Musculoskeletal System Chapter 23 PDF

Musculoskeletal System Chapter 23 Dr Lisa Cross  Structure and Function Skeleton is bony framework of body Bone and cartilage are specialized forms of connective tissue Bone is hard, rigid, and...

Musculoskeletal System Chapter 23 Dr Lisa Cross  Structure and Function Skeleton is bony framework of body Bone and cartilage are specialized forms of connective tissue Bone is hard, rigid, and very dense Joints, or articulations, are places of union of two or more bones Copyright © 2020 by Elsevier, Inc. All rights reserved. 2  Musculoskeletal Components Bone Location Cartilage  Temporomandibular joint (TMJ) Ligaments  Spine Tendon  Shoulder Joints  Elbow  Wrist and carpals Nonsynovial  Hip (immovable or slightly  Knee moveable)  Ankle and foot Synovial (freely moveable) Copyright © 2020 by Elsevier, Inc. All rights reserved. 3  Joints A joint (articulation) is formed when a bone meets another bone Three classes Synarthrosis (immovable) Amphiarthrosis (slightly movable) Diarthrosis (freely movable) Copyright © 2020 by Elsevier, Inc. All rights reserved. 4  Muscles /Tendons/Ligaments Copyright © 2020 by Elsevier, Inc. All rights reserved. 5  Muscle Movements Flexion- bending a limb of the body at a joint Pronation- turning the Extension- forearm so that the straightening a limb at palm is down a joint Supination- turning the Abduction- moving a forearm so that the limb away from the palm is up midline of the body Circumduction- moving Adduction- moving a the arm in a circle limb toward the midline around the shoulder Copyright © 2020 by Elsevier, Inc. All rights reserved. 6  Muscle Movements (Cont.) Inversion - moving the sole of the foot inward at the ankle Eversion - moving the sole of the foot outward at the ankle Rotation - moving the head around a central axis Protraction - moving a body part forward and parallel to the ground Retraction - moving a body part backward and parallel to the ground Elevation - raising a body part Depression - lowering a body part Copyright © 2020 by Elsevier, Inc. All rights reserved. 7  Muscle Movements (Cont.) Copyright © 2020 by Elsevier, Inc. All rights reserved. 8  Skeleton 206 Bones Made of connective tissue Cells continually turn over and remodel Joints are functional unit - “place of union of two or more bones” Copyright © 2020 by Elsevier, Inc. All rights reserved. 9  Joint Types Copyright © 2020 by Elsevier, Inc. All rights reserved. 10  Temporomandibular Joint Copyright © 2020 by Elsevier, Inc. All rights reserved. 11  Spine Copyright © 2020 by Elsevier, Inc. All rights reserved. 12  Shoulder Copyright © 2020 by Elsevier, Inc. All rights reserved. 13  Wrist /Carpals Elbow Copyright © 2020 by Elsevier, Inc. All rights reserved. 14  Hip Copyright © 2020 by Elsevier, Inc. All rights reserved. 15  Knee Copyright © 2020 by Elsevier, Inc. All rights reserved. 16  Ankle Foot Copyright © 2020 by Elsevier, Inc. All rights reserved. 17  Aging Adult Bone Remodeling Reaches peak at 25-35 years After age 40, bone resorption more rapid than bone formation= osteoporosis Decreased height d/t shortening of vertebral column Thinning intervertebral disks, and decrease in height of individual vertebrae d/t osteoporosis Postural Changes Kyphosis, hip/knee flexion Subcutaneous Fat age 40-50: Lose fat in face and onto abdomen/hips age 70-80: Fat loss in periphery Muscle weakness/atrophy Copyright © 2020 by Elsevier, Inc. All rights reserved. 18  Aging Adult (Cont.) Physical activity Prevents bone loss Increases skeletal mass Prevents osteoporosis Dose dependent Fast walking best prevention Other benefits of exercise Improve muscle strength: Falls/balance/posture control CVD, Cancer, Depression Copyright © 2020 by Elsevier, Inc. All rights reserved. 19  Focused Health History Pain Onset of symptoms Deformity Paralysis Trauma Chronic conditions Copyright © 2020 by Elsevier, Inc. All rights reserved. 20  Aging Adult: Additional History Any changes in weakness over the past month or years? Any increase in falls or stumbling over the past months or years? Do you use mobility aids to get around? Copyright © 2020 by Elsevier, Inc. All rights reserved. 21  Subjective Data: Functional Assessment Do your muscle/bone problems create limits on your usual activities of daily living?  Which ones? Copyright © 2020 by Elsevier, Inc. All rights reserved. 22  Subjective Data: Joints Pain Stiffness Swelling/heat/redness Limitation of movement Copyright © 2020 by Elsevier, Inc. All rights reserved. 23  Subjective Data: Muscles Pain or Cramping? Weakness?  Neuro/atrophy/tear Exacerbates or Relieves? Associated symptoms?  Flu/fever- myalgia Copyright © 2020 by Elsevier, Inc. All rights reserved. 24  Subjective Data: Bones Bone Pain? Trauma/Injury? Back pain  Radicular symptoms  Numbness/tingling?  Limping? Copyright © 2020 by Elsevier, Inc. All rights reserved. 25  Objective Data: Physical Examination Head to Toe Inspection Proximal to Distal Palpation Compare side to Range of Motion side Muscle Testing Ensure Privacy Copyright © 2020 by Elsevier, Inc. All rights reserved. 