NURS330 2024 Musculoskeletal System PDF

MUSCULOSKELETAL SYSTEM NURS330 2024 1  Concept Overview Motion: Mechanisms that facilitate and impair mobility. Interrelated concepts include: Oxygenation of blood to tissues. Intracranial regulation by brain, spinal cord & peripheral nerves...

MUSCULOSKELETAL SYSTEM NURS330 2024 1  Concept Overview Motion: Mechanisms that facilitate and impair mobility. Interrelated concepts include: Oxygenation of blood to tissues. Intracranial regulation by brain, spinal cord & peripheral nerves Pain from motion can limit movement. Nutrition must be adequate. Excessive weight can damage joints Elimination—Risk of constipation due to limited mobility 2 Subjective Data Joints: pain, stiffness, swelling, heat, redness, limitation of movement Knee joint (if injured) Muscles: pain (cramps) or weakness Bones: pain, deformity, trauma (fractures, sprains, or dislocation) Functional assessment (ADLs) Patient-centered care  Assessment  Neurologic & musculoskeletal work together to move and perform ADL’s Inspection & palpation  When assessing work from proximal to distal Ask if any pain  Support joint at rest; gently move to Inspect joints, muscles, bones minimize discomfort Size, symmetry, alignment, ROM, deformities, inflammation Use a measuring tape if asymmetry of extremity size: measure at same point on Observe gait each extremity and document Palpate for warmness, tenderness, muscle tone, crepitus. Unexpected: Contracture Unilateral deformity: ↓ ROM Disuse, atrophy, and shortening of the muscles 4 Contracture  Range of Motion Muscle tone & strength to support with minimal effort Active ROM Passive (PROM): move gently, do not go past resistance, or if pain As client performs ROM, feel with your hand (cup joint) Should be a coordinated, smooth, and full ROM without hesitation to any movement; absence of crepitus (crunching of air subq; air in fluid in alveoli, bone rubbing against deteriorated cartilage); without discomfort, hesitancy, obstruction Unexpected Cannot perform ROM, asymmetry, deformity, pain, hesitancy (resistance to movement of joint), crepitus, muscle spasm Hypermobile joints (double jointed) Go past normal ROM Is often benign More in children due to less developed connective tissue 5  Skeletal Muscles Movements Flexion: bending limb at joint (↓ angle) Flexion and extension: Neck, shoulder, Extension: straightening limb at joint elbow, wrist, fingers, thumb, hip, knee, (↑angle) toes Abduction : moving limb away from Hyperextension: Neck, shoulder, wrist, midline of body fingers Adduction : moving limb toward midline of Dorsiflexion and plantar flexion: Ankle body Lateral flexion: Neck Pronation: turning forearm so that palm is Abduction and adduction: Shoulders, down wrists, fingers, thumbs, hips, toes Supination: turning forearm so that palm is Opposition: Thumbs up (Soup) Pronation and supination: Forearm Circumduction: moving arm in circle Circumduction: Shoulders and hips around shoulder Jumping rope, pitching Hip Circumduction Skeletal Muscles Movement Inversion: moving sole of foot inward at ankle Eversion: moving sole of foot outward at ankle Rotation: moving head around central axis Protraction: moving body part forward, parallel to ground Retraction: moving body part backward, parallel to ground Elevation: raising a body part Depression: lowering a body part Inversion and eversion: Feet Rotation (internal and external): Neck, shoulders, wrists, thumbs, hips Retraction and protraction: Jaw 7 8 9 ???? Which movement is bending the limb at a joint? a. Pronation b. Flexion c. Extension d. Supination 10  Structure and Function  Musculoskeletal system consists of bones, joints, and muscles. Needed for support and to stand erect Needed for movement To encase and protect inner vital organs To produce RBCs in the bone marrow (erythropoiesis) Serve as a reservoir for storage of essential minerals  Musculoskeletal components: Bones and cartilage—specialized forms of connective tissue Bones covered by periosteum; provides nutrition, removes waste Fibrous, cartilaginous and synovial joints—joints or articulations are places of union of two or more bones Ligaments—fibrous bands connect bones; support joints; allow movement Tendons: connective tissue (collagen) that connect the