Musculoskeletal System Disorders PDF

MUSCULOSKELETAL SYSTEM DISORDERS Prepared By: Sangeeta James College of Nursing,Jazan PHYSIOLOGIC OVERVIEW • The musculoskeletal system is composed of bones,joints,muscle,tendons and liaments. FUNCTIONS• It provide protection for vital organs including the brain,heart and lungs. • It support and...

MUSCULOSKELETAL SYSTEM DISORDERS Prepared By: Sangeeta James College of Nursing,Jazan PHYSIOLOGIC OVERVIEW • The musculoskeletal system is composed of bones,joints,muscle,tendons and liaments. FUNCTIONS• It provide protection for vital organs including the brain,heart and lungs. • It support and protect body and foster movement of extremities. • Serves as a framework to support body structures. Physiology • Joints allow the body to move. • They also move to produce heat that helps maintain body temperature. • Helps in movement which facilitate the return of deoxygenated blood to the right side of the heart . • It serves as a reservoir for immature blood cells and essential minerals including calcium,phosphorus,magnesium and fluoride.More than 98% of total body calcium ASSESSMENT The nursing assessment of the patient with musculoskeletal dysfunction includes1.Health history 2.Physical examination 1.Health HistoryPast health,Social and Family history: a.The nurse should gather pertinent data to include in the patient’s health history,such as occupation,exercise patterns,alcohol consumption,tobacco use and dietary intake ( b.Concurrent health condition eg.diabetes ,heart diseas,chronic obstructive pulmonary disease,infection and disability. c.Related problems ( eg.Familial or enetic abnormalities) d.Any previous history of trauma or injury to musculoskeletal system or history of fall. 2.Physical assessment1.COMMON SYMPTOMSThe nurse ie responsible to assess and document ASSESSMENT Cont’d 1.Pain-Described as a dull,deep ache that is boring in nature. a.The pain is typically related to movement and may interfere with sleep. b.Rest relives pain or not.Pain that increases with activity may indicate joint sprain,muscle strain or compartment syndrome. c.Steady increaseing pain points indicates the 2.Altered SensationCont’d Sensory ASSESSMENT disturbances are frequently associated with musculoskeletal problems.This may describe paresthesias.Which are sensations of burning,tingling and numbness.These sensations my be caused by pressure on nerves or by circulatory impairment. 3.Muscle strength & sizeMuscular system is assessed by noting muscular strength and coordination,the size of the individual muscle and the patient ability to change position,weakness of a group of muscles. CLONUS-Rhythmic contraction of muscle. ASSESSMENT Cont’d 4.SkinThe nurse inspects the skin for edema, temperature and color ,palpation of the skin may reveal whether these area are warmer (inflammation) or cooler (decreased perfusion),cuts ,bruises, are present on skin or not. 5.PostureThe normal curvature of the spine is convex through the thoracic portion and concave through the cervical and lumber portion.Common Deformities of spine 1.KyphosisWhich is an increased forward curvature of the thoracic spine that causes bowing or rounding of the back. 2.LordosisSway back an exaggerated curvature of lumber spine. 3.Scoliosis-Lateral curving deviation of spine. 6.GaitGait is assessed by having the patient walk away from examiner for a short distance. 7.Bone IntegrityBony skeletan is assessed for deformities and alignment,symmetry,abnormal body growth due to bone tumors.Fracture findings,cripitus ( crackling sound) 8.Joint Function-Note range of motion , deformity,stability,tenderness and nodular formation. GAIT DISORDERS Diagnostic Evaluation • Musculoskeletal system diagnostic evaluations includes1.X-Ray studiesBone x-rays determine bone density,texture,erosion and changes in bone relationships.Multiple x-rays,with multiple views (anterior,posterior ,lateral) are needed for full assessment.Serial x-ray may be indicated to determine the status of healing process. X-RAY IMAGING 2-COMPUTED TOMORAPHY • Computed tomography (CT) scan,which may be performed with or without the use of oral or intravenous contrast agents,shows a more detailed cross-sectional images of the body. • It may be used to visualize and assess tumors,injury to the soft tissue,ligaments or tendons and severe trauma to the chest,abdomen,pelvis ,head or spinal cord. C.T.SCAN IMAGES • • • • • 3-MAGNETIC RESONANCE MRI is a noninvasive imaging technique that uses IMAGING magnetic fields and radio waves to create high resolution pictures of bones and