26  Measurements Copyright © 2020 by Elsevier, Inc. All rights reserved. 27 Measurements (Cont.)  Inspection Consider the entire body  Observe the patient’s gait  ROM Observe ease or discomfort associated with position changes Note size and contour of joint; symmetry, inspect skin/ tissues over joints for color, swelling, any masses or deformity Presence of swelling signals joint irritation Copyright © 2020 by Elsevier, Inc. All rights reserved. 29  Palpation Palpate each joint, including skin for temperature, muscles, bony articulations, and area of joint capsule Notice any heat, tenderness, swelling, or masses which signal inflammation Joints normally not tender to palpation  If tenderness occurs, localize to specific anatomic structures  For example, skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule Copyright © 2020 by Elsevier, Inc. All rights reserved. 30  Range of Motion (ROM) Ask for active voluntary ROM while stabilizing the body area proximal to that being moved Become familiar with the type of each joint and its normal ROM so that you can recognize limitations For limitations, gently attempt passive motion Anchor joint with one hand while other hand slowly moves it to its limit Normal ranges of active and passive motion should be same Copyright © 2020 by Elsevier, Inc. All rights reserved. 31  Range of Motions (Cont.) Joint motion normally causes no tenderness, pain, or crepitation Do not confuse crepitation with normal discrete “crack” heard as tendon or ligament slips over bone during motion Copyright © 2020 by Elsevier, Inc. All rights reserved. 32  Muscle Testing Test the strength of the prime-mover muscle groups for each joint; repeat motions for active ROM Ask person to flex and hold as you apply opposing force (tests resistance) Muscle strength should be equal bilaterally and should fully resist opposing force May use grading system (Review p. 583!!!) Familiarize yourself with different tests to assess for muscle strength Copyright © 2020 by Elsevier, Inc. All rights reserved. 33  Muscle Strength Scale 0 – No muscle contraction 1 – Trace muscle contraction, such as a twitch 2 – Active movement only when gravity eliminated 3 – Active movement against gravity but not against resistance 4 – Active movement against gravity and some resistance 5 – Active movement against gravity and examiner’s full resistance Copyright © 2020 by Elsevier, Inc. All rights reserved. 34  Question 1 An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: A. Long bones tend to shorten with age B. The vertebral column shortens C. A significant loss of subcutaneous fat occurs D. A thickening of the intervertebral disks develops Copyright © 2020 by Elsevier, Inc. All rights reserved. 35  Physical Examination Head Head Temporomandibular Joint- crepitus and pain with TMJ disorder Assess ROM  Open mouth  Move lower jaw from side to side  Stick out lower jaw (Protraction) Palpate temporalis and masseter muscles (Ask client to clench jaw) Test muscle strength against resistance; jaw thrust, jaw lateral movement Copyright © 2020 by Elsevier, Inc. All rights reserved. 36  Physical Examination Neck Neck: ROM and muscle strength:  Flexion- touch chin to chest  Extension- tilt head backward Cervical rotation- turn head to R and L Lateral bending- touch ear to R and L shoulders Repeat against resistance Copyright © 2020 by Elsevier, Inc. All rights reserved. 37  Physical Examination Shoulder Shoulder: Note posture erect or hunched Assess symmetry and position of clavicles. Palpate clavicles toward shoulders, palpate deltoid muscle. ROM and muscle strength  Forward flexion; Extension (at side); Hyperextension  Abduction; Adduction; Internal/External Rotation Test muscle strength: shrug, flexion, abduction Copyright © 2020 by Elsevier, Inc. All rights reserved. 38  Physical Examination Elbow Elbow: Inspect and palpate posterior surface Note- medial and lateral condyles of humerus and olecranon process of ulna ROM and muscle strength:  Flexion and Extension  Supination and Pronation Test muscle strength; flexion/extension Copyright © 2020 by Elsevier, Inc. All rights reserved. 39  Physical Examination Wrist Wrist: Grasp wrists, assess body processes of radius (thumb side) and the ulna. Palpate radiocarpal joint and remaining wrist joints. ROM and muscle strength:  Flexion and Extension and Hyperextension  Radial and ulnar wrist deviation  Circumduction Test strength against resistance; flexion of wrist Copyright © 2020 by Elsevier, Inc. All rights reserved. 40  Physical Examination Hand Hand: Use thumb and forefinger to palpate the metacarpophalangeal and interphalangeal joints ROM and muscle strength  Flexion and Extension and Hyperextension  Abduction- have patient spread fingers apart  Adduction- have pt. hold fingers together Thumb/Finger Opposition Copyright © 2020 by Elsevier, Inc. All rights reserved. 41  Assessing Upper Extremity Strength Copyright © 2020 by Elsevier, Inc. All rights reserved. 