muscles to bones; allows the bones to move. Bursa—enclosed fluid filled sac that serves as a cushion  Muscles allows for movement and Range of motion (ROM) of joints There are 3 types of muscle Skeletal Attaches to bone through tendons Muscles Skeletal muscles contract, for movement (stimulated by electrochemical impulse, neurotransmitter between nerve ending & the muscle) Give form & contour to body Main factor for body posture Smooth Lines organs of body Cardiac 12 The heart Head and Neck Cervical vertebrae and ligaments support Inspect muscles of face head and neck Open & close jaw Muscles provide movement Sternocleidomastoid, trapezius provide Inspect alignment of neck vertebra movement Expected Move jaw side to side (lateral) Symmetry and alignment Flex & extend chin to chest Unexpected Tilt head back (hyperextend) Asymmetry: measure Bend neck side to side Rotate to look over shoulder 13 ???? The patient is able to perform full ROM with some resistance notes. How will the nurse document this finding in the medical record? a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4 e. Grade 5 14  Stand behind the client and palpate Palpation vertebrae in neck Jaw Client should flex neck forward, placing chin on chest Place index, ring, middle fingers of each hand on temporomandibular joints Look for alignment of the vertebrae (TMJ). C-7 is more prominent. In front of tragus of ear & hinges lower Palpate the sternocleidomastoid, jaw movement. trapezius, and paravertebral muscles Ask the client to open and close their located on either side of the vertebrae jaw. Should be aligned, no deformities, no tenderness, no masses, symmetrical, May have some clicking of jaw equal sensation If pain or locking, needs further If pain or discomfort could be evaluation inflammation, nerve compression; ↓ sensation could be neurologic issue 15 Shoulders Ball & socket Allows for many motions Lateral rotation of shoulder & humerus Elevation of shoulder, scapular rotation, and posterior movement of the shoulder Subacromial bursa allows for smooth abduction of the arm. Should be no limitations, redness, swelling 16  Shoulder Palpate Inspect Should be full and firm Pain: location Dominant arm muscle slightly larger Could be: gallbladder disease, hiatal hernia, or heart or lung condition Unexpected Expected: Symmetry Swelling, heat, or tenderness Unexpected: erythema, change in Atrophy or unilateral swelling pigmentation, atrophy of the muscles, Shoulder that lacks the expected rounded deformity, irregularities, swelling shape and appears flattened (dislocation) ROM Extension, hyperextension, adduction, abduction, internal rotation, external rotation 17  Elbow Hinge joint (humerus, radius, ulna) Enclosed in synovial cavity Supination (supinator) & pronation (pronator) of forearm & hand Muscles allow flexion Biceps, brachioradialis Extension Brachialis, triceps Should be no swelling, bulges, redness Assess ROM 18  Elbow Unexpected Swelling, erythema or change in pigmentation around olecranon bursa Synovial joint thickness, fluid- bulging in hollows on either side of Inspect the olecranon process groove (may be gouty arthritis) Misalignment of the articular surfaces of the joint could be Both flexed & extended positions while dislocation of the elbow providing support to the forearm Palpation Assess the symmetry, alignment, color, Ask client to flex: palpate the lateral and medial epicondyles, the size, muscle tone, shape of the bones of olecranon process and the hollows on either side of this process the elbow, the muscles &joint capsule Expected Findings Symmetry, no pain Inspect the olecranon bursa for inflammation Olecranon process should be easily palpable and with no tenderness, swelling, warmth, nodules, or masses Should be depressions, on both sides of Unexpected Findings olecranon process (bony protrusion at Erythema, change in pigmentation, heat, and edema the tip of the elbow) (inflammation). Displacement of the olecranon process may indicate a dislocation of the elbow Skin surrounding the joint should be of Rheumatoid arthritis (RA) may have nodules that are elevated, even color and intact without erythema firm nontender masses that are freely movable. or change in pigmentation or swelling ROM (extension, flexion, pronation, 