soft tissues. It can be used to visualize and assess torn muscles,ligaments and cartilages,herniated discs and a verity of hip or pelvic conditions. The patient does not experience any pain during the procedure.MRI scanner is noisy and it may take 30-90 minutes to complete. An IV contrast agent may be used. Patient who expeience clustophobia may be unable to tolerate and need sedation. MRI IMAGING 4-BONE SCAN • A bone scan is performed to detect metastatic and primary bone tumors,osteomylitis,some fractures and aspetic necrosis. • A bone scan may accurately identify bone disease before it can be detected on x-ray,such as it may diagnose a stress fracture in a patient who continues to experience pain after x-ray findings are negative. • A bone scan requires the injection of a radio-isotope through an IV line and the scan is performed 2-3 hrs afterwards. BONE SCAN The second image shows metastasis from bone to breast 5-ARTHROSCOPY • Arthroscopy allows direct visualization for biopsy and treatment of tears,defects and disease processes may be performed through the arthroscope. • The procedure takes place in operating room under sterile condition. • Written concent is to be taken before procedure. ARTHROSCOPY Shoulder Arthroscopy 6-ARTHROGRAPHY • Arthrography is used to identify the cause of any unexplained joint pain and progression of joint disease. • A radio opaque contrast agent or air is injected into the joint cavity to visualize the joint structures such as ligaments,cartilage,tendons and joint capsule. • A joint is put through its range of motion to distribute the contrast agent while a series of xrays are obtained. ARTHROGRAPHY Shoulder & Knee arthrography 7-BONE DENSITOMETERY • Bone densitometry is used to evaluate BMD (bone metabolic diseases). • This can be performed through the use of x-rays or ultrasound.The most common modalities used include dual-energy x-ray absorptiometery (DXA or DEXA). • It predicts fracture risk through accurate monitoring of bone density changes in patients with osteoporosis who are undergoing treatment. BONE DENSITOMETRY Bone Densitometry Showing osteoporosis NURSING INTERVENTION DURING IMAGING TECHNIQUE Before the patient undergoes any of the imaging studies(X-Ray,CT SCAN,MRIs,Arthrography,Bone densitometry) the nurse prepares the patient: 1.Instruct the patient to lie still during procedure. 2.During MRI study ,the patient may hear a knocking sound. 3.The nurse assess for conditions that may require special consideration during study (prenancy, clustrophobia, disability or metal implants) 4.If contrast agents will be used for CT scan,MRI or arthrography,the patient is assessed for possible allergies. NURSING INTERVENTION DURING IMAGING TECHNIQUE CONT’D 5.The nurse provides additional comfort measures (mild analesics,ice bag etc.). 6.While performing MRI and CT scan metal pins or magenetic cards should be removed. 7.Patients with cardiac pacemakers are prohibited for MRI & CT scan. 8-ARTHROCENTESIS • Arthrocentesis (joint aspiration) is carried out to obtain synovial fluid for purposes of examination or to relieve pain due to effusion. • Examination of fluid is helpful in the diagnosis of septic artheritis and other inflammation or arthropathies. Arthrocentesis 9-ELECTROMYOGRAPHY • Electromyoraphy (EMG) provides information about the electrical potential of the muscles and the nerves. • Needle electrodes are inserted into selected muscle and responses to electrical stimuli are readed on an oscilloscope. • Warm compresses may relieve discomfort after the study. • The nurse inquires if the patient is taking anticoagulant medicines and assess for active skin infection. Electromyography Electrodes are attached to perticular muscles Electromyography 10-BIOPSY • Biopsy may be performed to determine the structure and composition of bone marrow,bone,muscle or synovium to help diagnose specific disease. • The nurse monitors the biopsy site for edema,bleeding,pain,hematoma formation and infections. • Ice is applied to control bleeding and edema. • In addition antibiotics and analgesic agents LABORATORY STUDIES • Serum calcium are altered in patients with osteomalacia,osteoporosis,parathyroid dysfunction,Paget’s disease,metastatic bone tumors or prolonged immobilization. • Serum Phosphorus. • Specific urine and serum biochemical markers are to be assessesd. • CBC is required to check hemoglobin and WBC count. REFERENCE • Smeltzer,S.C.,and Bare(2018),B.G.Brunner and Suddarth’s Textbook of Medical Surgical Nursing , 14th edition.Philadelphia: Lippincott Williams and Wilkins,2968-3009 Osteomyelitis,Osteoatheritis,Low Back Pain & Orthopedic surgery Prepared by: Sangeeta James Lecturer,College of Nursing Jazan University OSTEOMYELITIS Osteomyelitis is an infection of the bone that results in inflammation, necrosis and formation of new bone. RISK FACTORS OF OSTEOMYLITIS 1.Older adults 2.Poorly nourished 3.Obese 4.Person with poor immune system 5.Chronic illnesses(e.g. Diabetes, rheumatoid artheritis) 6.Patients with long term corticosteroid therapy. Post operative surgical wound infections typically occurs within 30 days after surgery. CLINICAL MANIFESTATIONS 1.Chills,high fever, rapid pulse and general malaise. 