data manage bladder function (excess fluid in the brain) for Alberta/Canada Perform surgery to close the sac; prevent infection May cause nerve damage and disability, and seizures; drain excess A sac that contains part of the affecting sensation, movement, and fluid from the brain; spinal cord and nerves; the most function of the lower limbs, bladder, and improve movement and Spina bifida severe and common form of spina bowel; may also cause hydrocephalus, daily living skills; improve myelomeningocele bifida; prevalence of 1.9 per 1000 chiari malformation (brain tissue communication; support live births in Alberta extending into the spinal canal), scoliosis the limbs; assist with (curved spine), and learning difficulties mobility; educate and support the patient and family Spina Bifida: Considerations in Pregnancy and Newborn Assessment Diagnostic tests Maternal serum screening Newborn assessment Nursing Assessment Details and Examples Ask about prenatal history, maternal serum screening, ultrasound, and amniocentesis results Ask about family HISTORY history, genetic counseling, and risk factors for spina bifida Ask about the patient’s symptoms, medications, allergies, and previous surgeries Assess for visible defect on the back, such as a sac or opening in the spine Assess for sensory deficits, such as NEURO numbness or loss of sensation in the lower extremities Assess for muscle strength, tone, and reflexes in the lower extremities Assess for heart rate, blood pressure, and peripheral pulses Monitor for signs of shock, hemorrhage, or infection CV Administer fluids, blood products, or vasopressors as prescribed Assess for respiratory rate, breath sounds, and oxygen saturation Monitor for signs of respiratory distress, RESP aspiration, or pneumonia Administer oxygen, suction, or ventilation as prescribed Assess for abdominal distension, bowel sounds, and stool pattern Monitor for signs of bowel obstruction, GI constipation, or diarrhea Administer laxatives, enemas, or stool softeners as prescribed Assess for bladder distension, urinary output, and urine characteristics Monitor for signs of urinary retention, GU incontinence, or infection Perform catheterization, irrigation, or bladder training as prescribed Assess for range of motion, posture, and alignment of the spine Monitor for signs of scoliosis, contractures, or MSK fractures Provide physical therapy, orthotic devices, or adaptive equipment as prescribed Assess for skin integrity, temperature, and moisture Monitor for signs of pressure ulcers, wounds, or infections INT Provide skin care, dressing changes, or wound care as prescribed Obtain blood samples for CBC, electrolytes, glucose, and coagulation studies Obtain urine samples for urinalysis, LABS/Diagnostics culture, and sensitivity Obtain imaging studies, such as MRI or X-ray, to determine the type and severity of spina bifida