19 supination)  Wrist and Hands Multiple bones allow motor skills, dexterity Wrist: radiocarpal (wrist), distal radioulnar joint, & intercarpal joints allow for flexion, extension, hyperextension, &rotation Carpal muscles- flexion of wrist Radial/ulna muscles- extension Muscles in arm: supination & pronation Thumb- flexion, extension, abduction, opposition Fingers- flexion, extension, abduction, adduction Names of joints in hand describe location: Distal interphalangeal (DIP) joint is distal joint of fingers. Proximal interphalangeal (PIP) joint is middle joint of each finger. Metacarpophalangeal (MCP) joint attaches metacarpal to carpal joint. Redness, swelling, nodules indicates inflammation (arthritis) 20  Carpal Tunnel Syndrome Phalen’s test Hold both hands back to back while flexing wrists 90 degrees Acute flexion of wrist for 60 seconds produces no symptoms in the normal hand Test reproduces numbness and burning in person with carpal tunnel syndrome Tinel’s Sign Direct percussion of location of median nerve at wrist Produces no symptoms in normal hand Produces burning and tingling along its distribution, which is a positive Tinel's sign for carpal tunnel syndrome Compression of median nerve Numbness or tingling in thumb and 2 nd, 3rd, maybe 4th fingers Pain extending to elbow Weak grip difficulty with fine motor movements 21  Wrist and Hands Inspect bilaterally Palpation Note shape & form of the bones, joints, and muscles. Look for swelling, masses, pain or tenderness Assess position of fingers in relation to the wrist and forearm Expected Findings Turn the client’s palm up and check that the muscles in Bones & joints should be smooth with no lumps, the hand are full (nodules), Expected Findings Symmetry Symmetry Unexpected findings Unexpected Swelling or nodules on the joints (arthritis) Tenderness, swelling, or nodules on the and require further investigation. Ulnar deviation: fingers not in alignment with wrist & forearm & deviate toward the ulnar side of the arm (arthritis). Non linear fingers or unable to extend fully Limitation in movement or asymmetry Ganglion cyst is a circular nontender nodule that is on the dorsal surface of the wrist Assess ROM and muscle strength Flex, extend, hyper-extend, adduct, abduct, opposition of thumb to fingers Provide resistance to determine if client can resist your movements Grip strength; finger strength 22  Spine Vertebrae are 33 connecting bones stacked in vertical column 7C, 12T, 5L,5S, 3 or 4 Coccygeal C and L concave; T and S convex Double S shape Slightly moveable joints Curves help distribute weight to pelvis Feel spinous processes in furrow down midline of back C7&T1 prominent at base of neck (vertebra prominens) In between cervical, thoracic, & lumbar vertebrae are fibrocartilaginous discs: Act as shock absorbers that cushion the spine during movement Too much compression, disk ruptures, compresses spinal nerves and causes pain Allow vertebral joints to glide over each other to ↑ flexibility. Sacral & coccygeal vertebrae are fused together Trapezius and latissimus major muscles Spinal cord passes through vertebral foramen Motions of vertebral column are flexion (bending forward), extension (bending back), abduction (to either side), and rotation 23  Spine Unexpected findings Lateral deviation of the head or spine Observe gait posture, position of head & neck, spinal curves Asymmetry shoulders or hips Alignment of shoulders, iliac crest, gluteal folds skin creases Exaggerated curvatures of the thoracic spine (kyphosis), lumbar spine (lordosis), or lateral curvature of the spine Horizontal imaginary line connecting highest point on each iliac crest (scoliosis) crosses L4 An unstable, ataxic, or shuffling gait and an inability to Expected Findings maintain posture Head to be held erect and in line with the neck and back. Palpation Symmetrical No tenderness, pain Iliac crests and the gluteal folds even and symmetric Spinous processes should be aligned straight without Buttocks should be of equal size and shape. any tenderness. Alignment of knees & feet should be equal, feet should face Symmetry forward. Unexpected Findings Spine should be concave at the cervical and lumbar areas & Curvature, tenderness during palpation, or spasm of the convex at