42  Physical Examination Hip Hip: Inspect and palpate hip joint and surrounding structures. Position pt. side lying and palpate iliac crest, greater trochanter, hip, thigh and buttock muscles ROM and muscle strength:  Flexion, Extension, Hyperextension  Adduction and Abduction  External rotation and Internal rotation Repeat against resistance Copyright © 2020 by Elsevier, Inc. All rights reserved. 43  Physical Examination Knee Knee: Inspect- note alignment, deformity, contour of quadricep muscle Palpate the suprapatellar pouch and note any tenderness, edema ROM and muscle strength:  Flexion and Extension Copyright © 2020 by Elsevier, Inc. All rights reserved. 44  Physical Examination Ankle Ankle: Compare the contour of R. and L. ankles. Palpate ankle and Achilles tendons. ROM and muscle strength:  Dorsiflexion- point toes upward.  Plantar Flexion- point toes downward.  Inversion- turn soles of feet inward.  Eversion- turn soles of feet outward.  Circumduction Test muscle strength; plantar & dorsiflexion Copyright © 2020 by Elsevier, Inc. All rights reserved. 45  Physical Examination Foot Foot: Inspect skin integrity, condition of nails and any deformities. Palpate the metatarsal bones and joints, squeeze each foot. ROM and muscle strength:  Flexion and Extension  Abduction and Adduction Copyright © 2020 by Elsevier, Inc. All rights reserved. 46  Assessing Lower Extremity Strength Copyright © 2020 by Elsevier, Inc. All rights reserved. 47  Physical Examination Spine Spine: While standing, have client bend a waist – inspect spine for curvature, ease of mobility Palpate vertebral column with fingertips, note tenderness or bony deformities ROM  Flexion and extension  Lateral bending  Spinal rotation Copyright © 2020 by Elsevier, Inc. All rights reserved. 48  Additional Assessment - Older Adult Assess functional status: Ask client to: Walk with shoes on Climb stairs / up & down Pick up an object from the floor Rise from sitting in chair Rise from lying in bed Copyright © 2020 by Elsevier, Inc. All rights reserved. 49  Bulge Sign- small effusions in suprapatellar pouch Copyright © 2020 by Elsevier, Inc. All rights reserved. 50  Sports Injuries Determine severity and extent of the injury before permanent damage occurs - key Guidelines for seeking medical assistance include:  Prolonged or non-subsiding pain continuing two weeks after the episode  Any injury that occurs in or near a joint  Any loss of function  Any injury that does not heal in three weeks or in which the structure is apparently abnormal or any sign of infection on or under the skin, presence of pus, red streaks swollen lymph nodes or fever  Any alteration in sensation, such as numbness / tingling Copyright © 2020 by Elsevier, Inc. All rights reserved. 51  Sample Charting Copyright © 2020 by Elsevier, Inc. All rights reserved. 52  Developmental Considerations- Pregnancy Increased mobility in joints changes posture Lordosis: most significant  Balances weight of fetus  Can result in low back pain Upper back changes  Ulnar and median nerve pressure from anterior flexion of neck and slumping shoulder girdle Aching, numbness, weakness in upper extremities Copyright © 2020 by Elsevier, Inc. All rights reserved. 53  Developmental Considerations- Infants Vertebral Column changes C-Curve @ birth Anterior curve C-spine @3-4 months Anterior curve lumbar spine @1.5 years Bone growth continues rapidly during infancy and steadily in childhood, until adolescent growth spurt Copyright © 2020 by Elsevier, Inc. All rights reserved. 54  Developmental Considerations- Children Long bones grow in 2 dimensions  Diameter and length  Epiphyses (end of the long bone; grows separately from the shaft)- closes age 20 Muscle & Fat:  affected by growth hormone, adrenal androgens, testosterone  Muscles hypertrophy and atrophy throughout life Copyright © 2020 by Elsevier, Inc. All rights reserved. 55  Additional History Developmental Considerations: Adolescents Sports related injuries Motor vehicle crashes Protective equipment used for both  Seatbelts, mouth guards Copyright © 2020 by Elsevier, Inc. All rights reserved. 56  Developmental Considerations- Aging Adult Bone Remodeling Reaches peak at 25-35 years, declines after age 40 osteoporosis Decreased height d/t shortening of vertebral column Thinning intervertebral disks, and decrease in height of individual vertebrae d/t osteoporosis Postural Changes Kyphosis, hip/knee flexion Muscle weakness/atrophy Copyright © 2020 by Elsevier, Inc. All rights reserved. 57  Osteoporosis Copyright © 2020 by Elsevier, Inc. All rights reserved. 58  Osteoporosis (Cont.) Copyright © 2020 by Elsevier, Inc. All rights reserved. 59  Abnormals to Know!!! Osteoporosis (p. 608 and 612) Osteoarthritis (p. 612 and p. 616) Scoliosis (p. 606 and p. 621) Copyright © 2020 by Elsevier, Inc. All rights reserved. 60  References Jarvis, C. (2020). Physical examination & health assessment, 8th edition. St. Louis, MI: Elsevier. ISBN Number 978-0-323-51080-6. Copyright © 2020 by Elsevier, Inc. All rights reserved. 61