2.The area become painful, swollen and extremely tender. 3.Pain-constant ,pulsating pain that intensifies with movement as a pressure of collecting purulent material (pus). 4.The surface area that lies over the infected bone is swollen, warm, painful and tender to touch. DIAGNOSTIC FINDING 1.X Ray findings shows abnormal finding. 2.Radioisotopes bone scan 3.MRI 4.Blood studies reveal leukocytosis and an elevated ESR 5.Wound & blood culture studies. MEDICAL MANAGEMENT The initial goal of therapy is to control and halt the infective process. 1.General supportive measures (e.g. hydration ,diet high in vitamins and protein, correction of anemia) 2.Immobilize the area to decrease discomfort and to prevent pathologic fracture of weakened bone. 3.Drug Therapy-Antibiotic therapy should be continue for 3-6 weeks. SURGICAL MANAGEMENT Surgical debridement is indicated. The infected bone is surgicaly exposed, the purulent and necrotic material is removed , the area is irrigated with sterile saline solution.Bone graft is done. PREVENTION OF OSTEOMYLITIS orthopedic surgery should 1.Elective be postponed if the patient has a current infection (e.g. urinary tract infection, sore throat). 2.During surgery strict asepsis should be maintained. 3.Prophylactic antibiotic is to be administered. 4.Urinary catheters and drains are removed as soon as possible 5.Aseptic post operative wound care is essential. REFERENCE Smeltzer,S.C., and Bare(2018), B.G.Brunner and Suddarth’s Textbook of Medical Surgical Nursing , 14th edition. Philadelphia: Lippincott Williams and Wilkins,3129-3135 OSTEOARTHERITIS Osteoarthritis • Osteoarthritis (OA): is a degenerative joint disease characterized by the breakdown of the joint's cartilage • Usually begins later in life. • Affects both sexes, with onset usually after age 4o. Causes 1-Unknown. 2-Heredity. 3-Excess weight (obesity) :puts extra stress on the weight-bearing joints, especially the knees and hips. 4-Joint injury: in sports 49 Osteoarthritis (cont’d) Clinical Manifestations: 1. Progression of pain is almost gradual. 2. Pain aggravated by use of extremity and relieved by rest. 3.Morning joint stiffness lasts less than one hour.Stiffness returns at the end of the day or after periods of activity. 4.Muscle spasm in the morning or after awakening usually lasts less than 30 minutes. 5.Bony node may be present on inspection & palpation Diagnosis: 1-History of symptoms 2-Physical exam. 3- X-ray 50 BONY NODE Nursing Interventions 1. Relieving pain-By take mild analgesic as aspirin. 2. Increasing physical mobility -To maintain muscle tone, joint support and reduce body weight heat application to the joint to relieve discomfort . 3- local anti-inflammatory -like cream or spray advice patient to avoid getting of these products inside eye, nose or mouth. or applying on any open skin not use it more than 3-4 times per 24 hour and stop using it if there skin irritation . 4- NSAID may be given. 5-In some cases long acting corticosteroid mixed with local aesthetic may injected directly into the joint although it relive pain it can increase cartilage breakdown if done frequently. 7-Arthroplasty reconstruction or replacement of joint through arthroscopic surgery . Total Hip Arthroplasty LOW BACK PAIN DESCRIPTION Low back pain also referred as LUMBAGO. Low back pain refers to pain felt in lower back Due to strain in muscle and tendon of the back caused by abnormal stress or overuse it involve the lumber,lumbosacral or sacroiliac areas of the back. Low back pain may be classified by the duration of symptoms. 1.ACUTE LOW BACK PAINWhen the duration of pain present for 4 weeks or less. 2.SUBACUTE LOW BACK PAINWhen the duration of pain present 5-12 weeks after injury CLASSIFICATION 3.CHRONIC (persistent) LOW BACK PAIN- When the duration of pain present ≥ 12 weeks after injury. 4-local pain caused by fracture, strains, sprains. 5-referred pain, caused by disorder of organs in the abdomen or pelvic as aortic aneurysm . 