thoracic area. Spinous processes may protrude client’s paravertebral muscles slightly. Pain Muscle movement should be smooth and coordinated with ambulation. Muscles should be symmetrical. ROM Expected Variations Flexion, lateral flexion, hyper-extend, rotate shoulders With aging, the intervertebral discs become more flattened Back single C shaped convex curve when flex forward resulting in a loss of height 24  The nurse is assessing the patient and percusses the median nerve at the wrist. The patient tells the ???? nurse they feel “burning and tingling there”. This test is called the _________test and is assessing for the presence of _________ disease. 25  Hip Ball & socket 2 bursae (fluid filled sacks) provides cushioning Groups of muscles allow movement: Flexor group consist of the iliopsoas muscle, allows for Flexion. Extensor group consists of the gluteus maximus muscle: Extension. Adductor group of muscles are located on the posterior medial portion of the femur, Adduction. The abductor group consist of the gluteus medius and minimus muscles: Abduction Articular capsule strengthens joint 26 Knees Articulations of femur, tibia, patellar Flexion & extension Hinge joint Bursae reduce friction Meniscus & ligaments provide support Quadriceps femoris & hamstring muscles support knee & allow movement. Bursae reduces friction 27 ???? What is the bump called at the base of the neck posteriorly? a. Costovertebral angle b. Costal angle c. Vertebra prominens 28  Hips and Knees Palpation Joint should be smooth Observe gait & alignment Expected Findings Expected Findings Joints should feel stabile & symmetric with no tenderness or pain Gait smooth and coordinated Palpation of the area should not elicit any pain or discomfort Tops of iliac crests and gluteal folds at same level bilaterally Bones & joints without nodules or masses Surface of the hips should have no bruising. Firm and solid feeling to soft tissues & muscle Knees symmetrical in shape and size, with equality of bony landmarks and Unexpected Findings the presence of hollow areas, or concavities, on either side of the patella Tenderness, pain, or crepitus Contour, or shape, of muscles symmetrical Swelling or nodules on the joints can indicate arthritis Shins should be straight and equal bilaterally. Swelling and tenderness Unexpected Findings ROM Asymmetry of the hips (curvature of the spine, deformity of the hip, or unequal length of the legs) Pain with movement or gait could be Flexion, extension, rotation, abduction, adduction neurological conditions, dislocation, or fractures Muscle strength Wide-based gait could indicate neurological deficits. Push against resistance Erythema or change in pigmentation, heat, swelling, or nodules on the joints of the knee can indicate arthritis Rise from chair without using arms Deviation of alignment Limitation in movement or asymmetry Absence of the hollows on either side of the patella Misalignment of the shin, an angulation deformity, appears as a bowing out of the tibia and fibula (genu varum) or a bowing in (genu valgum). Permanent state of flexion (contracture) 29  Hinge joint Foot and ankle Flexion (dorsiflexion), extension (plantar flexion) Rotation inversion, eversion, and adduction and abduction. 3 bones: Tibia, fibula, talus Medial/lateral ligaments= stability Additional joints provide movement Inversion, eversion of foot Metatarsophalangeal- toes Heal- calcaneus Medial malleolus- bony prominence distal end of tibia Lateral malleolus- bony prominence distal end of fibula 30  Ankles and Feet Palpate Symmetry, alignment Expected Findings Expected Variations Bones of the ankle, heel, and foot should feel smooth Little to no longitudinal or a high arch and firm. Unexpected Findings Unexpected Findings Swelling, inflammation, lesions, ulcers, corn, or Fullness or swelling of the joints or eliciting calluses tenderness Could be friction or injury ROM Misalignment of toes 1. Point their toes toward the floor (plantar flexion) Hallux valgus, when the distal aspect of the large toe sticks outward, away from the body, 2. Point their toes up toward their nose (dorsiflexion) Hammertoes involve the remaining toes and consists of hyperextension of the metatarsophalangeal and PIP 3. Turn soles of feet out, away from the body (eversion), joints and then in towards the midline (inversion) 4. Bend (flexion) and straighten their toes (extension) and then raise their toes up while keeping the foot flat on the surface (hyperextension) Muscle strength Keep their foot and ankle flexed against the force of your hand and arm Should be able to maintain flexion without pain or weakness 31 Trauma of extremity Sprain- injury to From twisting or ligaments or hyperextension tendons Strain- injury to Overuse or muscle or tendon stress on it Break in Fracture integrity of bone 32 33 Older Adult Reduced muscle mass, strength, range of motion, balance, ability, & stamina to perform activities Up to 75% loss of muscle mass Musculoskeletal (MS) disorders impact ADL’s Development of depression or anxiety due to inability to care for themselves ↓ bone size & density: ↑ risk of fractures ↓ bilateral deep tendon reflexes ↓sensation to vibrations ↓ motor coordination Slight sway when standing Kyphosis related to weakness, compression, or fractures of the spine Note if unequal muscle strength & resistance 34  The nurse is teaching a group of clients how to ???? protect a musculoskeletal injury. What will the nurse include in the teaching plan? 35  Osteoporosis Less bone produced Osteopenia: lower-than-expected bone mass or bone mineral density Milder version of osteoporosis Compression fractures of the spine result Calcium & phosperous do not stay in bone in pain, decreased height, kyphosis, Older adults may consume less foods with or Dowager’s hump calcium (due to lactose intolerance) Bone density (DEXA) scans & vertebral Less testosterone & estrogen ↑ risk of fractures fracture assessments can be performed to identify osteopenia or osteoporosis ↓ exercise Prescription medications are available to Medications can ↓ bone density help in the treatment of osteoporosis Dowagers Hump: abnormal outward curvature Bone Mineral Density (higher is more of thoracic vertebrae of the upper back related dense bone; less fracture risk) to osteoporosis. FRAX calculator Most females will have a fracture A bone mineral density test, like the DEXA (dual energy x-ray absorptiometry) scan Measurement at femoral neck best predictor of hip fracture 36 37  Osteoporosis: Risk Factors Non-modifiable Modifiable Over age 50 Vitamin D, Calcium deficiency Female Smoking Menopause Alcohol Family history Inactivity Low body weight/being small and thin Medications: corticosteroids, PPI, Fractures or height loss SSRI Risk for falls Risk factors Review medications (anti- Diseases: RA, SLE, MS, IBD, weight hypertensives) loss surgery 38  Osteoarthritis Slowly progressive disorder Causes inflammation, pain, & stiffness in joints & surrounding tissues Damage to cartilage & surrounding tissues Crepitus, popping, creaking, or heard at the joints Hands 30 million Americans Bony abnormalities in the proximal Most often in knees but also hands & spine interphalangeal (PIP) joints, known as Excessive weight worsens knee OA Bouchard’s nodes, or involvement of the Older age, females, Caucasian distal interphalangeal (DIP) joints, known as Heberden’s nodes Worse later in day Heberden (DIP) and Bouchard’s(PIP) nodes are hard & non- Pain in hips, upper thigh, or lower back with tender walking, stair climbing, and standing Irregular bony margins OA in spine: neck or low back pain with or Limited ROM without radiating pain, numbness, and Asymmetric joint involvement possible compression on the sciatic nerve, Stiffness, swelling with motion causing weakness of the lower extremities Gets better with rest Burning or tingling in the hands, back, legs or feet are associated with neurological involvement. 