6- pain of spinal origin associated with pathology of spine as disc disease. 7-muscle spasm pain is dull and accompanied by abnormal posture. SYMPTOMS 1.Back pain may be worse with bending or lifting. 2.Sitting may worsen the pain. 3.Standing and walking worsen the pain. 4.Pain may extend from the back into the buttock or outer hip area and down the legs. DIAGNOSTIC EVALUATION 1.MEDICAL HISTORY EXAMINATION. 2.IMAGING TESTSa. X-Ray b. MRI c. CT SCAN 3.BONE DENSITY TEST 4.Bone Scan AND PHYSICAL TREATMENT Non-surgical treatment1. Medications-several medications may be used to help relieve pain. These includesa. • Aspirin orally to relieve pain. b. Non steroidal anti- inflammatory drugs such as Ibuprofen reduces pain & swelling. c. Narcotic pain medications such as Morphine sulphate. d. Muscle relaxants-. Instruct patient to take medication on a routine schedule rather than as needed. NON-SURGICAL INTERVENTIONS Acupuncture An intervention consisting of the insertion of needles at specific acupuncture points Acupressure An intervention consisting of manipulation with the fingers instead of needles at specific acupuncture points. • • MASSAGE Soft tissue manipulation using the hands or a mechanical device INFRA RED HEAT heat application Ice application Ultra red heat application. Teach patient about rebound phenomenon of prolonged heat more than 30 minutes or ice therapy for more than 15 minutes cause reverse effect (increase pain&inflammation) BRACES OR BELT SURGICAL TREATMENT When all treatment fails, surgery is the last option. DISC REPLACMENTRemoving the disc and replacing it with artificial parts, similar to replacement of the hip or knee. PREVENTION OF BACK PAIN 1.Weight reduction as needed:Modify diet to achieve ideal body weight. 2.Avoid high heels 3.Walk daily and gradually increase the distance. 4.Avoid jumping. 5.Stretch to enhance flexibility.Do strengthening exercise. 6.Maintain good body mechanics. REFERENCE • Smeltzer,S.C., and Bare(2018), B.G.Brunner and Suddarth’s Textbook of Medical Surgical Nursing , 14th edition. Philadelphia: Lippincott Williams and Wilkins,3085-3095 Orthopedic surgery Many patient who have musculoskeletal dysfunction need to undergo surgery to correct the problem. Types of surgery 1-Open reduction the reduction and alignment of the fracture. 2-Internal fixation the stabilization of reduced fracture by use of metal nails,pins,plates. 3-Amputation the removal of body part 4-Arthoplasty repair of the joint 5-Total joint replacement replace of Total Hip Replacement • Femoral head impaction ● Final implant Indication of total hip replacement 1-Hip pain that limits everyday activities, such as walking or bending. 2- Hip pain that continues while resting, either day or night. 3- Stiffness in a hip that limits the ability to move or lift the leg. Post operative care Post operative care includes- 1-Assess pain carefully . 2-Give analgesic intravenous as ordered. 3-Use ice bags over the incision for comfort and swelling . 4-Wound suction to decrease fluid or blood accumulation that increases pain . 5-Continue your exercises a minimum of 2 to 3 times a day, unless your surgeon tells you differently. 6-Well balance diet with adequate protein and vitamins for wound healing. Patients- Remember your total hip precautions 1- Do not cross one leg over the other. 2- Do not rotate your toes or legs inward. 3- Sleep with two pillows between your legs. 4- Do not lean forward while sitting in a chair. 5-You should not bend your hip beyond 90° (a right angle). 6-You should not bring your operative leg up toward your chest. Hip abduction pillow Prevention of displacement of joint The nurse notes the following methods for avoiding displacement1.Keep knee apart all time. 2.Put pillow between the leg when seated. 3.Avoid bending forward when seated in a chair. 4.Avoid bending forward to pick up an object on the floor. 5.Use high seated chair and a raised toilet seat. 6.Do not flex hip to put clothing such as pants. Avoid bending forward & hip joint at 90 degree Do not bend Raised Chair & Toilet Seat Post operative complication A-Specific 1-Infection may lead to osteomyelitis 2-Loosening of the nails. screws 3-Dislocation of the prosthesis 4-Bone fracture B-General complication 1-Haemorrhage 2- Shock 3-Fat embolism 4-Deep vein thrombosis 5-Pulmonary embolus and death REFERENCE • Smeltzer,S.C., and Bare(2018), B.G.Brunner and Suddarth’s Textbook of Medical Surgical Nursing , 14th edition. Philadelphia: Lippincott Williams and Wilkins,3046-3064 THANK YOU