39 Rheumatoid Arthritis Chronic autoimmune inflammatory disorder that affects the joints Causes inflammation, painful deformities, immobility Painful, stiff, swollen joints that worsen with inactivity upon waking Fatigue Boney abnormalities of PIP & DIP joints of the fingers form, causing them to bend abnormally, known as a swan-neck deformity Hyperextension of the DIP joint with flexion of the PIP joint of the hands or toes are known as boutonniere deformity Risk factors for this condition include family history, female sex Women (2.5) to men Smoking, and obesity No cure, but newer medications are available to slow the progression and decrease the severity of the manifestations Hands warm; engorged veins Limited ROM Symmetric joints Bilateral swelling & stiffness Fatigue, weakness, anorexia, weight loss, low-grade fever, and lymphadenopathy 40 Promoting Bone, Joint, Muscle, and Neurological Health Calcium Consume adequate amounts of Build & maintain bone mass calcium& vitamin D 1000- 1200mg daily can ↓ risk for bone loss & Include physical activity in the daily fractures routine Dairy Avoid substance use Cheese, yogurt, milk Increase intake of protein Non-dairy Broccoli, kale, legumes Avoid stress and engage in activities that stimulate the brain Vitamin D Helps calcium be absorbed in GI tract 600-800 IU Egg yolks, fatty fish (salmon, tuna) Also those fortified with Vitamin D Milk, OJ 41  Pregnancy ↑mobility of pelvic joints begin at the 10th to 12th week due to hormone relaxin Joint mobility and laxity & lordosis of the lumbar spine as Separation of the abdominal muscle known as rectusrd pregnancy progresses (shift of the center of gravity as the uterus abdominis diastasis (RAD) is common especially in 3 enlarges) trimester because of the enlarged uterus and weakened abdominal muscle. Widening of the sacroiliac joints and symphysis pubis RAD usually resolves in 6 to 12 months postpartum. Low back pain. May worsen as pregnancy progresses due to Carpel tunnel may develop, but will resolve post partum exaggerated lordosis of the lower back, forward flexion of the neck, and downward shoulder movement to compensate for enlarging uterus and shift of the center of gravity Round ligament pain more frequently occurs on the right side of the abdomen or pelvis and often occurs upon waking (ligaments holding uterus stretch) Later pregnancy Joint discomfort Waddling gait Foot & knee pain and cramps while sleeping Unexpected Severe or persistent back pain that increases with cough, sneezing, and Valsalva maneuver 42 ???? The patient has a Dexa scan reading of -2.7. How does the nurse interpret this finding? a. Osteopenia b. Osteoporosis c. Severe Osteoporosis d. Healthy bone density 43  To assess for DDH: Head of femur not cupped in Newborn acetabulum Ortolani Inspect extremities for size, symmetry, and equal With the knees flexed to 90 degrees, abduct the upper movement leg applying gentle pressure on the trochanter. Assess palmar crease A positive test indicating possible developmental If single could be health or DS dysplasia of the hip (DDH) is noted by a clunk with this maneuver. Assess back for spinal contour Barlow Palpate clavicles, note if crepitus With the hips adducted, apply gentle pressure to the Thighs for crease symmetry posterior hip. If asymmetric DDH A positive test indicating possible DDH is noted by a Lift infant and examine back; note normal single clunk with this maneuver. C-curve of newborn’s spine Allis Inspect length of spine for any tuft of hair, dimple Unequal gluteal folds in midline, cyst, or mass; normally none is present Triangle-shaped posterior fontanel closes by 6-8 weeks (ATI-2-3 months), and diamond-shaped anterior fontanel closes between 12- 18 months 44 Additional Findings Syndactyly Polydactyly Webbed Extra digit 45  Infants’ movement is Infants, Children, and Adolescents assessed during voluntary movement By 3 months fetus- formed skeleton of Hip joints and feet are cartilage assessed for Bone growth rapid during infancy and abnormalities. steadily in childhood, until adolescent Children’s motor growth spurt development Lengthening occurs at epiphyses, or compared with growth plates standardized tables for Longitudinal growth continues until age and sequences closure of epiphyses; to age 20 Musculoskeletal Trauma or infection at these locations assessment of older puts growing child at risk for bone child and adolescent deformity follows same Muscles vary in size and strength in procedures as that for different people due to genetics, adults and reveals nutrition, and exercise similar expected findings All through life, muscles increase with use and atrophy with disuse 46  Preschool and School-Age Children Back Note posture Shoulders: level within 1 cm; scapulae symmetric; lordosis (sway back) common throughout childhood Observe legs and feet for various deformities, such as Bowleg, knock knees, flatfoot, pigeon toes Genu varum Genu valgum Metatarsus adductus 47 Adolescents Kyphosis common during adolescence because of chronic poor posture Screen for scoliosis with forward bend test From behind standing child, ask child to stand with feet shoulder width apart and bend forward slowly to touch the toes Expect straight vertical spine while standing and also while bending forward; posterior ribs should be symmetric, with equal elevation of shoulders, scapulae, and iliac crests 48  Health History Interview Ask questions that are specific to function of the musculoskeletal and neuromuscular systems Have you had a loss of function or weakness within the joint or Do you have a condition resulting in curvature of muscle the spine such as scoliosis, kyphosis, or lordosis? If so, does the loss of function impact your ability to perform If so, does this condition cause pain or activities of daily living, such as bathing or dressing? spasms in the back? How long have you experienced the loss of function? Do you experience associated manifestations such as difficulty with breathing? Have you had difficulty with maintaining balance or coordination? Do you have any neurologic disorders such as an Have you had any recent falls? injury to the head or spinal cord, stroke, or When was the last time you fell? seizures? Localized assessment questions should include asking about the Do you have a history of a neuromuscular joint pain, sensory loss, and any trauma or injury disorder? Have you had any joint pain? Have you experienced any recent tremors or an If so, rate the pain on a scale 0 to 10. When did you first inability to control movements? notice the pain? What makes it worse or better? Do you have any daily activities at home or work Does the joint have any swelling, erythema or a change in that involve heavy lifting or repetitive motions? pigmentation, or warmth? Have you noticed any difficulty in performing When did you notice the change? these tasks? Do you have numbness or tingling in your hands or feet? How often and what type of exercises do you participate in? How long ago did you notice this? What measures do you take to protect from Do you have a history of diabetes? (This can cause numbness and injury during exercise or sports? tingling in feet called peripheral neuropathy) Do you have any immediate family members with Do you have any back pain or spasms? a neuromuscular or musculoskeletal disorder? Have you had any trauma to an extremity? If so, did the trauma cause a fracture, broken bone, sprain, or contusion? How did the injury occur? Do you have any chronic pain or diminished sensation as a result of49the injury?  Problem Based History Pain Movement Where was pain felt? How long have you had movement When was it first noticed? problems? Is it related to movement? Are joints swollen, red, or hot to touch? Did pain occur suddenly or gradually? Have you had a recent sore throat? (Strep- When during day, when do you feel pain? rheumatic fever-affects heart/joints) Does pain move from one joint to another? Muscle weakness? Any injury, overuse, or strain of muscles or Which ones? joints? Does it get worse throughout day? What makes pain worse? Do knees or ankles give way with pressure? Does pain shoot to another part of your What do you think makes it happen? body? Joints felt as if locked and will not move? What was done to relieve the pain? When? How effective was that? What relieves it? What makes it worse? 50 ???? Which is a normal finding in a toddler? Lordosis Kyphosis Scoliosis Spondylosis 51  Are activities limited by musculoskeletal disorder? Problem- To what extent are activities limited? Based How do you compensate? History: Note that any impaired mobility or Problems function may cause a self-care deficit. with Daily For patients who have chronic disability or Activities crippling disease: How has illness affected interactions with family? Has it affected relationships with friends? 52  Examination: Procedures and Techniques Palpate bones, joints and muscles for tenderness, heat, edema, tone Bones nontender, joints or Inspect skeleton and extremities for muscles same temp as tissue, no alignment, contour, symmetry, size, and gross tenderness or edema on deformities: palpation; firm muscles Body symmetric, straight spine (normal curves), knees straight line (hips and Observe range of motion and palpate ankles), feet flat, forward major joints and adjacent muscles for tenderness on movement, joint Inspect muscles for size and symmetry: stability, and deformity Bilateral symmetry, muscle circumference Test muscle strength and compare Observe gait for conformity, symmetry, and sides. rhythm To examine musculoskeletal system, use a Conformity, regular smooth rhythm, leg cephalocaudal organization with side-to- swing, length symmetry, smooth swaying, side comparisons for examining bones, or symmetric arm swing muscles, and joints ???? The patient is seen in the ED and presents with the following symptoms: hard and non- tender Bouchard’s and Heberden’s nodes, crepitus and limited range of motion unilaterally. The nurse suspects that the patient has which condition? a. Rheumatoid arthritis b. Osteoarthritis c. Osteoporosis d. Gout 54 Get Up and Go Test Assessment as part of a routine evaluation of older adult Purpose is to detect “fallers” and to identify those who need evaluation. INITIAL CHECK All older persons who report a single fall should be observed as they: From a sitting position, stand without using their arms for support. Walk 10 feet, turn, and return to the chair. Sit back in the chair without using their arms for support. Individuals who have difficulty completing the above in less than 10 seconds or demonstrate unsteadiness performing this test require further assessment. 55 Follow Up Assessment In the follow-up assessment, ask the person to: Sit. Stand without using their arms for support. Close their eyes for a few seconds, while standing in place. Stand with eyes closed, while you push gently on his or her sternum. Walk a short distance and come to a complete stop. Turn around and return to the chair. Sit in the chair without using their arms for support. 56  Common Problems Osgood Schlatter Disease Gout Adolescents in sports Tophi are collections of sodium urate crystals caused by Growth spurts chronic gout in and around the joint. Crystals are strong Self-limited inflammation triggers that cause extreme painful swelling and joint deformity. They may erode through skin with a chalky discharge 57 Additional Epicondylitis Findings Pain at lateral epicondyle of humerus “Tennis elbow” Medial less common “Golfer’s elbow” 58 Complications of Immobility Skin breakdown, pressure ulcers, contractures, muscular weakness, muscular atrophy, osteoporosis, renal calculi, urinary stasis, urinary retention, urinary incontinence, urinary tract infections, atelectasis, pneumonia, decreased respiratory vital capacity, venous stasis, venous insufficiency, orthostatic hypotension, edema, emboli, thrombophlebitis, constipation and, loss of calcium from the bones Costly in terms of health care dollars and in terms of client suffering Key is prevention 59 60 Health Promotion When lifting, get ↑stress & injuries Use correct chair assistance, bend at (overuse of muscles, height, wrist supports, knees, spinal repetitive movements, monitor at eye level, alignment, use large poor posture & lifting) good posture muscles of thighs 61  Ergonomics Many injuries are due to improper lifting, bending, and positioning while working on computers Ergonomics focus on reducing stress and eliminating injuries related to overuse of muscles, repetitive movements, and poor posture and lifting techniques Proper techniques while working at a desk include correct chair height, support for wrists, monitors that are eye level, and good posture Proper techniques for lifting include assessing the weight and obtaining assistance when needed Maintaining spinal alignment, bending at the knees, and using the large muscles of the thigh when lifting can also help avoid injury 62  Maintain muscle function & strength ↓ bone loss Isotonic Exercise Improve ROM Tighten or tense Combination of activities is best Walk, swim Warm up Promote muscle Stretching contraction that Low impact aerobics changes muscle Strength training length Maintain muscle Weight bearing ↑ strength Jogging, tennis ↑ bone health Promote bone growth & strength Control body fat ↓ risk of injury Wear supportive shoes Drink plenty of water 63  Injury Prevention 64